Case 31 – Penny Wise, Pound Foolish
Melissa is a 19-year-old woman at 27 weeks gestation in her first pregnancy who presents for her first pre-natal visit at Country Health Clinic. She has not seen a health care provider thus far because she has not had coverage—she works at a local pizza restaurant and her employer doesn’t provide health insurance. The clinic social worker enrolled her in the Oregon Health Plan (a safety net program) and explained that she would have coverage during her pregnancy. Melissa lives with her sister in an apartment and does not have a car of her own. Her sister drives her to work, or she take the bus, so traveling to the clinic visits is difficult for her.
The nurse practitioner at the clinic determined that Melissa’s pregnancy had been uncomplicated thus far. She had some nausea and vomiting in the first trimester that had resolved, and she had not had any bleeding or contractions. Her history was significant for a previous abnormal pap that she had not followed up, and chlamydia that was treated as an outpatient 2 years ago. Melissa smokes a little over a pack of cigarettes per day and denies using alcohol or recreational drugs during the pregnancy. She has begun prenatal vitamins.
She is in a monogamous relationship with the father of the baby, who is currently incarcerated for theft. They have been together for 2 years and plan to marry when he is released next year.
Melissa’s examination was consistent with 27 weeks gestation, and the nurse practitioner performed a pap and cervical cultures. She drew prenatal labs and set Melissa up with an appointment for an ultrasound, although Melissa was not sure she would be able to get time off work for the appointment. She stated that her boss was very strict about time away from work, and she was afraid she would lose her job if she missed too much.
The nurse noticed that Melissa’s dentition was very poor and inquired when her last dental examination had been. Melissa could not remember exactly, but thought that it was at least several years ago. She admitted to some right-sided jaw pain. The nurse gave her the names of several dentists in the area and encouraged her to schedule an appointment.
Melissa wanted to know if dental care would be covered on the Oregon Health Plan, because she was afraid of a large dental bill that she could not pay.
The next week Melissa presented via ambulance to the emergency room with a premature onset of contractions. The labor and delivery physician obtained the records from the clinic and found that her chlamydia culture was positive and that the clinic had been unable to contact Melissa because her phone had been disconnected. The obstetrician treated Melissa with medications to stop her contractions, gave her antibiotics for the chlamydia infection, and looked for any other infections because infection is a common cause of premature labor.
He found an abscessed molar on her right side. The next day Melissa’s drug screen returned positive for opiates. After 2 days in the hospital a reviewer from the Oregon Health Plan indicated to her attending physician that her preterm labor was felt to be arrested enough the Melissa should be discharged. The physician did so, giving her strict instructions to see a dentist within the week to deal with the abscess, explaining to her that her preterm labor might return if she did not do so.
He also explained to her that the positive drug screen meant that Child Protective Services would need to be involved after her baby was born. Six days later Melissa returned to the hospital, having delivered her 29-week infant in the ambulance on the way to the hospital. Her infant was immediately taken to the neonatal intensive care unit (NICU), where it as placed on mechanical ventilation for respiratory distress syndrome. Melissa had not seen a dentist and still had the abscessed tooth.
The NICU nurse discussed her baby’s expected hospital course with Melissa, telling her as gently as she could that the baby would likely be in the hospital for 5 to 6 weeks and could potentially have long-term mental retardation, blindness, and chronic lung disease. Melissa looked around at her monitors and equipment in the NICU, and her tiny baby, and wondered how she would ever be able to pay for it all. She told herself that she would worry about the bills later and told the nurse, “I want everything possible done for my baby.”
Adapted from:
Beemsterboer, P. L. (2016). Ethics and Law in Dental Hygiene-E-Book. Elsevier Health Sciences.
Questions:
You are an oral healthcare member of the hospital review board who has been assigned to review this situation. Using the ethical decision-making model, analyze this case.
Probing questions to integrate in the ethical decision-making model
Research the Oregon Health Plan and determine medical and dental coverage for the patient in this case and integrate this information in your ethical decision-making model analysis.
Since infections may lead to premature delivery, what are the two competing infections that have been identified in this case study that you should consider in your review?
Probing legal questions to discuss in the case analysis
Drugs were found in Melissa’ laboratory tests, described the legal implications that should be considered from the providers’ and hospital perspective?
Describe the legal and contractual relationships occurring in this case with Melissa and the healthcare team that you should consider in reviewing this case.
Instructions
Provide your response to this case study in 1000-1500 words using APA referencing style.
Refer to this link –
https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/general_format.html
for APA formatting and referencing style if you do not have the APA Publication Manual 7th ed.
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