Can You Recognize Munchausen's Syndrome by Proxy?

CAN YOU RECOGNIZE MUNCHAUSEN'S SYNDROME BY PROXY (MSBP)? Nurses are familiar with Munchausen's Syndrome. However, in this extraordinary Massachusetts case the courts were confronted with MSBP. The case involved a situation in which a mother (who was a licensed practical nurse) deliberately caused the long-term illness of her son.

ON MAY 11, 1990, SIX MONTH OLD KEEFE WAS HOSPITALIZED WITH VOMITING AND DIARRHEA. He had an ulcerated digestive tract. Physicians inserted feeding tubes, a G-tube which delivered nutrients into the stomach and J-tube which delivered nutrients to the small intestine, and a central line which delivered nutrients directly into the bloodstream, all bypassing as much of the digestive system as necessary. The tubes remained Keefe's sole source of nourishment until he was seven years old. Many heard Keefe say he "was hungry and wanted to eat," only to hear his mother tell him that "if he did, he would get sick." In those seven years, Keefe experienced more than thirty-eight inpatient hospital admissions. Despite a healthy immune system, he suffered from seven times the expected rate of infections in his central line according to Massachusetts General Hospital (MGH) records. These infections were caused by an "unusually large number of different organisms." The organisms themselves were of sorts not often seen in central line infections. This high rate of infection was especially noteworthy since all of Keefe's caretakers were trained nurses. He was admitted to South Shore Hospital in November of 1996 with another infection. Complications from treatment proved life-threatening. Keefe was transferred to the pediatric intensive care unit at MGH. Physicians at MGH began an extensive review of Keefe's medical history and determined that he likely was a victim of MSBP. A pediatric intensive care fellow filed a complaint with the Department of Social Services (Department). It was determined that the complaint was supported. Once MSBP was the working diagnosis, Keefe's treatment team initiated a "definitive diagnostic test." His mother's visitation was restricted and a 24-hour-a-day sitter was in Keefe's room. At the same time, all of the fifteen or twenty medications Keefe had been taking were discontinued. Within ten days, Keefe went from nothing but central line feedings to a normal diet. During these ten days, Keefe's mother refused to release Keefe's medical records from other hospitals, resisted the feeding plan, and told Keefe at every opportunity that he was "going to be sick." After he had tolerated normal food by mouth for several days with no problems, she told Keefe that coming to this hospital was "the biggest mistake we ever made." Keefe was discharged from MGH in the temporary custody of the Department directly into the foster home of his paternal aunt and uncle. He remained there for sixteen months before court proceedings. During that time, and for a total of three years, Keefe showed no sign of medical problems. The Department filed a petition in the Boston Division of the Juvenile Court to terminate the requirement for Keith's mother to consent to his being adopted. The court granted the petition. Keefe's mother appealed.

THE COURT OF APPEALS OF MASSACHUSETTS HELD THAT THE THERE WAS EVIDENCE OF `PARENTAL UNFITNESS'. Accordingly, the court concluded that there was ample evidence to support the order granting the petition to dispense with the need for parental consent to adoption. After twenty-two days of trial over the course of five months, the trial judge issued findings of fact and conclusions of law, all of which, together with 314 subsidiary findings of fact supported the evidence that Keefe's mother was not a fit parent. The court rejected the mother's contention that it was inheritly prejudicial to use "profile" testimony. Nearly twenty volumes of testimony was offered, not to prove that the mother conformed to a stereotypical "profile", but a well recognized medical diagnosis, MSBP, a relative of battered child syndrome.

A DIAGNOSIS OF MSBP IS DEPENDENT ON INFERENCES. However, the court concluded that evidence within the area of expertise of the physicians whose familiarity with numerous instances of genuine illnesses qualified them to express (with reasonable probability) that a particular illness or group of illnesses is not genuine but is instead the result of induction or fabrication of symptoms. Several other jurisdictions have admitted expert testimony concerning MSBP. Kudos to the physician who reported the suspected MSBP! Nurses as well as other health care providers should be aware of the telltale indications which lead to the conclusion that there may be MSBP. Adoption of Keefe, 733 N.E.2d 1075 - MA (2000)

Meet the Editor & Publisher: A. David Tammelleo, JD, is a nationally recognized authority on health care law. Practicing law for nearly 40 years, he concentrates in health care law with the Providence, R.I., firm of A. David Tammelleo & Associates. He has presented seminars on medical, nursing and hospital law throughout the United States. In addition to his writings as Editor of Medical Law's, Nursing Law's & Hospital Law's Reagan Reports, his legal articles have been published in the most prestigious health law journals. A prolific writer, his thousands of articles, as well as his achievements as an attorney and lecturer, have won him recognition in Martindale-Hubbell's Bar Register of Preeminent Lawyers and Marquis Who's Who in American Law.