Ho spit al Pl ay Speci ali st C a se Stu dy No .4

A Case Study: A 7-year-old Male
Who Refused Laser Therapy under General Anesthesia- Through Collaborative Work with Other Healthcare Staffs Hideko

Konagaya*I. Introduction
One of pedatric treatments that the department of our plastic surgery practices is laser therapy
used for treating dermal melanocytic nevi including aberrant mongolian spot. The difference of thetreatment from the other is that it is practiced rather for a cosmetic reason than for a therpeutic
reason so that the treatment is often proceeded due to requests from child’s parents who areconcerned about the child’s well-being otherwise. A period of the treatment may take years.
Numerous times of treatment can be required sometimes.
Many patients start the treatment when they are still infant and it usually is planed to complete
before they start going to elementary school. Since a treatment period can be very long, treatments
corresponding to the level of one’s development are required over time. A 7-year-old male, K-kun,
was one of those patients and eventually he started refusing to take the treatent strongly. His
treatment began when he was 5 years old. He had done four treatments but started refusing fromthe third one. It took more than half an hour to convince him to enter a treatment room at the
fourth treatment.
Children grow up everyday. As K-kun developed, it appeared that there was changes in the levelof his understanding and his way of thinking that eventually led to the “rejection” toward thetreatment. In our hospital, staffs of the periatric ward including hospital play specialists(hereinafter referred to as HPS) and of the surgery room work together for children and tehirfamilies. A couple weeks prior to one’s hospitalization, HPS staffs practice pre-surgery preparationand hospital tour for the purpose of supporting a child who is planned to stay in hospital.
Because of such work of HPS, it is assumed that children who will stay in hospital alreadyunderstand their surgeries and hospitalization to a certain extent and they are more or lessmentally prepared. It was, however, that the importance and necessity of individual preparationconsidering the developmental phase of a child for cases like K-kun who had to repeatedly undergo
treatments had been overlooked. There was a discrepancy between K-kun: “I don’t need thetreatment anymore” and his parents: “the treatment will make his skin look better and it is for his
future”. The department of plastic surgery, of pediatrics, of anasthasia, the surgery room, ourperiatric ward and HPS worked together in this case to come up with a method to respect the
feelings of both K-kun and his family regarding the treatment and decisions that eventually weremede by K-kun himself. The procedure and the result are reviewed in this report.
II. Case Summary
Subject: K-kun (7-year old male)
Name of disease or symptom: Aberrant mongolian spot in his left chest
Treatment: Laser therapy under general anasthesia
Proposed frequency of treatment: 6 times in total. 4 out of 6 had been already practiced (the1st treatment; August XXXX(year), the 2nd; October, the 3rd; December, the 4th; August
XXXX)
5. Period of hospitalization for this time (for the 5th treatment): From December xx(date),
XXXX(year) to December xx (three day in total).
6. Development: Appropriate for his age
7. Family members: Father, Mother, Brother (5-year old), Grandfather

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KONAGAYA：A Case Study: A 7-year-old Male who refused Laser Therapy under General Anesthesia

8. Previous history and status: A preparation for pre-surgery was given with his mother. K-kun
was not expressive and seemed very nervous. The first day of his hospitalization for the firsttherapy, he visited to a playroom with his mother 3 hours after the admission. Though hismother initially prodded him to play on the first day, he became used to the playroom a little
by the following. He went back and forth between his room and the playroom on his own. On
the day of the 1st laser therapy, he did not seem refusing to go to the therapy room though helooked nervous when he left his room. 5 hours after the therapy, he visited to the playroom
with his mother and played game even with a smile on his face.
At the 2nd therapy, though K-kun seemed relaxed as he enjoyed palying right after headmitted to hospital, he muttered “no” with a grim look when he left his room to the therapy
room. He entered the therapy room while his mother was prodding him.
At the 3rd therapy, though he was active in playing, he raised his voice and said “I’m fed up
with it. Mom, you go ahead and do it!” and it took time for him to move forward. As you may
see, the more he repeated the procedure, the more he was able to focus on playing, but themore aggressively he refused to take the therapy.
III. Result
１．The 4th treatment
At the time of his admission, though he seemed a little nervous, he enjoyed creating decoration
seals in the playroom to put them around his bedside. He played actively with creating seals, a toy
sword, handicrafts with sea shells, and games. He requested “I want to do a lot of handicrafts” soonafter he came into the playroom.
On the day of the therapy, he refused to stand up by saying “ I don’t want to do it” when a nurse
came to take him to the thrapy room. He cried out in front of the thrapy room and said “ I don’t
mind not having good-looking skin. It is my mum who just wants me to do it. I don’t want to do it
anymore”. His mother pasuaded him by saying “I want you to do it. Please. I’ll come to pick you up
right after when the therapy is over”. He barely walked into the therapy room.
When the theapy was finished, his attending doctor removed a respirator when his mother waspresent in the room. For that procedure, there was an agreement between the doctor and themother beforehand. His mother was called by the doctor and she woke up K-kun. K-kun and his
mother then went back to his room together. His mother later told HPS that K-kun was talikng in
his delirium “I want to go to the playroom”.
On the day of leaving hospital, K-kun, his mother and HPS were talking about the current
hospitalization together. During the hospitalization, K-kun made his own Kiwanis doll with a little
monster face. Regarding the therapy, he said “ I just remember the time when I was playing.
Otherwise I don’t remember anything. I don’t know. I don’t remember”. His mother commented “Ireally appreciate the doctor for letting me be with him before he woke up in the thearpy room. So I
was able to keep the promise with my son. I was glad when he said to me “mum..” as he was waking
up”.
２．The collaborative work of healthcare staffs for the 5th therapy
On November xx (date), XXXX (year), HPS had a talk with his attending plastic surgeon at his
request regarding how we should approach to K-kun for the forthcoming treatment. HPS suggested
that the attending doctor directly tell K-kun about his current status and any further treatment
since his parents strongly felt the necessity of the treatment. His attending doctor mentioned that
he was going to suggest K-kun’s parents to contimue the treatment after taking some interval
depending on the K-kun’s condition and that he would refer them a pediatrician in the same

KONAGAYA：A Case Study: A 7-year-old Male who refused Laser Therapy under General Anesthesia

hospital for the second opinion about K-kun’s treatment.
When the parents visited the referred pediatrician, the parents told the pediatrician thatnebulizer was applied to K-kun for his asthma when he was 3 years old, and since then he hadrefused to put on a mask. The pediatrician told K-kun’s parents that it was not recommended topress K-kun to take the treatment against his will since it could affect his development. K-kun
always said “I don’t like the mask for anesthesia”, “I don’t care whether I take the therapy or not.
Mum, you decide”. Eventually parents decided to let K-kun take the total of 5 treatments. Though
the initial schedule was 6 in total, they revised it and there would be only one more therapy left.
3. The 5th therapy
1) Day 1 (The first day of hospitalization)
K-kun visited to the playroom right after he admitted to the hospital. He was proudly said “Hi, I
came here again because there would be two more therapies for me. Well, no, it’s not true. I was toldthat the doctor would finish everything this time even though there actually were supposed to be
two times left”. Regarding types of play in the playroom, he said “I want to make a cage for insects,
like for beetles and grasshoppers” and he seemed highly-motivated to play.
It was however, that he became anxious when a nurse came to take him to the therapy room. He
refused to stand up when he was asked to choose the scent of a mask. He said “Please sak my mum.
I choose whatever she chooses”. He eventually answerd “Sicne mum said I should choose
myself…I’d like (the scent of) pudding” after his mother’s nudge. The attending pediatrician
informed K-kun and his mother that a practice for intravenous access would be provided at 8:30 in
the following morning.
When HPS was about to leave his room in the late afternoon, K-kun said to HPS with smile“Don’t be late tomorrow. If you are late, I’ll run back home and blow up my house. OK?”. Whileobserving K-kun who acted silly, mother told us “He has been nervous for the last few days and yes,definitely he dislikes the mask, but he was looking forward to playing in the playroom”.
Further, a change in some part of procedure was informed to K-kun and his family. It was toreduce the distress of K-kun who did not like the mask for anesthasia. The revised procedure wasthat nurses of the therapy room, an anesthesist and a plastic surgeon would visit to K-kun’s room inorder to apply anesthetic agent to him through an intravenous drip. Later, his mother informed HPSthat K-kun was very pleased about the procedure change.
２）Day 2（The day of laser therapy）：
At 8:10 a.m., right after HPS arrived, K-kun came into the playroom by saying “good morning”
with a lively voice. As promised in the previous day, K-kun played a game with HPS but he seemed
restless. HPS showed him a watch and told him that a strow (intravenous line) for water(intravenous drip) would be introduced to his arm at 8:30. K-kun asked to HPS “Which arm do theyuse?” He told HPS “I drew a picture yesterday” and showed his work (Pic. 1). He drew a rabbit that
seemed being crying. K-kun explained to HPS “The color was dripped down somehow…”
During the procedure of intravenous access, K-kun was sitting on his mother’s lap while having a
distraction with pictorial puzzles. He did not even move during the procedure and did it well since
he focused on the puzzles so well. When nurses praised him after the procedure, he smiled shyly.
He then went straight back to the playroom and chose to create diorama of an insect cage before theactual laser therapy. He was not restless unlike that morning and he was happily talking about
larvae of his favorite beetles (Pic. 2).
While he was making the diorama, he was called for anesthetic procedure. He went to the room ina positive manner and lay on the bed on his own. He fell asleep after the administration of sedative
agents by an anesthesist. He was, then taken to the therapy room. After the therapy, K-kun cameover the playroom with his mother. Though he was trying to cotinue creating diorama that he wasKONAGAYA：A Case Study: A 7-year-old Male who refused Laser Therapy under General Anesthesia

doing in the previous day, he was not able to do it very well since he felt pain at the radiated part ofhis body. Because K-kun wished to complete the diorama by the following day, HPS promised him toprepare an instruction how to make it. Then he seemed relieved and started playing a ball game.
3) Day 3 (The day of leaving the hospital)：On the day of leaving the hospital, it seemed that K-kun could not wait for HPS arriving in themorning. He entered the playroom at the same time when HPS entered. He said to HPS “I’d better
make something for my brother..” and started creating a beetle with play dough as a souvenir for
his younger brother. He also played with his favorite games.
Regarding the therapy, he said to HPS “Everything was fine because there was no mask”. HPS
replied to him “Well, now you completed the therapy. Thank you for your cooperation even though
there were things you did not really like. I’m glad that it’s all over”. Then he looked down on thefloor and said to HPS in a caring manner “But who knows? I may come back here again. I may takethe therapy again”. He did not make a Kiwanis doll this time. He said to HPS “My brother will be
sad if I bring back only my own doll”.
His mother reflected the present procedure and said to us “Actually we had no worries for him as
we were convinced that the therapy had nothing but good consequences for him. We did notunderstand initially why we were required to receive the second opinion from the pediatrician. But
we were stunned to hear that there would be a risk of some adverse developmental outcomes. I
really appreciate that many doctors were involved in my son’s therapy and discussed the best way
together. We have nothing left to desire when we leave here”. Before leaving the hospital, K-kun
was reluctant to go home and wanted to continue playing games by saying “Oh, wait! I just want toplay this game!” Eventually his parents gently pulled him away and left hospital together.

Picture 1．A play during hospital stay（image）

Picture 2. A play during hospital stay（image）

KONAGAYA：A Case Study: A 7-year-old Male who refused Laser Therapy under General Anesthesia

IV. Discussion
K-kun’s strong rejection toward his 4th laser therapy was considered as a protest.
Despite his refusal, the therapy was to be continued. Article 18 of The United Nations
Convention on the Rights of the Child states that “Parents or, as the case may be, legal
guardians, have the primary responsibility for the upbringing and development of thechild”. In Japan, the above article is interpreted as that parents have the primary
responsibility for rearing a child with good intentions and parents are the ones who are
to be decision-makers for the child.
In western countries however, the will of a child shall be respected except someemergency cases and any procedure can be canceled if the procedure is found against thechild’s will at any moment.
Ogawa (2010) states that “The structure of adecision-making process in pediatric care can be complicated since there may bediscrepancies in opinions among three parties (parents - a decision-maker; a health careprovider - the one who performs what has been decided; and a child – a receiver of theresult of the decision).
Since the laser therapy required only a short-stay in hospital (for a few days),healthcare staffs may have overlooked the will of K-kun. Further, since the therapy wasa repetitive process, it was also considered that K-kun and his family had assumed they
already understood the process. At the age of 5, when K-kun started his therapy, a childhas a full of imagination and tends to misunderstand things easily. People around K-kun
should have provided more opportunities for him to express his feelings back then.
At the 4th therapy, K-kun made a Kiwanis doll with a monster’s face. He smarked
when he saw his mother’s shocked look and it could be his hidden desire to upset his
parents at the time. One of reasons that he refused to put on a mask could be caused bya negative experience of having a nebulizer when he was 3 years old. If that information
was given earlier, we could have avoided his strong rejection much earlier.
It is important for HPS to work with health care providers of other depertments on aroutine basis and to share aquired children’s information through playing with them.
For K-kun’s case, because the attending plastic surgeon asked for consultation from
HPS regarding the forthcoming therapy, sharing information between HPS and otherdepartments was realized. As a consequence, each department brought up ideas for
reducing K-kun’s distress based on their specific knowledge and information. Eventually
not only K-kun and his family but also all staffs of involved departments together
overcame the situation. Considering above, one of our important roles is, therefore, toprovide an opportunity for families to make an optimal decision for their child.
As a conclusion, though a series of the laser therapy was a hard experience for K-kun,
he truly enjoyed his playtime in the playroom, sometimes with his family, just like anyother 7-year-old child. We first met him when we provided a pre-surgery preparation.
Though it was only 20minutes session, K-kun grasped the idea of the importance ofself-expression and securing his own space through our introduction including
information on play and showing his room in the hospital. In the end of his stay he said
to HPS “I may come back here again” that can be a proof of the trust relationshipbetween him and us. For the future, a preparation model that meets a various changes

KONAGAYA：A Case Study: A 7-year-old Male who refused Laser Therapy under General Anesthesia

in children’s development shall be established in cooperation with other departments.
References
Rei Ogawa. (2010). Parental Decision Making in Children's Healthcare：A Concept
Analysis. Journal of St.Luke’s Society for Nursing Research, vol.14, no. 2
The United Nations Convention on the Rights of the Child. The Japan Committee for
UNICEF, transl.
The United Nations Convention on the Rights of the Child. World Vision Japan, transl.