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MATTER TARA CABRERA (01/13/89)

filed: January 13, 1989.

IN THE MATTER OF TARA CABRERA, A MINOR. APPEAL OF FRANK AND VIRGINIA INGRAM. IN THE MATTER OF TARA CABRERA, A MINOR. APPEAL OF TARA CABRERA


Appeal from the Order of the Court of Common Pleas of Philadelphia County, Family No. Juv. Misc. 88-001. Appeal from the Order of the Court of Common Pleas of Philadelphia County, Civil No. Juv Misc 88-0001.

COUNSEL

Stuart J. Schatz, Norristown, for appellants (at 1799).

Kenneth L. Klothen, Philadelphia, for appellant (at 2006).

Tamilia, Popovich and Hoffman, JJ.

Author: Popovich

[ 381 Pa. Super. Page 101]

This case involves cross-appeals from the order (later reduced to judgment) entered in this matter on the 6th day of June, 1988, adjudicating Tara Cabrera dependent and appointing a guardian ad litem to consent to her blood-transfusion-therapy for a period of one year. We affirm.

The facts, unlike the legal conclusions to be drawn therefrom, are not in dispute and reveal that Frank and Virginia Ingram, on the 18th day of February, 1988, transported their six-year-old daughter Tara to Children's Hospital of Philadelphia for diagnosis and treatment for her fever, limp and pain in her hip.

Dr. Kwaku Ohene-Frempong, the Director of the Sickle Cell Program and Hematology at Children's Hospital of

[ 381 Pa. Super. Page 102]

Philadelphia, was the attending physician for incoming patients diagnosed as having sickle-cell anemia.*fn1 After a series of neurological and orthopedic tests, a CAT scan revealed evidence of "an old stroke" in Tara's brain. Her symptoms were diagnosed as the recurrence of her initial stroke.

In order to calculate the extent of damage sustained by Tara, Dr. Frempong recommended a blood transfusion to reduce the number of sickle-cells in her system. This would avail the doctor the opportunity to gauge more accurately the damage caused by the stroke(s), and, thus, prescribe a course of treatment.

The Ingrams refused, on both medical and religious grounds, to give consent to the transfusions. As a result, Children's Hospital of Philadelphia filed a petition with Common Pleas Court seeking its appointment as special guardian to Tara to consent to a series of blood transfusions.

A hearing was held on March 2, 1988, in which Doctor Frempong testified that Tara's condition was consistent with other children with sickle-cell anemia who have had strokes and are not transfused, i.e., 70% of them will have a recurrent stroke and 80% of those recurrences will take place within the first three years after the initial stroke. As a consequence thereof, Doctor Frempong noted the likelihood of increased risk of crippling and mental retardation. As for the risk of death in such cases, he stated: "The risk of death is smaller in children and much higher" in adults. The "only" treatment presently available for the illness, as observed by Doctor Frempong, was blood transfusions, which, it was stated, would prevent strokes from recurring in 90% of the cases.

[ 381 Pa. Super. Page 103]

Albeit there are inherent risks in administering transfusions,*fn2 Doctor Frempong believed it "may be the best of two evils" in the treatment of sickle-cell patients. Once the tests were conducted, the doctor would have a better idea of the damage to the blood vessels in the brain, and what risks would be involved if transfusions were not ordered.

Mrs. Ingram appeared at the hearing and voiced her objections to the transfusions. Her religious ground was linked to her being a Jehovah's Witness, a tenet which does not subscribe to the use of blood in any form on the individual. As for her medical objections, she pointed to the fact that Doctor Frempong would not assure ("guarantee") her that Tara would not die immediately after the transfusions. Since she perceived her daughter to be in good health, she saw no need for the transfusions.

The court disagreed with Mrs. Ingram and permitted Children's Hospital of Philadelphia to conduct the transfusions to assess Tara's brain damage, if any. Then, once this was completed, it could be determined whether transfusions would be in order for four years or more to minimize a recurrence of another stroke.

At the follow-up hearing held on April 5, 1988, Doctor Frempong testified that the results of Tara's arteriogram indicated that she had blood vessel damage to the right and left sides of her brain. This type of damage was consistent with "sickle cell children who have had strokes." As for Tara, who clearly showed signs of "major" vessel disease, Doctor Frempong opined that the probability of recurrence of a stroke would be in the 70-80 percentile range. In

[ 381 Pa. Super. Page 104]

    regard to the risks associated with the treatment to Tara in this case, the doctor stated:

We know for a fact this child has a very high risk for recurrent strokes and that with recurrence of strokes there is more brain damage, more potential for crippling brain damage and also mental retardation . . . . [A]against all the risks, we still feel this is the best treatment available for children with sickle-cell disease who have had strokes. It is by no means the best one would have hoped for, but it is the only treatment available. (Emphasis added)

Before the court made its decision on whether to order additional transfusions, the parents of Tara were afforded the chance to secure opinions from other doctors as to alternative forms of treatment for this child. As a result thereof, a hearing was held on the 29th day of April, 1988, wherein Mrs. Ingram presented evidence from two doctors supposedly supportive of her contention that blood transfusions, and their inherent risks, were not the only means by which to minister to Tara's condition.

The first physician was a Doctor Pourfar, a hematologist residing in New York City. Mrs. Ingram and Tara visited him, and he examined the patient and her hospital records. He recommended, in his two-page hand-written letter, that transfusions should be implemented only if Tara's hemoglobin (Hb) level dropped below 7.5 grams. He noted that folic acid and aspirin should be continued to be administered to the patient.

The second doctor, one William H. Pogue, was a hematologist from New Britain, Connecticut, and he prepared a two-page typed report in which he made reference to alternative methods of treating Tara, e.g., antiplatelet agents (coumadin, aspirin and sulfinpyrazone). However, he conceded in his report that he could "find no evidence in the medical literature of any systematic study of alternative therapy." In essence, it would appear that Doctor Pogue was ...


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