WAYS OF KNOWING IN A CLINICAL CASE 1

Scenario

Katy, a full term female infant, was transferred to the Neonatal Intensive Care Unit
(NICU) from normal newborn on day of life. Katy’s condition was primarily attributed to central
nervous system symptomology including irritability, tremors, increased muscle tone, excessive
sucking, poor feeding, interrupted sleep-wake cycle, and exaggerated Moro reflex.
Katy’s mother, Missy, was a twenty-eight-year-old first-time mother with a history of
oxycodone addiction. Missy sought treatment for her addiction when she found out she was
pregnant because she did not “want to harm her baby”. Missy was prescribed methadone to
replace oxycodone to avoid detoxification during her pregnancy which is associated with fetal
distress and increased fetal loss. Missy was compliant with her treatment plan. Her urine drug
screen was negative at delivery with the exception of methadone. Missy was distraught during
her visits and would frequently cry and leave the room when she could not console her baby. She
voiced she thought her baby would be “fine” because she switched to methadone during her
pregnancy. Social work had been consulted and had cleared Katy for discharge to her mother
when medically cleared.
Katy’s care involved administering methadone by mouth as pharmacologic treatment for
her withdrawal to determine therapeutic response. Non-pharmacologic treatment included
swaddling, decreased environmental stimuli and handling, pacifier use, and gentle rocking. Non-
pharmacologic interventions were based on Katy’s cues as no one or combination of
interventions seemed to work consistently. Katy was difficult to feed and required swaddling,
frequent rest periods, and decreased environmental stimuli during feeds to be able to consume
sufficient volume for growth. Katy was fed “on-demand” so it was critical to be able to discern
between excessive sucking associated with withdrawal and genuine hunger cues.
Although Katy was the patient, care also had to be provided for Missy so she would be
able to assume the role of primary caregiver at discharge. Missy was educated on recognition and
management of Katy’s withdrawal symptoms to include feeding and soothing techniques and
parental coping strategies. She was encouraged to spend time with her daughter so she would
feel confident in her parenting ability. Missy was treated as a parent first and not a person with a
substance abuse problem. Communication with Katy was facilitated by providing a non-
judgmental environment where she was comfortable asking questions and voicing her worries,
fears, and concerns.
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Application of Ways of Knowing in the Solution

Empirical Knowledge

Carper describes empirical knowledge as the science where knowledge describes,

explains, and predicts “phenomena of special concern to the discipline of health care. Examples

of use of empirical knowledge in the care provided in this case scenario are many. The

practitioner safely administered methadone. The practitioner experimented with various non-

pharmacologic care measures known to be effective in ameliorating withdrawal symptoms

including modification of the environment, rocking, pacifier use, and small, frequent feeds.

Practioner encouraged maternal involvement in care which has also been found to be beneficial

in this patient population.

Esthetic Knowledge

Carper describes esthetic knowledge as the “art” and the ability of the health provider to

perceive the “need that is actually being expressed by the behavior. The ability to perceive (or

intuit) the needs of patients requires the practitioner to be empathetic; the more skilled the

practitioner becomes at empathizing, the more understanding will be gained from the interaction

and the practitioner will be able to design effective care. Empathy and perception were utilized to

determine that Missy was distraught. Practitioner attempted to create a therapeutic, non-

judgmental relationship in which Missy felt comfortable voicing her fears, concerns, and

worries. The relevance of esthetic knowledge when caring for neonates cannot be overstated;

neonates are non-verbal so interventions are founded on observed behavior and health provider

perceptions based on experience and intuition.

Personal Knowledge
WAYS OF KNOWING IN A CLINICAL CASE 3

Carper describes personal knowledge as the ability of the practitioner to incorporate

“therapeutic use of self” to develop an authentic patient-client relationship whereby the patient is

accepted as a unique individual. Practitioner accepted Missy as a unique individual and

approached her in a non-judgmental manner. It is so easy to judge the drug-dependent mother

and practitioner have seen the detrimental results of this approach many times. If practitioner had

judged Missy, the therapeutic relationship would have been compromised and Missy would not

have been receptive to teaching and learning the skills necessary to care for Katy.

Ethical Knowledge

Ethical knowledge, per Carper , is the moral code which guides the ethical conduct of

health provider and is focused on the “obligation of what ought to be done”. The worth, integrity,

dignity, uniqueness and human rights of patients, employers, colleagues, students, employees,

parents and families of the infant will be respected regardless of ethnicity, gender,

social/economic status or physical or mental challenges. Therefore, treating the drug-dependent

mother with dignity and respect is ethically “what ought to be done”. Practitioner was able to

maintain practitioners’ moral integrity despite being faced with the moral conflict of providing

guidance and support for a mother whose lifestyle choices had caused such suffering in her

infant. Practitioner couldn’t help but wonder if Missy would be able to parent Katy after

discharge with twenty-four hour a day responsibility. Would Missy be able to handle the

stressors of everyday life, her addiction, and a demanding baby? Would Katy be abused or

neglected? As a health provider, the practitioner wanted to protect Katy but realized Missy was

the one who would be taking her home. After all, Missy was Katy’s parent. By recognizing
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practitioners’ feelings, practitioner was able to make a conscious effort to develop a meaningful,

therapeutic relationship with Missy giving her the best chance to be a successful parent which in

turn would positively affect Katy’s outcomes.

Conclusions

Caring for an infant with the substance-abusing parent, although not technically

challenging, poses one of the most difficult, demanding clinical situations. The health provider

must care for both the infant and the parent; each presenting the health provider with a unique set

of clinical problems. I was able to utilize all the “ways of knowing” to provide comprehensive,

therapeutic care for this dyad.