Informed consent when caring for minors
Understanding the nuances of consent is critical when dealing with minors.
A Sunday Clinical Forum explored the anesthetic considerations for the teenage patient and delved into pediatric informed consent as a medical ethical issue.
Typically, parents or legal guardian are assumed to be the ones who provide legal consent for minors. Most of the time, the parents’ consent aligns with those of the medical community and have the best interests of the pediatric patient at heart. However, in some instances, they do not align.
What happens then? Dominic Carollo, MD, Ochsner Medical Center, in New Orleans, said autonomy and competence matter in those cases.
For a minor to prove competence, he or she needs to prove they have achieved sufficient intelligence to understand fully what is proposed. The criteria for testing this capacity include that the patient understands in simple terms the nature, purpose, and necessity of the procedure as well as the risks and alternatives. The patient also believes that the information proposed applies to them and is making the choice without pressure or coercion.
Although every U.S. state has variations on the point at which a minor can provide consent, Dr. Carollo said most follow the Rule of Sevens, in which if the individual is less than 7, they can’t, if they are 7-14, you can assume they do not, and if they are older than 14, you should assume yes.
In those instances, the rules for informed consent are that the patient understands the explanation of the condition, recommended treatment, the risks and benefits, and any alternatives. The medical staff should make an assessment of the person’s understanding of the provided information, the competence of the minor or surrogate to make medical decisions, and be confident that the patient or surrogate has the ability to choose freely without coercion.
Dr. Carollo said there are exceptions to informed consent such as a medical emergency or if there is reason to doubt the parents will always act solely in the best interests of the child. He said other exceptions, which were beyond the purview of the session, include sterilization, organ donation involving siblings, and abortion. These are usually state-specific.
He cited instances of refusal of treatment that might involve forced treatments. However, he warned of the long-term psychological harms of forcing treatment. In those instances, he usually postpones a procedure until he gains a full understanding of the reasons for the refusal and is able to remedy them. Legal intervention should only be used as a last resort, he said.
Dr. Carollo also reviewed which minors can provide consent. Although this varies by state, typically it is an emancipated minor, a pregnant minor, a married minor, and is dependent on the services sought.
He also defined the mature minor doctrine, which states that a minor is mature enough to make a decision if he or she is older than 14, is capable of giving informed consent, that the treatment will be a benefit and does not provide great risk, and is well within established protocols.
Even when they do not yet have the legal right to give their own consent to treatment, Dr. Carollo said he likes to approach the child first and the parent second. For instance, he finds teens are so involved in their cell phones that it is hard to get their full attention. In those instances, he asks to get his picture taken with the teen on their phones as a way of engaging them. Although they may not have the legal right to provide informed consent to their own treatment, there are notable benefits to involving them in the decision-making process, he said. It demonstrates respect for the minor and provides them power, which usually helps with outcomes.
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