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.     

Overcoming legal obstacles involving the voluntary care of children who are separated from their legal guardians during a disaster

A large-scale disaster may separate children from their parents or guardians and may strand many children in the care of temporary caregivers, including physicians and nurses. In general, unless a physician or nurse is a member of a public sector emergency response program (a "VHP"), parental consent is required for the treatment of minors outside of an emergency department unless the minor is suffering from an imminently life-threatening condition. Physicians or nurses who are not VHP's may be held liable (civilly, criminally and administratively) if they provide care without parental consent outside of an emergency room to a child who is not suffering from an imminently life-threatening condition. The existing rules regarding parental consent would, in many cases, limit (or at least discourage) the provision of optimal health care to children in a large-scale disaster by restricting care aimed to alleviate pain, the treatment of chronic conditions as well as the treatment of conditions, or potential conditions, that could worsen or develop in the absence of treatment.Additionally, "Good Samaritan" laws that generally limit the liability of health care providers who voluntarily provide care in an emergency may not apply when care is provided in a crude or makeshift clinic or when care is not provided at the scene of the emergency. Thus, benevolent physicians and nurses who voluntarily provide care during a large-scale disaster unjustly risk liability. The prospect of such liability may substantially deter the provision of optimal medical care to children in a disaster. This article discusses the shortcomings of current laws and proposes revisions to existing state laws. These revisions would create reasonable and appropriate liability rules for physicians and nurses providing gratuitous care in emergencies and thus would create reasonable incentives for health care providers to deliver such care. ("Gratuitous care" is the legal term for care provided voluntarily and without expectation of payment.).     

Parent salvage and parent sabotage in the care of chronically ill children

Adaptive parental behaviors produced from dealing with prolonged illness may sabotage medical care of the chronically ill pediatric patient. Such parental behaviors may be the result of unsuccessful intrapsychic or interpersonal salvage operations in the response to the strains resulting from illness in their child. They may resemble psychopathology, but actually can be reversible. Five cases are presented to illustrate differential diagnosis of parent difficulties ranging from adaptive strain in normal parents to Munchausen's syndrome by proxy in parents of children with chronic illness. A typology of parent-child pathology in health and chronic illness is presented. The literature is reviewed, diagnostic features are elaborated, and management strategies are suggested.     

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.     

Munchausen syndrome by proxy presenting as a developmental disability

Munchausen syndrome by proxy (MSBP) is a form of child abuse in which a parent falsifies illness in a child by fabricating or producing symptoms and presenting the child for medical care while disclaiming knowledge as to the cause of the problem. This report presents the case history of a child diagnosed with MSBP who was portrayed as having multiple developmental disabilities by her mother. Three elements of the case are noteworthy. The emphasis by the mother on multiple developmental disabilities has not been reported. The complexity of this case is unusual and may reflect the complexity of the mother's psychopathology. The interdisciplinary team evaluation was instrumental in making the diagnosis.     

Preadoption opportunities for pediatric providers

International adoption pairs the most vulnerable and high-risk pediatric population with the lowest risk parent group. International adoption also presents unique and rewarding challenges for primary care pediatricians. After receiving information from the medical reviewer, a parent must determine whether or not this child is "their child." The position of the medical reviewer is to provide the family with as much information as possible about the health status of the child by explaining the terminology in the report and assessing the photograph or videotape. It is also the reviewer's job to guide the parent's expectations of the adoption by explaining the inherent differences in the development of children in institutions. In the preadoption phase, we must remember that our ultimate goal is to aid in the permanent placement of a child with a family that has realistic expectations and is well prepared to aid that child to reach his or her fullest potential.     

Munchausen syndrome by proxy: an outpatient challenge

Primary health care providers are well aware of the physical findings that suggest a child has been intentionally maltreated. Practitioners must also be aware of a more subtle form of child abuse in which the parent victimizes the child by presenting fictitious medical history that initiates a sequence of unnecessary diagnostic and therapeutic interventions. A 4 1/2-year saga of such a case, an example of Munchausen syndrome by proxy in the outpatient setting, is reported.     

Dealing with the parent whose judgment is impaired by alcohol or drugs: legal and ethical considerations

An estimated 11 to 17.5 million children are being raised by a substance-abusing parent or guardian. The importance of this statistic is undeniable, particularly when a patient is brought to a pediatric office by a parent or guardian exhibiting symptoms of judgment impairment. Although the physician-patient relationship exists between the pediatrician and the minor patient, other obligations (some perceived and some real) should be considered as well. In managing encounters with impaired parents who may become disruptive or dangerous, pediatricians should be aware of their responsibilities before acting. In addition to fulfilling the duty involved with an established physician-patient relationship, the pediatrician should take reasonable care to safeguard patient confidentiality; protect the safety of the patient and other patients, visitors, and employees; and comply with reporting mandates. This clinical report identifies and discusses the legal and ethical concepts related to these circumstances. The report offers implementation suggestions when establishing anticipatory office procedures and training programs for staff on what to do (and not do) in such situations to maximize the patient's well-being and safety and minimize the liability of the pediatrician.     

À propos d’un cas de syndrome de Münchhausen par procuration à expression psychiatrique

The factitious disorder by proxy or syndrome of Münchhausen by proxy is the production of symptoms to a child by a mistreating adult who wishes to play the sick role through this child. This syndrome is a child abuse where the care system is instrumented. The medical profession becomes itself maltreating by scheduling more and more invasive additional examinations: the mortality would be 5 %. The symptoms most frequently presented to the paediatricians are sleep apneas and convulsions. The disease by proxy questions the clinicians in front of its unusual form and its absence of anatomoclinical parallelism. If all somatic symptoms were described, forms of artificial disorder by proxy with psychiatric expression are probably underestimated. After a review of the literature on the syndrome of Münchhausen by proxy on one hand and its psychiatric expression on the other hand, we shall explain a clinical case illustrating this atypical presentation. The psychotic symptoms adduced by the mother were able to be thwarted during an observation in protected environment which is ended the medical nomadism. The diagnostic of factitious disorder by proxy is very complex. The child can present an authentic psychiatric disorder establishing a differential or tangled diagnosis. On the other hand, the complications are numerous. The victim can develop psychological aftereffects of this child abuse like behavioural problems. The child can even secondly participate to the presentation of the symptoms in a morbid alliance with the simulated parent. We shall return on diagnostic and therapeutic measures of care to offer to the maltreated child but also to the parent too, whose psychopathological determiners will be useful to clarify.     

Relational Aspects of Parent and Home Health Care Provider Care Practices for Children With Complex Care Needs Receiving Health Care Services in the Home: A Narrative Review

Children with medical complexity have ongoing health needs that may require dependence on medical technologies. While hospital admissions are an important focus of care delivery for these children, a majority of the time they are cared for in their own homes. Parents’ report feeling overwhelmed and stressed by the scope of their responsibilities, but they become sophisticated care providers and assume greater authority when providing their children's care at home. Communication, decision-making, and dealing with conflict with members of health care teams have been central concerns in parents’ reports of their home health care experiences. The objective is to review literature on relational aspects of parent and home health care provider care practices for children with medical complexity receiving home health care services. A narrative review was conducted. A search of MEDLINE, EMBASE, EBM Reviews, PsychINFO, ERIC, and CINAHL databases for English language studies published since database inception was carried out. Eligible studies focused on relational aspects of parent and home health care provider care practices for children with medical complexity receiving home health care services. Nine empirical studies were selected for this review. Literature describes parents’ and providers’ experiences managing a child with medical complexity in the home and the effects for the family and the parent-health care provider relationship. Parents want to be actively involved in all aspects of care that affects their child and ultimately their family. Further investigation is needed to better understand relational aspects of parent-home health care provider care practices to support child/family health and well-being in the home setting.     

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.     

Malingering by proxy: a form of pediatric condition falsification

The deliberate production or feigning of signs or symptoms in a child by a caretaker is well recognized as factitious disorder by proxy, a psychiatric condition commonly reported in the pediatric literature. However, it is not as well recognized that the false illness portrayal may also be the result of a parent instructing the child to malinger. A case report of a 13-year-old patient who feigned an immobile upper extremity for the purpose of obtaining a legal settlement is presented. Physicians are encouraged to make protecting the child from parental or iatrogenic harm a priority. Recommendations for careful confrontation and expedient resolution are made.     

Why Parents Seek Care for Acute Illness in the Clinic or the ED: The Role of Health Literacy

Objective

To explore the decision to seek care and decision-making regarding location of care among parents with low and adequate health literacy.

Is sharing really caring? Viewpoints on shared decision‐making in paediatrics

Shared decision‐making (SDM), the cornerstone of family‐centred care and the gold standard in health decision‐making, occurs when the patient, family members and the health‐care team members partner to make health decisions about the child. This partnership involves an exchange of medical information and information about patient/family preferences and values. Together, the health‐care team, parent and patient deliberate to determine the best course of action for the child. Despite high‐quality evidence supporting its positive impact on outcomes, SDM has not been widely adopted in paediatric clinical practice. Greater understanding of the impact of SDM on all members of the decision triad (parent, patient and health‐care provider) may increase the likelihood of SDM adoption. Therefore, we present the viewpoints of a paediatric patient, parent and paediatrician about the use of SDM. A youth living with a rare chronic disease discusses the impacts of being involved and excluded from health decisions. A mother of a son living with a rare nephrotic condition discusses working with a health‐care team who are committed and skilled in SDM and the positive impacts SDM has had for her son's care. A general paediatrician with research expertise in SDM discusses the individual and system level challenges and rewards of using SDM in her clinical practice. Based on the viewpoints presented, we offer pragmatic recommendations for using SDM in paediatric clinical practice.     

Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting

The condition widely known as Munchausen syndrome by proxy comprises both physical abuse and medical neglect and is also a form of psychological maltreatment. Although it is a relatively rare form of child abuse, pediatricians need to have a high index of suspicion when faced with seemingly inexplicable findings or treatment failures. The fabrication of a pediatric illness is a form of child abuse and not merely a mental health disorder, and there is a possibility of an extremely poor prognosis if the child is left in the home. In this statement, factors are identified that may help the physician recognize this insidious type of child abuse that occurs in a medical setting, and recommendations are provided for physicians regarding when to report a case to their state's child protective service agency.     

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.     

The impact of child care problems on employment: findings from a national survey of US parents

ObjectivesMany parents struggle to secure high-quality, consistent child care services, and this may impact employment decisions. Our objectives were to determine the type of employment problems that parents attribute to difficulties in securing child care and to identify whether having a child with behavior problems and/or chronic illness is independently associated with child care–related employment problems in the United States.MethodsThis study included parents of children aged 0 to 13 years by using household-level sampling from the nationally representative random digit dial survey Gallup panel. We included 9 measures of child care–related employment problems. Poststratification weights were applied based on census region, income, and education by using Stata’s poststratification commands.ResultsA survey was conducted of 1431 households with at least 1 parent employed. Overall, 46% of households reported 1 or more child care–related employment change. Being absent from work (21%) and changing the work schedule (27%) were the most prevalent changes reported. Two-parent households were significantly less likely to report child care–related employment changes compared with single parent households. Households with a stay-at-home parent were less likely to report child care–related absenteeism but more likely to report recently quitting work compared with households without a stay-at-home parent. Having a child with behavior problems or a serious chronic health condition was associated with double to triple odds of many child care–related employment problems.ConclusionsChild care–related employment problems are common among families with a child with chronic illness or behavior problems. These findings support the need for pediatricians and policy makers to strive for the implementation of more parent-friendly labor conditions.     

Agreement Between Parent Proxy Report and Child Self-Report of Pain Intensity and Health-Related Quality of Life After Surgery

Objectives

Monitoring patient-centered health outcomes after hospital discharge is important for identifying patients experiencing poor recovery after surgery. Utilizing parent reports may improve the feasibility of monitoring recovery when children are not available to provide self-report. We therefore aimed to examine agreement between parent and child reports of child pain and health-related quality of life (HRQOL) in children after hospital discharge from inpatient surgery.

Patient- and family-centered care and the role of the emergency physician providing care to a child in the emergency department

Patient- and family-centered care is an approach to health care that recognizes the role of the family in providing medical care; encourages collaboration between the patient, family, and health care professionals; and honors individual and family strengths, cultures, traditions, and expertise. Although there are many opportunities for providing patient- and family-centered care in the emergency department, there are also challenges to doing so. The American Academy of Pediatrics and the American College of Emergency Physicians support promoting patient dignity, comfort, and autonomy; recognizing the patient and family as key decision-makers in the patient's medical care; recognizing the patient's experience and perspective in a culturally sensitive manner; acknowledging the interdependence of child and parent as well as the pediatric patient's evolving independence; encouraging family-member presence; providing information to the family during interventions; encouraging collaboration with other health care professionals; acknowledging the importance of the patient's medical home; and encouraging institutional policies for patient- and family-centered care.     

Benefits of Medical Home Care Reaching Beyond Chronically Ill Teens: Exploring Parent Health-Related Quality of Life

Background

Caring for teens with special health care needs places physical and mental health burdens on parents, which can be exacerbated by the stresses of transitions to independence. Medical homes can improve teen transitions to greater self-management and reduce health care–related time and financial burdens for families. We examined the association between parent-reported teen medical home status and caregiver health-related quality of life (HRQOL).