How to minimize liability when providing nonurgent care in parent’s absence

Pediatricians often are asked to care for children when the parent is not present. In nonurgent situations, the pediatrician can take a number of practical steps to maximize their patients’ access to care while minimizing liability exposure.

These steps are discussed in the AAP clinical report Consent by Proxy for Nonurgent Pediatric Care from the AAP Committee on Medical Liability and Risk Management. The report, a revision of a 2010 clinical report, is available at http://dx.doi.org/10.1542/peds.2016-3911 and will be published in the February issue of Pediatrics.

The report makes the following recommendations for pediatricians:

• Determine whether the practice will see minor patients without a parent or guardian present. It usually is best if all physicians within the practice adopt the same policy; otherwise, problems can occur during coverage situations.
• If the practice decides not to provide nonurgent care to patients without a parent or guardian present, then the office policy and an information sheet explaining it should be provided to patients and their parent or guardian.
• If the practice decides to provide nonurgent care to patients accompanied by someone other than their parent or guardian, it should establish a policy and procedural guide for the office as well as a patient information sheet that explains the policy.
• It is advisable to create a template consent form to be used in cases in which individuals other than the parent or guardian may be expected to accompany a child to the office. The report suggests a number of items to include.
• The proxy relationship should be verified and documented periodically. Additionally, when the office or pediatrician does not know the proxy personally, photo identification, such as a driver’s license, may be required.
• Establish an office procedure for providing and documenting informed consent for proxies with limited English proficiency (LEP), hearing impairment or limited health literacy. Similarly, information sheets related to office policies should be accessible for proxies with LEP and limited health literacy.
• Pediatricians need to be aware of state and federal laws that affect the ability to give consent by proxy (see www.plol.org). Additionally, it is advisable to have legal counsel review office policy and supporting documents to promote compliance with applicable laws.
• It is recommended that informed consent, including consent by proxy, be included in residency training and continuing medical education. Such educational efforts have been effective in improving knowledge and attitudes about informed consent.
• When in doubt about informed consent in a proxy situation, pediatricians should use discretion in deciding whether to treat and should base the decision on the child’s best interests.

Most important is for the pediatrician to recognize and distinguish between appropriate and inappropriate proxy consent. It is perfectly appropriate to perform a rapid test for Group A streptococcal infection in a patient with a sore throat with consent by proxy. It would be inappropriate, on the other hand, to perform genetic testing for Huntington disease.

Dr. Fanaroff is lead author of the clinical report and chair of the AAP Committee on Medical Liability and Risk Management.