Laurel Hyle, JD, MPH Karla Fredricks, MD, MPH

1. Respect for All Persons: Optimizing Care of Immigrant Patients by Pediatric Healthcare Professionals Laurel Hyle, JD, MPH Karla Fredricks, MD, MPH Assistant Professor of Pediatrics, BCM Assistant Professor of Pediatrics, BCM Chief, Ethics, TCH Director, Program for Immigrant and Refugee Child Health , TCH This is not and does not constitute legal, medical or other professional advice. If you desire professional advice, you should seek it from an appropriate professional.

2. Disclosures We do not have any conflicts of interest to report.

3. objectives • Define ethical principles that are important to consider when providing clinical care for patients. • Describe examples of cases that may present ethical dilemmas. • Identify how Texas Children’s Hospital professionals can help optimize care for immigrant children and families from an ethical perspective.

4. Administration to allow longer detention of migrant families

5. How Does Ethics Fit Into All of This? • Ethics: • Ethics Service, including the Ethics Consult Service • Ethics Section • Ethics Committee • Ethics helps individuals and groups work through and resolve ethical dilemmas • What is an ethical dilemma? • Often an ethical dilemma occurs in situations with conflicting values or where the appropriate course of action is unclear • What are some of the key principles of ethics, which are applied to resolve ethical dilemmas?

6. Ethical Principles • Respect for persons, including autonomy: • “At a minimum, personal autonomy encompasses self-rule that is free from both controlling interference by others and limitations that prevent meaningful choice…” • Justice: • includes, but is not limited to distributive justice, which pertains to, “fair, equitable, and appropriate distributions of benefits and burdens determined by norms that structure the terms of social cooperation.” Also, are like cases being treated in a like manner? • Beneficence: • contributing to the welfare of others • Nonmaleficence: • refraining from causing harm to others Beauchamp, T. and Childress, J. Principles of Biomedical Ethics. Oxford University Press, Seventh Edition. 2013.

7. Case 1 “Ramon” • 11-yr-old male from Honduras • Came to U.S. without parent • Staying at shelter for unaccompanied minors in Houston area • Presents to TCH emergency for testicular pain, diagnosed with R testicular torsion. Brought in by shelter staff. Who provides consent for the testicular surgery? Who should be informed about his condition and treatment?

8. Case 2 “Emely” • 16-yr-old female from Guatemala • Came to U.S. without parent • Staying at shelter for unaccompanied minors in Houston area • Presents with staff to TCH emergency for difficulty breathing with exertion. CXR shows a mediastinal mass. Admitted to floor. Who should be involved in medical decision-making for Emely? What should the medical team do if Emely does not want the diagnostic work-up?

9. Ethical analysis • Benefits/Burdens (Beneficence/Nonmaleficence) • Respect for Persons/Autonomy • Justice

10. How Might a Guidance Document Help? • Guidance regarding when unaccompanied minors can consent for their own care • Guidance regarding when an unaccompanied minor’s parent or former guardian should be contacted and how to approach this • Guidance regarding when other individuals may consent for an unaccompanied minor • Guidance regarding when an independent ‘patient advocate’ might be useful

11. Case 1 “Ramon” • 11-yr-old male from Honduras • Came to U.S. without parent • Staying at shelter for unaccompanied minors in Houston area • Presents to TCH emergency for testicular pain, diagnosed with R testicular torsion. Brought in by shelter staff. Who provides consent for the testicular surgery? Who should be informed about his condition and treatment?

12. Case 2 “Emely” • 16-yr-old female from Guatemala • Came to U.S. without parent • Staying at shelter for unaccompanied minors in Houston area • Presents with staff to TCH emergency for difficulty breathing with exertion. CXR shows a mediastinal mass. Admitted to floor. Who should be involved in medical decision-making for Emely? What should the medical team do if Emely does not want the diagnostic work-up?

13. Unaccompanied Minor Key Points • As for all pediatric patients, it is important to discuss medical decisions with unaccompanied minors (as cognitively and maturationally appropriate) • In general, involve parents as you usually would • Interpreters should be used to communicate with patient and family if health professional is not medically fluent in their preferred language, consistent with institutional policy • For assistance with complex medical cases of unaccompanied minors • Consult to Ethics can be requested via TCH Page Operator • Consult to Immigrant Health can be requested in EPIC

14. Case 3 “Deisy” • 5-yr-old female from SW Houston • Brought to TCH emergency by her father for vomiting, fever, and abdominal pain • Diagnosed with appendicitis, appendectomy done • Floor team notes that her mother has not visited during her hospital course and Deisy is crying for her. Dad says mother is “scared to come because she does not have papers.” What courses of action could the team take?

15. Case 4 “Abhi” • 9-yr-old male from Bangladesh, came to the US with his parents 3 years prior and granted Medical Deferred Action • Has chromosomal anomaly and is unable to walk, talk, or do any activities of daily living on his own • Has frequent admissions, currently inpatient for aspiration pneumonia The floor receptionist receives a call asking whether or not Abhi’s father is present in the hospital. What could she do?

16. Case 5 “Rosina” • 22-yr-old pregnant female from El Salvador • Brought to PFW in active labor • Accompanied by officials from Immigration and Customs Enforcement (ICE) • ICE insists that she remain handcuffed to the bed and are refusing to leave the room during delivery What are some of the provider’s options in this scenario?

17. How Might a Guidance Document Help? • Guidance regarding how to create spaces where individuals feel they are secure and safe in receiving confidential healthcare services • Guidance regarding how to respond to requests for information about patients or their family members/surrogate medical decision makers • Guidance regarding other matters of concern

18. Case 3 “Deisy” • 5-yr-old female from SW Houston • Brought to TCH emergency by her father for vomiting, fever, and abdominal pain • Diagnosed with appendicitis, appendectomy done • Floor team notes that her mother has not visited during her hospital course and Deisy is crying for her. Dad says mother is “scared to come because she does not have papers.” What courses of action could the team take?

19. Case 4 “Abhi” • 9-yr-old male from Bangladesh, came to the US with his parents 3 years prior and granted Medical Deferred Action • Has chromosomal anomaly and is unable to walk, talk, or do any activities of daily living on his own • Has frequent admissions, currently inpatient for aspiration pneumonia The floor receptionist receives a call asking whether or not Abhi’s father is present in the hospital. What could she do?

20. Case 5 “Rosina” • 22-yr-old pregnant female from El Salvador • Brought to PFW in active labor • Accompanied by officials from Immigration and Customs Enforcement (ICE) • ICE insists that she remain handcuffed to the bed and are refusing to leave the room during delivery What are some of the provider’s options in this scenario?

21. Immigrant families Key points • Circumstances related to immigration often impact an individual’s interactions with the health care system • Immigration history -- e.g., country of origin, countries traversed, date of immigration, trauma in home country or on journey -- should be obtained as relevant to clinical care • Immigration status - - documentation

22. Role Definition & Boundaries • As health professionals, our role is to provide appropriate clinical care for all patients • Ethics (ethical concerns), Legal/Risk Management (legal/risk concerns), and the Program for Immigrant and Refugee Child Health (clinical concerns) are internal resources available

23. Discussion & Questions?