AAP Updates Advice for Proxy Consent in Nonurgent Visits

Marcia Frellick

January 23, 2017

A new American Academy of Pediatrics (AAP) report updates its 2010 guidance for physician practices regarding how to set up rules of consent for nonurgent care when the person accompanying the child to a visit is not the parent or legal guardian.

The report, by Jonathan M. Fanaroff, MD, JD, from University Hospitals in Cleveland, Ohio, and colleagues on the AAP Committee on Medical Liability and Risk Management, was published online January 23 in Pediatrics.

Dr Fanaroff told Medscape Medical News that one of the main points in updating the guidance was to include census data that reflect the reality for today's families seeking pediatric care.

The report notes that about one third of US children do not have two parents in their home who can consent to treatment. In addition, an increasing number of children (5.4 million, or 7%) are living with a grandparent.

As a consequence, at the first visit, physicians should ask about living arrangements, and thereafter, ask about changes to home life either directly or through a questionnaire, the authors write.

The authors also point out that physicians should be cautious if a proxy accompanies a patient to an initial visit, as information from the proxy may not be entirely correct.

"There's just been a lot more awareness about the legal and ethical considerations when someone other than the parent brings a child in for care," Dr Fanaroff said.

In addition, the guideline strengthened areas around English proficiency and overall health literacy, he said.

"Health care providers may be placing themselves at risk of liability if proxies have problems understanding them because of a language barrier," the authors warn.

They urge physicians not to rely on written forms that contain translated language because the textbook translation may not match the comprehension abilities of the reader.

"The recommendation in those situations is that you have a professional medical translator available, usually not in person but via Internet or telephone," Dr Fanaroff says. "We have to do our best so that they can provide truly informed consent."

The report notes that a translator who will explain the illness, treatment options, risks, and benefits in the proxy's language should be medically knowledgeable, and the practice should keep the name, address, and background of the translator on file.

Dr Fanaroff says because of the emphasis on teams in healthcare, practices should discuss the liability risks and come to a consensus on whether to provide care to a patient without a legal guardian or a parent present. It helps if all physicians in the practice follow the same guidelines to make coverage more seamless.

He emphasized that these guidelines are for nonurgent care and that if physicians suspect the care may become urgent, "we recommend treating the patient based on the best interest of the child."

Nonurgent care in this report includes preventive medicine, including immunizations and screenings, and outpatient encounters for minor injuries and illnesses.

The AAP has policies around informed consent, and this guidance does not supersede that. "This is an adjunct to those," Dr Fanaroff said.

The authors acknowledge that so far, physicians being liable in treating a patient without consent of a legally authorized representative is not common.

However, "the concepts of informed consent and consent by proxy have evolved both ethically and legally," the authors point out.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online January 23, 2017. Full text

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