PRENATAL TESTING
Who's the father?
My pregnant patient is stressed out because she isn't sure who the father of her baby is. Neither one of the potential fathers wants to get involved if the baby isn't his. Is any noninvasive testing available?-S.C., MONT.
Yes. Although paternity can be determined before birth through amniocentesis and chorionic villus sampling, these invasive procedures carry risks, including fetal loss.1 They also typically can't be used before 10 to 15 weeks of pregnancy.
With a newer, noninvasive technique, a blood sample from the mother can be used to help determine paternity as early as 9 weeks into the pregnancy, although some labs don't perform the test until 10 to 14 weeks. It also requires a DNA sample from any potential fathers, who are then "ruled out" or "not ruled out."
Studies have shown a few fetal cells enter the maternal circulation through the placental villi. These fetal cells can be analyzed for particular DNA sequences. This testing can also be used to diagnose aneuploidy such as trisomy 21 and determine the baby's gender.1 Invasive testing is considered more reliable; for instance, the blood test can't detect neural tube defects because they involve multiple genes as well as environmental factors. Any defects detected from the blood test must be confirmed by invasive testing.2
The noninvasive testing is more than 99% accurate for determining paternity.3,43,4 However, it's more expensive than postnatal testing using an infant buccal swab or cord blood. The American Pregnancy Association recommends paternity testing from a lab accredited by the AABB.3 If legal action is anticipated, it's essential to use a state-approved facility that follows strict chain of custody documentation for client identification, specimen collection, and specimen shipment. This will ensure the legal DNA paternity test results are admissible by all courts and government agencies as legal documents.
REFERENCES
1. The Internet Pathology Laboratory for Medical Education, Mercer University School of Medicine. Hosted by the University of Utah Eccles Health Sciences Library. Prenatal diagnosis. http://library.med.utah.edu/WebPath/TUTORIAL/PRENATAL/PRENATAL.html. [Context Link]
2. American Congress of Obstetricians and Gynecologists (ACOG). ACOG Practice Advisory on Cell-Free DNA Screening. 2015. http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/ACOG-Practice-Advis. [Context Link]
3. American Pregnancy Association. Paternity testing. 2015. http://americanpregnancy.org/prenatal-testing/paternity-testing/. [Context Link]
4. Ryan A, Baner J, Demko Z, et al. Informatics-based, highly accurate, noninvasive prenatal paternity testing. Genet Med. 2013;15(6):473-477. [Context Link]
RESOURCE
Guo X, Bayliss P, Damewood M, et al. A noninvasive test to determine paternity in pregnancy. N Engl J Med. 2012;366(18):1743-1745.
FAMILY CONFLICT
Nurse bears the brunt
I'm a retired RN. My mother has been living with me for the past 4 years because she needs help with meal preparation and medication administration. I recently called a family conference with my three siblings because I want to get their help now and plan for her care in the future (I'm 72). But when I asked for their suggestions, they said, "You're a nurse. What do you suggest?" How can I get them to take on their fair share of the caregiving duties?-A.S., N.C.
You're in a tough position, but the good news is that your family looks up to you and respects your nursing knowledge.
Sometimes it's hard for nurses to ask for help because they're so used to being in the caregiving role. It may be time for you to step up to a leadership role in your family. You may need to tell them the specific help you need. For instance, you could say, "I need someone to stay with Mother two nights a month so I can go out with friends. I need someone to bring us a meal once a week. I need an occasional weekend or week off; can someone stay with Mother, or do you all want to help pay for respite care?" You could ask someone to research and visit long-term-care facilities and explore home care options in case you become ill or have another emergency. Don't be afraid to ask for specific help so you don't burn out. Everyone will benefit.
HIPAA FACTS
Weighing privacy and mental health concerns
My patient Mr. T, 36, has schizophrenia. He won't give permission for his healthcare team to share information with his family. What options do his family members have if they're concerned about Mr. T's mental health? Can the family share relevant information about Mr. T with us?-D.B., WASH.
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits a healthcare provider to disclose information to the family members of an adult patient who has mental capacity and indicates that he or she doesn't want it disclosed-but only if the provider perceives a serious and imminent threat to the health or safety of the patient or others and the family members are in a position to lessen the threat. Otherwise, under HIPAA, the provider must respect the wishes of the adult patient who objects to information being disclosed.
On the other hand, HIPAA doesn't prevent healthcare providers from listening to family members or other caregivers who are concerned about the health and well-being of the patient. The healthcare provider can take the information shared into account when caring for the patient.
If Mr. T later requests access to his health record, any information disclosed to the provider by someone else who isn't a healthcare provider that was given under a promise of confidentiality (such as that shared by a concerned family member), may be withheld from the patient if the disclosure would be reasonably likely to reveal the source of the information. This exception lets family members disclose relevant safety information with healthcare providers without fear of disrupting the family's relationship with the patient.
Source: U.S. Department of Health and Human Services. Health information privacy. HIPAA privacy rule and sharing information related to mental health. http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/mhguidance.html.