II. Indications: Guardian consent not needed

  1. Emergency with threat to life or limb (EMTALA)
  2. Right to treatment (state protected)
    1. Child Abuse
    2. Pregnancy
    3. Sexually Transmitted Disease
    4. Substance Abuse
    5. Outpatient mental health (in some states)
  3. Emancipated minor (state defined)
    1. Married
    2. Member of the Armed Services (e.g. Navy, Marines, Air Force, Army, Coast Guard)
    3. Living independently and self-supporting (reportable case)

III. Approach: Parent and Surrogate Decision Making for Children

  1. Contrast surrogate decision making in young children with that of older children and adults
    1. In adults, substituted judgment is based on knowing a patient's opinions and values
    2. The surrogate acts on what they believe the adult patient would want
  2. Younger children do not typically have the ability to understand their medical options and make decisions
    1. Instead, parents and surrogates practice what they interpret as best interests of the child
    2. "Best interest" is often difficult to determine, and may reasonably vary from one surrogate to another
    3. Nonmaleficence ("do no harm") may be a more manageable way to judge surrogate decision making
      1. The clinician should consider whether surrogate decision making risks significant child harm
      2. Does the decision making risk life or health loss or deprive basic needs?
  3. When surrogate decision making appear to break Nonmaleficence and put the child at significant risk
    1. Consider whether the surrogate is transiently incapacitated (e.g. Intoxication)
    2. Attempt to negotiate with the parent or surrogate if the have maintained capacity
    3. Involve law enforcement and hospital security if a compromise that is safe for the child cannot be made

IV. Approach: Resuscitation

  1. Advanced Directives (including DNR)
    1. Prevalence of life limiting illness in U.S. children: 500,000
    2. Less than 3% of U.S. children with life limiting illness have an Advanced Directive
  2. DNR Orders
    1. Confirm certified paperwork or medical alert bracelet before following DNR order
    2. Perform full Resuscitation in acutely life threatening cases where the DNR order can not be verified
    3. The legal guardian may revoke a DNR order at any time

V. References

  1. Seeyave, Sherman and Ward (2020) Crit Dec Emerg Med 34(1): 19-25
  2. Bukata (2013) Emergency Pediatrics, EM Bootcamp, CEME

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