II. Indications: Guardian consent not needed
- Emergency with threat to life or limb (EMTALA)
- Right to treatment (state protected)
- Child Abuse
- Pregnancy
- Sexually Transmitted Disease
- Substance Abuse
- Outpatient mental health (in some states)
- Emancipated minor (state defined)
- Married
- Member of the Armed Services (e.g. Navy, Marines, Air Force, Army, Coast Guard)
- Living independently and self-supporting (reportable case)
III. Approach: Parent and Surrogate Decision Making for Children
- Contrast surrogate decision making in young children with that of older children and adults
- In adults, substituted judgment is based on knowing a patient's opinions and values
- The surrogate acts on what they believe the adult patient would want
- Younger children do not typically have the ability to understand their medical options and make decisions
- Instead, parents and surrogates practice what they interpret as best interests of the child
- "Best interest" is often difficult to determine, and may reasonably vary from one surrogate to another
- Nonmaleficence ("do no harm") may be a more manageable way to judge surrogate decision making
- The clinician should consider whether surrogate decision making risks significant child harm
- Does the decision making risk life or health loss or deprive basic needs?
- When surrogate decision making appears to break Nonmaleficence and put the child at significant risk
- Consider whether the surrogate is transiently incapacitated (e.g. Intoxication)
- Attempt to negotiate with the parent or surrogate if the have maintained capacity
- Involve law enforcement and hospital security if a compromise that is safe for the child cannot be made
IV. Approach: Resuscitation
-
Advanced Directives (including DNR)
- Prevalence of life limiting illness in U.S. children: 500,000
- Less than 3% of U.S. children with life limiting illness have an Advanced Directive
- DNR Orders
- Confirm certified paperwork or medical alert bracelet before following DNR order
- Perform full Resuscitation in acutely life threatening cases where the DNR order can not be verified
- The legal guardian may revoke a DNR order at any time
V. References
- Seeyave, Sherman and Ward (2020) Crit Dec Emerg Med 34(1): 19-25
- Bukata (2013) Emergency Pediatrics, EM Bootcamp, CEME