Understanding Informed Consent for Pediatric Patients
Laura M. Cascella, MA, CPHRM
Informed consent is a pillar of patient engagement and patient-centered care. It helps patients gain a full understanding of the benefits and risks of proposed procedures and treatments, thus allowing them to make educated decisions. But what happens when patients are infants, children, or adolescents?
The right to consent to treatment or refuse treatment generally applies to competent adults. Thus, healthcare providers who treat pediatric patients — such as pediatricians, family medicine physicians, physician assistants, nurse practitioners, and pediatric dentists — should be well-versed in how to address informed consent with patients who are minors. Doing so requires understanding specific state laws related to informed consent and developing thorough organizational policies to guide the consent process.
State Laws
In the United States, consent for treatment of minors in nonemergency situations is addressed in state laws, which can vary from state to state. Typically, parents or legal guardians must consent to treatment if a child is not of the age of majority (usually 18).1 However, exceptions apply, particularly in regard to adolescents.
As noted in guidance from UpToDate, “The circumstances in which adolescents may consent for their own care and in which confidentiality is protected vary from state to state depending upon the adolescent's status as a minor or adult, the service involved, and the provider’s level of concern regarding harm to the patient or others.”2
State laws generally include definitions of mature minors or emancipated minors, and they might have provisions allowing minors to consent to treatment of sexually transmitted diseases, sexual assault, pregnancy, and substance abuse.
| Involving Pediatric Patients in the Informed Consent Process |
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| Pediatric patients can range in age from infants to teenagers and have varying degrees of cognitive development and maturity. The American Academy of Pediatrics’ policy statement Informed Consent in Decision-Making in Pediatric Practice advocates that “patients should participate in decision-making commensurate with their development” and “they should provide assent to care whenever reasonable.”3 Including pediatric patients in healthcare decisions and the informed consent process as they mature can help nurture the concept that patients should be active partners in their care. |
Additionally, exceptions to consent laws might apply in emergency situations in which no parent or guardian is present or in circumstances in which lack of parental or guardian consent might result in serious patient harm. The AMA Journal of Ethics states that “Under federal law, the Emergency Medical Treatment and Active Labor Act (EMTALA) mandates initial evaluation (a medical screening exam) and treatment for all patients presenting to an emergency department with an emergency medical condition. Neither parental nor patient consent or assent is needed for such care.”4 Further, 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.”5
Healthcare providers who treat pediatric patients should know their state laws and ensure that organizational policies related to informed consent for minors adhere to these laws.
Organizational Policies
When developing organizational informed consent policies, healthcare providers should take into account situations in which minors may present to the office for clinical care or treatment without their parents or guardians present. For example, the patient might arrive alone or be brought in by a grandparent or sibling. Each organization’s policies should include specific guidance for managing these types of scenarios.
For example:
- Determine if and under what circumstances minors will be seen if they arrive alone or without a parent or guardian present (unaccompanied minors).
- Explain your policies related to informed consent for minors and treatment of unaccompanied minors in your practice’s welcome brochure/informational packet and on your website.
- Determine the types of procedures/treatments that will be made available to unaccompanied minors.
- Communicate in advance the limitations of services and care provided to unaccompanied minors.
- Require parents/guardians to provide a phone number where you can readily reach them in the event that questions arise about minors’ care.
- Specify that additional treatment (beyond what office policy allows for unaccompanied minors) will require specific consent discussions.
- Have parents/guardians sign a consent form in advance permitting general treatment of unaccompanied minors.
- Document all care provided in accordance with the organization’s informed consent policies.
Consent policies for minor patients also should include guidance related to assurance of parental/custodial rights for informed consent or refusal, particularly in cases of divorce, separation, protection from abuse orders, etc. For example, for minors whose parents are divorced or separated, “reasonable steps should be taken to determine which parent(s) has the legal authority to consent to treatment, to what extent each parent must be involved in the decision-making process, and who may access information regarding the minor.”6
Organizational leaders and providers also should consult their legal counsel to help review and provide guidance on consent policies for minors and to address questions that arise related to the care and treatment of minor patients.
Resources
The Guttmacher Institute provides a state-by-state overview of minors’ consent law in the United States, including consent for medical services related to contraception, sexually transmitted infections, prenatal care, abortion, and more. For more in-depth information about the informed consent process, see MedPro’s guideline titled Risk Management Strategies for Informed Consent.
Endnotes
1 McNary, A. (2014). Consent to treatment of minors. Innovations in Clinical Neuroscience, 11(3-4), 43–45. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC4008301/
2 Olson, K. A., & Middleman, A. B. (2020, June). Consent in adolescent health care. UpToDate. Retrieved from www.uptodate.com/contents/consent-in-adolescent-health-care
3 AAP Committee on Bioethics. (2016). Informed consent in decision-making in pediatric practice. Pediatrics, 138(2):e20161484
4 Rettig, P. J. (2012, October). Can a minor refuse assent for emergency care? AMA Journal of Ethics, 14(10), 763-766. doi: 10.1001/virtualmentor.2012.14.10.ecas2-1210
5 The American Dental Association. (n.d.). Types of consent. Retrieved from www.ada.org/resources/practice/practice-management/types-of-consent
6 McNary, Consent to treatment of minors.
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