The legal implications of physician trainees and non-physician practitioners for the emergency physician

Emergency physicians (EPs) often supervise physician trainees and non-physician practitioners (physician assistants or nurse practitioners) in the emergency department (ED). As a supervisor, the EP must guide clinical care, screen for medical acts of negligence, and promptly correct them to avoid harm to a patient. The legal liability of the EP can vary if harm is caused to a patient through the negligence of a physician trainee or non-physician practitioner. Direct or indirect (vicarious) liability may be ascribed to the ED attending physician based on his level of involvement in patient care and/or his specific role as a supervisor. Although the liability attached may be extensive, it is not limitless. The EP is most protected from an act of negligence by a physician trainee or non-physician practitioner when his level of patient contact and supervision are appropriately documented. The precise limits of liability for the EP may be defined more clearly in the future and are certain to vary between local jurisdictions.     

Ethics, law and paediatric medicine

Medicine is practised within an ethical and a legal framework. Doctors must obtain the broad consent of their patients before treatment begins, and tell them of their choices and the material risks inherent in treatment. Where children are the patients, it is their parents or guardians who must give their consent, unless the situation is an emergency or the children have been removed from parental custody and care. Today, mature teenagers may consent to their own medical treatment. Doctors must protect their patients' confidential information, however acquired. There are very limited exceptions where confidential information may be revealed, and a few where revelation is mandatory. Effective communication between doctors and their patients, or their parents, is of signal importance.     

Consent for emergency medical services for children and adolescents

Parental consent generally is required for the medical evaluation and treatment of minor children. However, children and adolescents might require evaluation of and treatment for emergency medical conditions in situations in which a parent or legal guardian is not available to provide consent or conditions under which an adolescent patient might possess the legal authority to provide consent. In general, a medical screening examination and any medical care necessary and likely to prevent imminent and significant harm to the pediatric patient with an emergency medical condition should not be withheld or delayed because of problems obtaining consent. The purpose of this policy statement is to provide guidance in those situations in which parental consent is not readily available, in which parental consent is not necessary, or in which parental refusal of consent places a child at risk of significant harm.     

Consent by proxy for nonurgent pediatric care

Minor-aged patients are often brought to the pediatrician for nonurgent acute medical care or health supervision visits by someone other than their custodial parent or guardian. These surrogates can be members of the child's extended family, such as a grandparent or aunt. In cases of divorce and remarriage, a noncustodial parent or stepparent may accompany the patient. Sometimes, children are brought for care by adults living in the home who are not biologically or legally related to the child. In some instances, a child care professional (eg, au pair, nanny) brings the pediatric patient for medical care. This report identifies common situations in which pediatricians may encounter "consent by proxy" for nonurgent medical care for minors and explains the potential for liability exposure associated with these circumstances. The report suggests practical steps that balance the need to minimize the physician's liability exposure with the patient's access to health care. Key issues to be considered when creating or updating office policies for obtaining and documenting consent by proxy are offered.     

Informed decision making and refusal of treatment

Informed consent serves as the cornerstone of modern bioethics. Ideally, patients should be provided with enough information to make informed decisions regarding proposed tests or treatment options. However, as the following cases suggest, informed consent in the emergency setting can be very difficult, because time is limited, injuries often require immediate attention, and there may be competing claims regarding who has decisional authority. What are the elements of consent? What happens when conflicts arise between pediatric patients and their parents? When should physicians treat minor patients without parental consent? This article uses three illustrative cases to explore the role of informed consent in pediatric emergency medicine.     

Passive euthanasia of defective newborn infants: legal considerations.

The recent increase in reporting of passive euthanasia of defective newborn infants has not been accompanied by extensive analysis of the legality of the practice or the appropriateness of current law. There appears to be criminal liability on several grounds for parents, physicians, nurses, and administrators. Such liability may include charges of homicide by omission, child neglect, and failure to report child neglect. Increasing public exposure of the practice increases the probability that such prosecutions may be brought. Individuals involved in such decisions should be aware of their possible legal liability. If existing legal policy is inappropriate, it sould be changed through open discussion and not subverted through private action. Two alternative policies are described: establishment of criteria for the class of infants who can be allowed to die or a better process of decision making. We conclude that a committment to process would be preferable.     

The role of the pediatrician in rural emergency medical services for children

In rural America, pediatricians can play a key role in the development, implementation, and ongoing supervision of emergency medical services for children. Pediatricians may represent the only source of pediatric expertise for a large region and are a vital resource for rural physicians (eg, general and family medicine, emergency medicine), other rural health care professionals (physician assistants, nurse practitioners, emergency medical technicians), and local emergency medical services medical directors. They can provide education about management and prevention of pediatric illness and injury; appropriate equipment for the acutely ill or injured child; and acute, chronic, and rehabilitative care. In addition to providing clinical expertise, the pediatrician may be involved in quality assurance, clinical protocol development, and advocacy and may serve as a liaison between emergency medical services and other entities working with children (eg, school nurses, child care centers, athletic programs, and programs for children with special health care needs).     

Legal basis of consent for health care and vaccination for adolescents

State law is generally the controlling authority for whether parental consent is required or minors may consent for their own health care, including vaccination. At the federal level, no vaccination consent law exists; however, federal law requires that vaccine information statements be given to the parent or another person who is qualified under state law to consent to vaccination of a minor. All states allow minors to consent for their own health care in some circumstances on the basis of either (1) their status (eg, age, emancipation, marriage) or (2) the kind of health care services they are seeking (eg, family planning services, treatment of sexually transmitted disease). In each state, a specific analysis of laws will be required to determine the circumstances under which a minor can consent for vaccination.     

Exploration for physicians of the mature minor doctrine

The "mature minor doctrine" is the common-law rule that allows an adolescent who is mature to give consent for medical care. Ethical decisions regarding consent and confidentiality should be distinguished from legal requirements. Recent court decisions have altered the law, especially in regard to consent for refusal of life-sustaining treatment. There are statutory exceptions to the rule of parental consent regarding emergency care, sexually transmitted diseases, drug treatment, mental health care, pregnancy, contraception, and emancipation. A detailed analysis of the mature minor exception is presented, utilizing court case vignettes. There is minimal legal risk in allowing adolescents older than 14 years of age to give consent for treatments entailing small degrees of risk, when they can make adultlike decisions and demonstrate signs of maturity.     

Parental presence during procedures in an emergency room: results from 50 observations

This report describes the physician-parent-child encounter during an invasive medical procedure in a pediatric emergency department. Fifty children underwent venipuncture or intravenous cannulation performed by 22 physicians and 6 nurses. The median age of the children was 12 months. Parents remained with their children during 31 (62%) of the 50 procedures. Parents were more likely to stay if they had previously stayed when this child (P = .05) or another (P = .02) had undergone a procedure. Parental decision to stay was not related to parental age, gender, race, marital status, or level of education, nor to the residents' age, gender, or level of training. Only 43% of the parents who did stay were given that option by the residents, and of those who did not stay 37% reported that physicians asked them to leave. Nonverbal cues by the residents, such as pulling the curtain closed or turning their back toward parents, were noted in 58% of the encounters in which parents did not stay. The residents and nurses indicated that parents should stay with their child for the following procedures: laceration repair, 66%; venipuncture, 58%; intravenous cannulation, 48%; arterial blood sampling, 32%; suprapubic aspiration, 20%; and lumbar puncture, 14%. In the emergency room studied, it appears that for venipuncture and intravenous cannulation, the majority of parents stay with their children. Parental decision to stay or leave is frequently made without discussion with the physician.     

Consent by proxy for nonurgent pediatric care

Minor-aged patients are often brought to the pediatrician for nonurgent acute medical care, physical examinations, or health supervision visits by someone other than their legally authorized representative, which, in most situations, is a parent. These surrogates or proxies can be members of the child's extended family, such as a grandparent, adult sibling, or aunt/uncle; a noncustodial parent or stepparent in cases of divorce and remarriage; an adult who lives in the home but is not biologically or legally related to the child; or even a child care professional (eg, au pair, nanny). This report identifies common situations in which pediatricians may encounter "consent by proxy" for nonurgent medical care for minors, including physical examinations, and explains the potential for liability exposure associated with these circumstances. The report suggests practical steps that balance the need to minimize the physician's liability exposure with the patient's access to health care. Key issues to be considered when creating or updating office policies for obtaining and documenting consent by proxy are offered.     

Parental involvement in treatment decisions regarding their critically ill child: a comparative study of France and Quebec.

OBJECTIVE: To examine whether physicians or parents assume responsibility for treatment decisions for critically ill children and how this relates to subsequent parental experience. A significant controversy has emerged regarding the role of parents, relative to physicians, in relation to treatment decisions for critically ill children. Anglo-American settings have adopted decision-making models where parents are regarded as responsible for such life-support decisions, while in France physicians are commonly considered the decision makers. DESIGN: Grounded theory qualitative methodology. SETTING: Four pediatric intensive care units (two in France and two in Quebec, Canada). PATIENTS: Thirty-one parents of critically ill children; nine physicians and 13 nurses who cared for their children. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Semistructured interviews were conducted. In France, physicians were predominantly the decision makers for treatment decisions. In Quebec, decisional authority practices were more varied; parents were the most common decision maker, but sometimes it was physicians, while for some decisional responsibility depended on the type of decision to be made. French parents appeared more satisfied with their communication and relationship experiences than Quebec parents. French parents referred primarily to the importance of the quality of communication rather than decisional authority. There was no relationship between parents' actual responsibility for decisions and their subsequent guilt experience. CONCLUSIONS: It was remarkable that a certain degree of medical paternalism was unavoidable, regardless of the legal and ethical norms that were in place. This may not necessarily harm parents' moral experiences. Further research is required to examine parental decisional experience in other pediatric settings.     

Affirming parental love in the pediatric intensive care unit.

OBJECTIVE: To argue that that there has been a remarkable absence of discussion of the importance of parental love in the pediatric intensive care literature, and that this silence has been to the detriment of both medical and nursing pediatric intensive care practice. CONCLUSIONS: Research and anecdotal literature to date have focused on the negative changes that occur in the parental role during a child's pediatric intensive care unit admission. In contrast, the love that a parent holds for his or her child is profoundly positive and stable; it is not a "role" that can be taken away or threatened. It is proposed that the recognition and acknowledgment of this love will alter the critical care encounter for parents, physicians, and nurses and result in a better understanding by the staff of parental attitudes and behaviors. This may be particularly effective in situations where it is perceived that unreasonable demands are being made for futile therapy.     

Family presence during invasive procedures in the pediatric intensive care unit: a prospective study.

OBJECTIVES: To determine if allowing 1 or both parents to be present during invasive procedures reduces the anxiety that parents experience while their child is in the pediatric intensive care unit; to evaluate if the parent's presence was helpful to the child and parent; and to determine whether this presence was harmful to the nurses or physicians. DESIGN: A prospective study using surveys (5-point Likert scale) of parents of children requiring intubation, placement of central lines, or chest tubes. Additional surveys were completed by bedside nurses to evaluate the effects of parental presence. SETTING: A 12-bed pediatric intensive care unit in upstate New York. PARTICIPANTS: The study population consisted of the parents of 16 children undergoing 1 or more procedures; 7 had undergone intubation, 11 had central lines placed, and 2 had chest tubes placed. The control population consisted of the parents of 7 children undergoing 1 or more procedures; 7 had undergone intubation, 5 had central lines placed, and 3 had chest tubes placed. RESULTS: Parental presence significantly reduced the parental anxiety related to the procedure (P = .005; Mann-Whitney test), but did not change condition-related anxiety (P = 0.9; Mann-Whitney test). Thirteen of 16 parents found their presence helpful to themselves (10 very, 3 somewhat) and the medical staff (11 very); 14 of 16 found their presence helpful to their child (11 very). Fifteen (94%) of 16 parents would repeat their choice to watch. Fifteen (94%) of 16 nurses found parents' presence helpful to the child (9 very) and to the parents (10 very). One nurse found a parent's presence somewhat harmful to nurses and very harmful to the parent. Thirteen (72%) of 18 nurses indicated that allowing parents to observe procedures was an appropriate policy. There were no significant differences noted in response of nurses based on years of experience. CONCLUSIONS: Allowing parental presence during procedures decreases procedure-related anxiety. The implications of such a policy change on physicians and other aspects of pediatric intensive care, including medical education, need further evaluation.     

Discrepancies between Physician and Parent Perceptions of Psychosocial Problems of GHD Children Undergoing GH Therapy in Japan

This study examined discrepancies between the perceptions of physicians treating short children with GH deficiency (GHD) using GH replacement therapy (GHRT) and the perceptions of the parents of these children and identified the major causes of parental anxiety. Three attending pediatric endocrinologists and the parents of 31 GHD children participated in this study. The physicians and parents completed a specially designed questionnaire to rate the types and degrees of psychosocial problems that GHD children might experience. For 6 of the first 11 questions, the physicians rated psychological problems differently than the parents did, tending to over- or underestimate parental concerns. This discrepancy did not disappear with treatment. However, the difference in the perception of anxiety between the physicians and parents changed for issues regularly discussed between them. Physicians and nurses were ranked as the most reliable providers of information. The parents of children who had previously undergone GHRT were a highly desired source of information. Psychosocial problems remain largely unaddressed by endocrinologists. Endocrinologists treating short stature are encouraged to be more involved in understanding parents’ anxieties, evaluation of misperceptions concerning parents’ expectations, and addressing these issues in future communication with parents. Support by experienced psychologists may help endocrinologists with this issue.     

Standards for clinical evaluation and documentation by the emergency medicine provider

Pediatric emergency medicine is full of challenges. When a pediatric patient has a poor outcome after treatment in an emergency department (ED), a malpractice lawsuit is likely to result. Pediatric emergency medicine (PEM) physicians might sometimes alter their medical care and practice "defensive medicine" in hopes of avoiding a malpractice lawsuit. Radiographs and other diagnostic studies might be ordered without true indications to "completely rule out" a diagnosis. This can result in excess radiation for a child. On the other hand, failure to order the appropriate study or misinterpretation of a radiographic study by a radiologist or an emergency physician can result in a malpractice lawsuit. PEM physicians must work cooperatively with radiologists to improve the care for children in the ED. Together these specialists can decide on appropriate studies for children in the ED, keep radiation exposure to a minimum and ensure proper management based on these studies.     

The suicidal pediatric patient: an emergency medicine focus

Suicide in children is an increasing concern to emergency physicians. Suicide is a leading cause of death and lost years of potential in children and adolescents. Children who are acutely suicidal often present to the emergency department for medical and psychiatric care and evaluation. This article will discuss the epidemiology of suicide in children and provide the emergency physician a framework in which to evaluate and manage children who are acutely suicidal.     

Early integration of pediatric palliative care: for some children, palliative care starts at diagnosis

PURPOSE OF REVIEW: Pediatric palliative care, with its emphasis on symptom management and quality of life, is an important aspect of care of children with life-threatening illnesses. We review recent publications with implications for care of these children. RECENT FINDINGS: Invasive and life-sustaining measures continue to be part of care for many children with life-threatening illnesses, even at the end of life. While these measures may seem reasonable when recovery is possible, they may not fit with a family's preferences for end-of-life care. One possible cause of the prevalence of invasive measures in children at the end of life is that complex illness trajectories in children make it difficult to predict the timing of death. Inadequate communication by clinicians can also lead to poor preparation for the end-of-life period. Early integration of palliative care allows for improved symptom management, parental adjustment, and preparation for the end-of-life care period. Families who have the opportunity to prepare for the end-of-life period, including learning what to expect, are more likely to feel that their care has been of high quality. Bereaved parents also recognize the value of talking about death with their children. SUMMARY: Early integration of palliative care can allow children and families to make decisions about care that fit with their values, and should become a standard of care for all children with life-threatening illnesses.     

Acute care and antibiotic seeking for upper respiratory tract infections for children in day care: parental knowledge and day care center policies

BACKGROUND: Children who attend day care are high consumers of antibiotics. Studies suggest that physicians prescribe unnecessary antibiotics for upper respiratory tract infections (URIs) for children who attend day care on the basis of perceived pressure from parents and/or day care centers. OBJECTIVE: To determine both parental and day care-level predictors of acute care and antibiotic seeking for children who attend day care. METHODS: We conducted a day care center-based cross-sectional survey of parents and day care center staff. Two hundred eleven parents of children attending 36 day care centers in Massachusetts completed a survey. Day care center staff completed a separate survey addressing their day care center's policies for ill children. RESULTS: Few parents reported day care staff pressure to seek care from a physician (3.9%) or antibiotics (1.9%). In multivariate models, higher parental knowledge about URIs was related to decreased acute care seeking for 3 upper respiratory symptoms (clear rhinorrhea, green rhinorrhea, and cough) in the absence of fever (odds ratios and 95% confidence intervals: 0.45 [0.31-0.65], 0.66 [0.52-0.85], and 0.57 [0.45-0.72], respectively). Parent-reported acute care seeking was not related to a day care center's polices for exclusion or physician clearance for these illnesses. Similar results were also found for the parental belief that antibiotics expedite return to day care for these symptoms. CONCLUSION: Although it has been suggested that inappropriate day care center policies for exclusion motivate parental acute care and antibiotic seeking, this study suggests that parental knowledge is a more important predictor of these reported behaviors than are day care center policies.     

Adolescent substance abuse. Confidentiality and consent

Although all states have laws that allow minors to consent to substance abuse treatment, there is variability from state to state. Health care providers need to be aware of laws within their states. When providing health care to adolescents, many situations arise in which the provider must make a determination of the patient's competence to consent and whether parental notification would be in the patient's best interest. Confidentiality should be honored when possible, with limitations of the extent of confidentiality explained. Adolescents are able to consent for alcohol and drug treatment in most states, but involvement of the family is optimal in most cases. Physicians and other medical care providers also need to manage confidentiality issues in drug testing, billing of services, and medical records and need to work with clinical administrative staff to clarify and implement policies to maintain confidentiality. Proposed changes to medical privacy regulations may compromise confidentiality for medical care of adolescents. Medical providers should continue to work with their professional societies and legislators to ensure that appropriate consent and confidentiality statues exist to provide optimal health care to adolescents.