Casey's Family

Introduction Casey, a female infant aged 3 months, is a patient of the Bayview Children's Hospital NICU. Casey has significant bronchopulmonary dysplasia (BPD) secondary to exposure to high levels of oxygen therapy and mechanical ventilation, and at this point remains dependent on ventilator support. At birth, Casey was only 33 weeks old in gestational age and weighed only 2 lbs and 14 oz. In addition to her lung condition, Casey also has a congenital heart anomaly that will require a surgical repair if she is to survive long term. Up until 2 days ago, the treatment plan was to continue the course of mechanical ventilation, with the highly uncertain prospect of weaning Casey from the ventilator so home care becomes possible. Surgical repair of her heart might then have been possible in the next 12-18 months, if lung function improved enough to ensure a reasonable chance of surviving the surgery. However, Casey now has a significant acute respiratory infection, and her survival is very tenuous.

Social Hx. Casey is the third child of Abbey (age 28) and Fred (age 27). Their oldest child, Debra, is 6 and is attending the first grade, and their younger son Nick is 4 and in pre-school. Although Nick is reported by both parents to be developing normally, Debra has been diagnosed since age 4 with ADHD, and is currently being treated with Adderall. Prior to Casey's conception, both parents acknowledge that were in the process of negotiating a separation, in large part arising from their inability to agree on how to parent Debra and disagreements about medication. Casey's conception occurred during a weekend reconciliation that ultimately failed until the pregnancy was known. Although Abbey and Fred have since remained together and both express a commitment to keeping the family together. Fred in particular is dubious about their ability to care for Casey's special health care needs and effectively parent Debra and Nick. Financially, the family has been able to afford their modest home with both Fred and Abbey's fulltime employment. Abbey works the evening shift and two Saturday's a month as a checker at Safeway, and Fred works for a small electrical contractor. Both sets of grandparents live in California, and only Abbey's grandparents have been financially supportive and helped with child care.

Current Situation When not working, Abbey spends most of the day at the hospital with Casey and Fred visits briefly at least 3 evenings a week. During this current crisis Abbey is exhausting her remaining sick days to spend more time at the hospital and Fred is taking time off to take over child care and management of the home. Abbey is getting very little sleep, is often angry at the staff over the care of Casey and has identified some staff as being "incompetent" to care for Casey. Last evening, Fred and Abbey had a very loud argument in the hallway outside the NICU after Fred had asked Abbey whether it made sense to continue Casey's antibiotic therapy. According the ward clerk who overheard much of the argument, Fred is concerned that their insurance benefits are being exhausted and that there will be very little if anything available to support home care even if Casey survives her current crisis. The health care insurance underwriter has assigned a case manager to Casey, who is requesting that a patient care conference be scheduled ASAP. Dr. Smyth, Casey's pulmonary physician does not want to do a case conference until the current lung infection crisis is resolved.