Developing Strategies to Address Informed Consent Challenges in Pediatric Dentistry
Laura M. Cascella, MA, CPHRM
Informed consent plays a crucial role in patients' rights to autonomy and to make educated decisions about their healthcare. The right to consent to treatment or refuse treatment generally applies to competent adults. When patients are children, the process of informed consent is slightly different, but no less important.
The most notable difference in pediatric informed consent is that the process usually involves a surrogate decision-maker. Typically, parents or legal guardians must consent to treatment if a child is not of the age of majority (usually 18). Exceptions to this standard can apply — for example, in situations involving emancipated minors — and pediatric dentists should be aware of laws that address informed consent in the state(s) in which they practice.
Although the fundamental elements of informed consent do not differ based on a patient's age, consent involving pediatric patients can present some unique challenges. Consider the following case example:
An 8-year-old male patient needs treatment for caries and related oral health issues. His mother brings him to a dental office, and the dentist devises a treatment plan, to which the mother agrees. Before treatment begins, the patient's father contacts the office and says that he does not want any treatment to occur. Both parents are the biological parents; the father has dental insurance, but the mother does not.
In addition to parents not agreeing on treatment decisions and plans, other conflicts or problematic issues might occur with pediatric patients, such as:
- Parents might not make decisions in the best interest of the child.
- Pediatric patients might present for treatment alone or with someone who isn't legally authorized to consent to their treatment.
- Emergency situations might complicate the informed consent process.
Handling any of these situations might be daunting if dental practice staff members do not know the appropriate steps to take. Thus, dental practices should develop comprehensive informed consent policies that address pediatric informed consent and provide guidance for handling challenging scenarios.
Below are some general risk management strategies related to each of the potentially problematic circumstances described previously.
| Child Abuse/Neglect |
|---|
| Healthcare decisions that do not appear to protect a child's best interests might raise questions about suspected child abuse or neglect. Dental practices should develop an abuse/neglect policy and educate employees about their reporting obligations under federal and state laws. Practices should consider posting their policy or including it in welcome materials so that parents are aware of these regulations. |
- Parents do not agree on treatment decisions:
- Conduct a family meeting to try to arrive at a consensus.
- Use written and signed agreements/forms when possible (including informed refusal forms).
- Document all conversations and discussions. Use specific and objective language when documenting.
- If possible, determine who has legal decision-making authority for the patient (e.g., through intake discussions or forms). Maintain any related documentation in the patient's health record. Consult the practice's legal counsel if questions arise.
- Determine whether the health and well-being of the child are at risk.
- Parents do not make decisions in the best interest of their child:
- Try to determine the parents' rationale, and factor in considerations such as health literacy, logistical issues (e.g., transportation, timing, and work conflicts), financial barriers, and fears/dental phobia.
- Use an informed refusal process, thoroughly document the process, and include any relevant forms in the patient's health record.
- Contact child protective services if you have reason to believe the patient is abused or neglected.
- Pediatric patients present for treatment alone or without an authorized decision-maker.
- Be aware of state regulations regarding informed consent for minors.
- Establish policies and procedures for unaccompanied minors, and do not make exceptions.
- Communicate in advance the limitations of services and care provided to unaccompanied minors.
- Develop appropriate marketing and teaching materials (e.g., "welcome to the practice" and "introduction to clinic procedures" brochures) that explain the practice's policies related to unaccompanied minors.
- A potential emergency occurs:
- Review state regulations to determine any guidance related to informed consent during emergency situations. The American Dental Association notes that "Many state laws allow the healthcare provider to proceed without parental consent if an emergency situation arises and delaying treatment could endanger the child's health."1
- Use your best judgment to determine if the situation requires emergency intervention. Consider whether failure to act could endanger the child's health.
- Inform the patient's parent/guardian as soon as possible and obtain consent for ongoing treatment.
Informed consent is a legal and ethical requirement of sound clinical practice. Although the process might seem straightforward, many challenges can occur — particularly in the provision of care to pediatric patients. Dental practices can mitigate these risks by developing thorough pediatric informed consent policies that include guidance on handling complicated, sensitive, and potentially contentious situations. Proactively communicating these policies to parents/guardians can help avoid misunderstandings and set the stage for successful clinical encounters.
For more information about informed consent, see MedPro's Risk Resources:Informed Consent.
Endnote
1American Dental Association. (n.d.).Types of consent. Retrieved from www.ada.org/resources/practice/practice-management/types-of-consent
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