Andrea Gonzalez

Andrea Gonzalez is an 18-year-old single mother who works on a mushroom farm. Ms. Gonzalez was referred to a tertiary medical center for prenatal care when her fetus was found by her community health center to have low amniotic fluid, a sign of a birth defect. An ultrasound showed the unborn baby had extremely small kidneys and there was a significant chance that, after delivery, her kidney function would be insufficient for survival.

            The baby, Lynn, was spontaneously born at 38 weeks. Though full term, her bladder is completely absent and she has kidney failure. Despite these problems, she is able to produce some urine. She also has normal urethral, vaginal, and rectal orifices. She has no abnormalities of the nervous system to suggest that she will have problems walking and talking, or to suggest that she will be mentally challenged. She is able to breathe completely on her own and there is no evidence of any problems with the heart, lungs, or digestive system that would affect quality of life. The situation does not require an immediate decision, but clearly, medical intervention will be necessary if she is to be given some chance of a reasonably extended life. She was admitted to the Infant Intensive Care Unit for evaluation and management of her condition.

            The attending physician, Dr. Watson, is a neonatologist who is in charge of baby Lynns’ care. Dr. Watson does not think it possible to construct a bladder for her at this time. Dr. Watson called for a nephrology consult. The nephrologist, Dr. Hyde, sees only two possible options. Baby Lynn could be started on peritoneal dialysis with the intention of listing her for kidney transplant when her weight reaches 10 kg, or the team could recommend supportive care to help the mother keep her baby comfortable until she peacefully dies of kidney failure. In examining these options, Dr. Hyde believes that it is not possible for the mother to perform outpatient peritoneal dialysis and recommends supportive care only.

            Dr. Watson, however, thinks it is mandatory to start dialysis and plan a transplant for baby Lynn, whose disabilities are confined to her urinary system. She strongly believes that baby Lynn could develop to live a reasonably normal life in which she could become educated, employed, and married, if her kidney problem can be managed.

            Ms. Gonzalez loves her baby and does not want Lynn to die, but she has a very low income and no family support. She is incapable of providing the necessary outpatient care for her baby without substantial assistance. She is the only decision-maker for Lynn’s care.