Diagnostic Uncertainty and Ethical Dilemmas in Medically Complex Pediatric Patients and Psychiatric Boarders

Pediatric hospitalists face many patients with diagnostic and therapeutic uncertainty. Confronted with this issue, they may question their obligation to continue treatment plans they do not agree with or are not comfortable providing. Additionally, hospitalists manage an increasing number of patients with psychiatric disease, as the lack of intensive psychiatric services has placed a greater burden of behavioral problems on inpatient care wards. We offer the following case to consider the ethical obligations of the hospitalist to continue an outside provider’s treatment plan and how to provide the best care of complicated psychiatric patients without a disposition. An adolescent young man presents to the emergency department after ingestion of a nontoxic household product. He is admitted to the hospitalist service due to continued decline of executive functions, increased self-neglect, and increase in bizarre behaviors. His past medical history is significant for receptor-negative autoimmune encephalitis diagnosed 2 years before presentation. By report, he was a healthy, normally developing child until 2 years ago when he began having bizarre movements, repetitive behaviors, emotional lability, intrusive thoughts with hallucinations and hearing voices, and progressive cognitive decline. A diagnosis of receptor-negative autoimmune encephalitis was given at an outside institution, as extensive laboratory work and imaging were negative for a specific diagnosis. The patient was treated with intravenous infusions of immunoglobulin (IVIG), steroids, and additional immunomodulators, administered in the PICU for behavioral concerns, with little improvement. Psychiatric diagnoses, including schizophrenia, were considered previously but not seriously regarded by the family. His interim behavior after treatment has been difficult to control, including running away requiring an Amber alert, aggression toward family members, and severe neglect of self-care. There is no history of overt suicidal thoughts or behaviors. No focal neurologic findings were present to suggest intracranial pathology. Attempts to engage the patient in conversation were met …