Question re: seeing pediatric patients

Esme12, ASN, BSN, RN · Dec 6, 2011

http://windsports.com/waivers/medical_release.pdf

as a general rule, parents have the right to make decisions about the health care services that their minor children do or do not receive. (the legal definitions of "minor" and "child" vary from state to state. emergency professionals are expected to know their state's definitions.) this authority derives from the more general authority that parents have over their children to decide things, large and small, such as where they will live, what they will eat, where or whether they will worship, and whether they will be educated in public or private schools.

minor children do not have the right to make the very same decisions about their own health care. if they rebel at the idea of inoculations, surgery, or orthodontia, their parents have the authority to impose such things on them anyway-along with religion, schooling, spinach, and ballet classes instead of television-if that is the parental choice. these, of course, are general rules, and as the term suggests, there are a number of exceptions to these rules, as well as broad limitations on parental authority.

such control ends where child abuse or neglect begins-a rule simpler to state than to define but worth noting nonetheless. parental authority also gradually diminishes as the child's capacity to make responsible decisions increases, not only as a matter of law but also as a practical matter. and, without a parent to make a necessary decision when one must be 'made immediately to avoid harm to the child, necessity dictates that decisions be made by others, on behalf of the parents, for the benefit of the child. sometimes this authority is expressly delegated, such as when a parent enrolls a child in a boarding school; at other times it is implicitly delegated, such as when the child is in the custody of a baby sitter, relative, or neighbor.

the law requires that parents make decisions that are in the "best interests" (however vaguely defined the term may be) of their children. anyone acting in place of the parents, whether selected by them, imposed by the state, or resulting from circumstance, is required to be guided by the same standard.

informed consent requirement

when a person being treated by a physician is an adult, the administration of treatment without that person's consent is a legal wrong-specifically, a "battery." the physician may be liable to the patient not only for any harm that may have been occasioned by the treatment, but also, even if there is no harm, for the act of non-consensual treatment which is regarded as a legal injury (though the damages awarded may be nominal). further, even if consent is obtained, it is not legally effective if the physician has not explained, before treatment, the relevant therapeutic or diagnostic options and the risks and benefits of each-that is, if the physician has failed to obtain "informed consent. failure to provide required information is a type of negligence for which damages may be imposed if the patient is injured and if treatment would have been refused had proper information been provided. the same is true in the case of a minor child, except that it is a parent, rather than the child, who must be informed and who must give consent before treatment is rendered.

there are a number of situations in which, depending upon the nature of the situation, one or both of the legal requirements to disclose pertinent information and to lain consent may be disregarded. the relevant exception examined here is for medical emergencies. the rationale for non-disclosure or not obtaining consent in an emergency that any delay could seriously compromise the health or life of the patient. if the patient is unconscious, consent can and should be sought from (and disclosure made to) patient's legal representative, if taking the time required to do so will not jeopardize the patient's well-being. if the patient is conscious, but time is still critical, there may be situations in which consent should be sought from the patient but no disclosure made. if, however, there is adequate time to make disclosure and obtain consent without serious jeopardy to the patient, informed consent must be obtained; for legal purposes, it is not "emergency."

consent for minors

treatment in a hospital ed often falls into the gray area between emergency and elective procedures. in such situations, common sense should rule but often does not, especially in the treatment of minor children. children are, by hospital policy, often kept waiting for hours until parents at work or who are traveling can be contacted to authorize treatment. sometimes, parents cannot be located even after monumental efforts, so consent is obtained from a distant relative on two common, but often mistaken, assumptions: (a) that consent from some relative is an absolute prerequisite to treatment unless the child will die without it, and (b) that the consent of a relative is acceptable.

in fact, hospitals need only make reasonable efforts to obtain parental consent and then render the "standard of care" standard, accepted medical treatment for an injury or suspected injury to the child. furthermore, obtaining consent from another relative will not shield the hospital or the physician from liability if they render standard or nonstandard treatment in a negligent manner.

consent for minors

a. parental consent is not required for emergency treatment.

b. state laws may allow minors to be treated for venereal diseases, drug and alcohol abuse, mental illnesses, and rcproductive matters without parental consent.

c. mature minors may authorize their own medical treatment. (emancipated minors and/or seeking std treatment or birth control/pregnaqncy)

the key here is to never "delay treatment" if it is truely an emergency and as long as every "reasonable attempt" to obtain consent was tried, in most states "implied consent" prevails. know your individual state laws.

Editorial Team / Moderator · Dec 6, 2011

And please quote your sources ...

http://www.galenpress.com/extras/extra21.htm

Altra, BSN, RN · Dec 6, 2011

This is an offshoot of another thread discussing an NP's experience treating a pediatric patient accompanied by a grandparent in an office setting.

If I am reading the OP's question correctly, it does not concern the legalities of treating minors without parents/guardians present, but whether or not the familial but non-parental adult present with the minor has the right to seek medical evaluation and treatment. And the unspoken element here is that doing so may incur financial obligations for the non-present parent.

Speaking strictly from an ER point of view ... I would think that EMTALA overrides these concerns. We are required to evaluate all presenting patients. Things may get a little more dicey in urgent care, clinic and office settings not bound by EMTALA, and I'm sure there are ANers who can address that situation better than I can.

Having worked in 3 different ERs with very different demographics ... I think that in practice, the prevailing attitudes of the region determine how aggressively parental consent is pursued. In the urban ER where I work now pediatric patients present frequently with extended family members and sometimes with adults whose connection to them is pretty convoluted. Obtaining parental consent is often just not feasible.

Double-Helix, BSN, RN · Dec 6, 2011

If a child is brought to you in an emergency situation, you're obligated to provide treatment regardless of who is bringing the child in. Just like an emergency in the hospital, you don't need a parent to consent to emergency treatment. I do believe that it's standard to take the name and contact information of the person occompanying the child. Of course, that name could be compared to the child's name, but it's not uncommon for parents to have different last names.

In the urgent care centers that I have been to, I was asked to sign a consent for treatment. Children would need the same form signed. I don't know the exact wording, but I believe the adult would have to sign that they are the guardian of the child, authorized to make health care decisions. If that document is signed falsely, it becomes the legal problem of the adult, not the urgent care center.

In the case of a doctor's office, if the child has been to the doctor's office in the past, the office should have record of who the parents are and would know that the adult who brought the child in is not a parent.

If you know that the accompanying adult is not the parent, then (I'm not sure on this) you would need to try to reach the guardians and obtain consent for treatment.

Even in the Peds ICU, we don't require proof that the parent is the parent, such as a birth certificate. Once the parents signs the consent form, we trust that they are the legal guardian.

Esme12, ASN, BSN, RN · Dec 6, 2011

And please quote your sources ...
http://www.galenpress.com/extras/extra21.htm

I always do:o, it was at the top with the example for parental consent to treat and I didn't check to see if it attached.....thanks!

jenfromjersey · Dec 6, 2011

My hospital has a detailed policy specific to minors presenting for treatment in the ED. We are obligated to provided emergency life saving care regardless of consent when the situation is warranted. However, if a patient presents with a non-life threatening injury without a parent we cannot provide care until a parent is reached and gives consent. Grandparents, aunts, uncles, babysitters, siblings all come with children requesting treatment for minor injuries and unless they have legal proof of guardianship in hand we do not treat. In my experience, most foster parents and school employees know the drill and come with the correct paperwork in hand. It's usually the family members that don't. We must locate the legal guardian of the child, name and phone number and document that verbal consent was obtained. (Now, granted, I have questioned at times that we are not proving that we are actually speaking with the real parent by calling a number provided and asking for someone whose name was provided to us) We also request that verbal consent is acceptable to start to treat but that mom or dad needs to come in to actually sign for the discharge papers and obtain instructions.

EMTALA only requires that a medical screening exam is completed, not that care needs to be provided in a non life threatening situation. We will triage the patient, obtaining a medical history including medications and allergies and vital signs along with a presenting complaint. If the patient is deemed non-urgent then they will not be brought back until parental consent is obtained.

I have had patients admit that their parents were unaware they were at the ER as they were doing something they weren't supposed to or somewhere they shouldn't have been. Also, non-custodial family members may not want the parent to know that the child was hurt while in their care. We do not want to facilitate any deception.

CompleteUnknown · Dec 6, 2011

OP, this is a really interesting question for me as I'm a grandmother myself and it's something I hadn't really thought about before. If I was looking after my grandchild for the day, say, and I felt she needed to be seen by a doctor, I would take her to the doctor. I know where my daughter goes when the kids are sick, but I don't actually know which doctor she sees. The records would be there though but how would they know the child was who I said she was? (Actually, unless you've been to the doctor so often that everyone knows who you are every time you walk in the door, how do they know for sure it's the mother with the child when it actually IS the mother?)

However, if I couldn't get in there on that day I would go somewhere else. I don't know how it would work here in that situation (I'm not in the US so the financial side of it wouldn't be an issue) but it raises some really interesting questions. I'd imagine the doctor would want to check with the parent by phone but it's quite possible that the parent may not be near a phone, didn't have their phone with them, etc.

Hopefully, common sense would prevail and the doctor would see the child and prescribe appropriate treatment. Maybe I should find out for sure in case I ever find myself in a situation like this!

noahsmama · Dec 7, 2011

I'd imagine the doctor would want to check with the parent by phone but it's quite possible that the parent may not be near a phone, didn't have their phone with them, etc.
Hopefully, common sense would prevail and the doctor would see the child and prescribe appropriate treatment. Maybe I should find out for sure in case I ever find myself in a situation like this!

Your daughter should make sure she has her phone with her if at all possible when her child is in your care. If you're really concerned about this issue, you could also have your daughter write a letter stating that she gives you her permission to take her child to the doctor to seek and receive treatment if, in your judgement, this is necessary, when she leaves the child in your care.

tryingtohaveitall · Dec 7, 2011

In my pediatric facility if we have a non-custodial parent or family member bring a child in and we can't reach the parent/guardian by phone, we obtain administrative consent until the parent can be reached.

Of course, in an emergency, treatment is never delayed but staff contact administration ASAP for the consent. This happens frequently in the event of accidents or where a child is brought in by helicopter or ambulance without parents.

CompleteUnknown · Dec 7, 2011

Your daughter should make sure she has her phone with her if at all possible when her child is in your care. If you're really concerned about this issue, you could also have your daughter write a letter stating that she gives you her permission to take her child to the doctor to seek and receive treatment if, in your judgement, this is necessary, when she leaves the child in your care.

I'm not really concerned about it, it's just one more thing in a long list of things that could possibly happen. :)

It's an interesting topic though, not so much for emergency life or death things, more for fairly urgent things that probably could wait, but it would better not to, if you know what I mean. Good idea about the letter, but then again, I could write it myself, who would know?

I remember working in the ED, years ago, and a child was brought in with quite a bad chest infection. The child was crying, and saying "Mummy, mummy, mummy". A few of us were suspicious as it seemed to mean "I want mummy" rather than normal distress caused by feeling miserable. Turns out that the woman with the child was in fact her mother, but really, how would you know?

AngelfireRN, MSN, RN, APRN · Dec 7, 2011

In regard to this, and with respect to the financial obligation to the non-present parent (the offshot thread was one I started, BTW, lol)...this particular patient was not insured. Nor did she have regular pedi wellcare checks, she did have a PMD but the one that she was supposed to be seen by "they didn't like". I got to hear all about it.

From what I was told, there was insurance available for the kiddo through an employer, but the parents would not make arrangements for it due to cost. And I got to listen to a diatribe on the unfairness of the government, because the state in which the child lives refused to approve her for its version of Medicaid/Allkids, etc., since she did in fact have the opportunity for insurance to be made available. Therefore, no insurance, This was purely a choice made by the parent, was my understanding.

So, no potential for financial burden on the parent. Gm stated several times "I said I'd pay for it. I paid for her to be seen. I paid $80 for you to tell me to treat this with OTC crap." Nope, no financial burden to the parent at all, lol.

As far as legality, I did not get the impression that the GM was circumventing, more that the mother did not want to be bothered with having to take the kiddo to be seen (and truly, she did not require a doc visit, but I'm not going there).

I do wonder though, if a non-custodial adult brings in a minor child for suspicion of abuse, how is that handled? If the suspected abuser is a custodial figure, naturally they would not consent to treatment or eval. What would be the best course of action at that point. I would assume a call to authorities, but would that occur before or after examination, and is it different according to state?

Never had it happen, and hope I never do, just curious.