Principle of Best Interest

Principle of Best InterestDecision should be made in view of the

GOOD OF THE INDIVIDUAL PATIENT

Not the higher good of society nor a class good

Who are given the right to make such judgment for another? Knows the person well

Loving concern for his/ her well- being

Who are given the right to make such judgment for another? Presumption that a parent, spouse or next kin will judge rightly based on BOND OF LOVE

1. Affection for the child


2. Long Term relationship with the child


3. Legal obligation to care for the child

Who are given the right to make such judgment for another? Presumption to have a Legal and Ethical Right1. Parents, spouse and next of kin

Who are given the right to make such judgment for another? Presumption to have a Legal and Ethical Right2. Physicians or Ethical counselors

Who are not given absolute right to make such judgment for another? Does not seem to be in accord with the good of patient

Ethics committee or civil authorities

Physician, nurses and hospital administrators

DocumentationIn the absence of the parents of a child there must be someone to accompany a child to the pediatricians office.

Reference: AMERICAN ACADEMY OF PEDIATRICS CLINICAL REPORT: Guidance for the Clinician in Rendering Pediatric Care by Jan Ellen Berger, MD, MJ, and the Committee on Medical Liability

DocumentationParents or legal custodian are REQUIRED to write a written consent for the proxy (caregiver)

** Name of custodial parent or legal guardian

** Name of person to whom the parents legal authority to consent has been delegatedReference: AMERICAN ACADEMY OF PEDIATRICS CLINICAL REPORT: Guidance for the Clinician in Rendering Pediatric Care by Jan Ellen Berger, MD, MJ, and the Committee on Medical Liability

DocumentationParents are REQUIRED to write a written consent for the proxy

** Relationship of the proxy to the child

** Authorized signatures may be required,and state law may require that signatures benotarized


DocumentationWhen pediatrician has any doubts about the caregivers capability to provide permission for medical care

- the pediatrician may need to consider deferring elective care until parental permission can be obtained.Reference: AMERICAN ACADEMY OF PEDIATRICS CLINICAL REPORT: Guidance for the Clinician in Rendering Pediatric Care by Jan Ellen Berger, MD, MJ, and the Committee on Medical Liability

DocumentationThe topic could talked early discussions of child care arrangements at prenatal or newborn visits or adressed during medical encounters before the parent returns to employment outside the home.

The pediatrician explains the importance of the therapeutic alliancebetween the pediatrician, parent, and patient and emphasizes why it is preferable for at least 1 parent to be present during preventive and acute care visits.


DocumentationOffering extended office hours (evenings or weekends) is another way pediatricians have made it possible for working parents to attend their childrens medical appointmentsReference: AMERICAN ACADEMY OF PEDIATRICS CLINICAL REPORT: Guidance for the Clinician in Rendering Pediatric Care by Jan Ellen Berger, MD, MJ, and the Committee on Medical Liability

DocumentationLegal right to delegate consent

* persons who have not yet reached the age of majority do not have the right to consent to their own medical care. In most states, the age of majority is 18 years.

* the law requires the physician to obtain consent from a parent or legal guardian before performing a medical or surgical test, procedure, or treatment on a minor.

DocumentationWhom can the power to consent to health care for a child delegated

The guardian of a minor must have the right to consent to medical treatment for that minor

2.) the guardian must be legally and medically competent to delegate the right to consent to medical treatment for that child;

3.) the right to consent to medical treatment for the child must be delegated to a legally and medically competent adult.

DocumentationWith what limitations can the power to consent to health care for a child be delegated?

limited to initial treatment for nonurgent acute care but not authorized to consent to follow-up care/referral to specialists.

For example, the proxy may consent to treatment for a childs sprained ankle, but may not be authorized to take child to referred visit with the orthopedic surgeonReference: AMERICAN ACADEMY OF PEDIATRICS CLINICAL REPORT: Guidance for the Clinician in Rendering Pediatric Care by Jan Ellen Berger, MD, MJ, and the Committee on Medical Liability

DocumentationAuthorization of proxy consent verified and documented

Verify that the parent or surrogate accompanying the patient is the same person to whom proxy has been delegated on the aforementioned form.

Requesting a dated signature and photograph identification from the surrogate is one way to document that verification.


DocumentationWhen does this information on proxy consent needed to be updated?

Dissimilar signatures may indicate a problem.

Check to be sure that the person is authorized to consent to the specific care that will be provided.

Legal counsel may offer additional suggestions for verifying the surrogates ability to consent to the patients care.

DocumentationIn clinical situations with increased potential for problems related to consent, it may be prudent to contact the parent or legal guardian by telephone before rendering nonurgent care.


Documentation If parental permission is secured via telephone, it should bedocumented and kept in the patients chart.

If the parent or guardian cannot be reached and the pediatrician decides to provide the care, then the efforts to contact the parent or legal guardian to obtain parental permission for care should be documented and kept in the patients chart.

A legal opinion could be sought on whether the use of witnesses is necessary when obtaining consent by telephone.Reference: AMERICAN ACADEMY OF PEDIATRICS CLINICAL REPORT: Guidance for the Clinician in Rendering Pediatric Care by Jan Ellen Berger, MD, MJ, and the Committee on Medical Liability

Variations in family living arrangements and so many parents in the workforce, it is fairly common for someone other than the childs custodial parent or legal guardian to company a child to the pediatricians office. With so many variations in family living arrangements and so many parents in the workforce, it is fairly common for someone other than the childs custodial parent or legal guardian to accompany a child to the pediatricians office. Although this affords an opportunity to assess the relationship between the child and the caregiver, it precludes face to- face contact between the pediatrician and the parent.If it has been anticipated that a caregiverother than a childs parent or legal guardian maybring the child to pediatric visits, arrangementsshould be made for the custodial parent or legalguardian to provide a written consent by proxy. Ingeneral, these documents specify the name of thecustodial parent or legal guardian, the name of personto whom the parents legal authority to consentto the childs medical care has been delegated, andthe relationship of that person to the child. Suchdocumentation may need to delineate the extent ofthe surrogates authorization (ie, the circumstances,the kinds of medical services, or the specified timeperiod for which the surrogate may provide consentfor medical care). Authorized signatures may be required,and state law may require that signatures benotarized

In case that the pediatrician has any doubts about the caregivers capability to provide permission for medical care like lack of maturity, presence of intoxication, unclear legal standing, or the inability to understand risk communication perhaps because of language barriers)

- the pediatrician may need to consider deferring elective care until parental permission can be obtained.

If the pediatrician is uncomfortable with consent by proxy arrangements, this needs to be communicated with parents up front. The topic could be broached during early discussions of child care arrangements at prenatal or newborn visits or addressed during medical encounters before the parent returns to employment outside the home. Typically, the pediatrician explains the importance of the therapeutic alliance17 between the pediatrician, parent,and patient and emphasizes why it is preferable for at least 1 parent to be present during preventive and acute care visits. Offering extended office hours (evenings or weekends) is another way pediatricians have made it possible for working parentsIf the pediatrician is uncomfortable with consent by proxy arrangements, this needs to be communicated with parents up front. The topic could be broached during early discussions of child care arrangements at prenatal or newborn visits or addressed during medical encounters before the parent returns to employment outside the home. Typically, the pediatrician explains the importance of the therapeutic alliance17 between the pediatrician, parent,and patient and emphasizes why it is preferable for at least 1 parent to be present during preventive and acute care visits. Offering extended office hours (evenings or weekends) is another way pediatricians have made it possible for working parentsExcept for situations in which a minors right to consent to care has been legally established, in general, persons who have not yet reached the age of majority do not have the right to consent to their own medical care. In most states, the age of majority is 18 years. Thus, in general, the law requires the physician to obtain consent from a parent or legal guardian before performing a medical or surgical test,procedure, or treatment on a minor.

However, caselaw and legislative action have resulted in severalexceptions to the parental consent requirement (eg,emergency treatment; treatment of an emancipatedminor; treatment for sexual assault, sexually transmitteddiseases, drug abuse, and alcohol dependency).Some states attempt to balance the rights ofthe minor and the parent by requiring parental notificationfor medical tests or treatments consentedby minors.

Documents

Principle of Best Interest