Transcript Creating Clarity in the Grey Zone: Consent and

Adolescent Confidentiality: Balancing
Provider Responsibilities and Patient Rights
July 22, 2014
Presentation for CT-AAP by:
Sheryl Ryan, MD
Jennifer Cox, JD
Objectives
• Using a cased-based discussion, clinicians will be
able to:
– Describe Connecticut laws and their effect on an
adolescent’s ability to consent to medical and mental
health care
– Describe the limits of laws pertaining to consent and
confidentiality for adolescents
– Explain the clinician’s obligations to protect
adolescent’s privacy around medical and mental
health care
– Assist clinician in understanding mandated reporting
laws and guidelines around adolescent behaviors and
medical issues
Why is it important to provide
confidential care?
• Concerns about privacy decreases willingness to
seek health care and communicate concerns.
– 17% reported forgoing health care because of
concerns that parents would “find out”
– Assurance of confidentiality increased willingness to
disclose sensitive information from 39% to 46.5%
– 67% of teens assured of confidentiality were willing
to return for future visit, versus 53% who heard no
mention of confidentiality
• Unconditional confidentiality 72% vs. conditional 72%
Ford, CA JAMA. 1997; 278: 1029-1034
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Why is it important to provide
confidential care?
• Reddy et al. – Survey of family planning clinics
in Wisconsin
– One-half of single, sexually active females <18 years
reported that they would stop using clinics under
conditions of mandatory parental notification for
contraceptives.
– Additional 12% reported intent to delay or
discontinue using specific services for STDs.
– 1% indicated that they would stop having sexual
intercourse
Reddy DM et. al. JAMA 2002; 288-710-714.
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Consent for Care
• General rule is that minors do not have capacity
to make legal decisions, so parents control
healthcare decisions for their children but there
are many exceptions that return control to the
minor.
– Gray zone!!! There are many circumstances
where there is no clear legal rule
– Professional judgment is often required to
decide whether parent should be made aware
of medical information
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Minors and Parents
• In Connecticut a minor is defined as someone under the
•
age of 18, unless a law gives a different age to apply for
limited circumstances.
– “Emancipation” is possible, but exceedingly rare
Usually a natural or adopted parent has decision-making
powers, but courts can reassign that to DCF, guardian,
other appointees
– Step-parents do not have independent authority
– Non-custodial parents still have rights, unless court has
restricted these rights
• Foster parents rarely have decision-making authority
over foster children
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Minor Controls (Not Parent)
• Minor controls the following:
– STIs
• No notice to parents, bill must go only to minor
• 12 y.o. or younger = mandatory DCF abuse & neglect report
– Substance abuse treatment
• State and federal laws allow minor to consent
– HIV testing and care
• For testing, minor controls; for treatment, minor controls only if
physician documents why parent is not being involved (e.g., to
avoid patient elopement from care)
– Abortion counseling
• Providers have set of questions to review with patient
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Mental Healthcare
• Outpatient. Minor controls for outpatient mental
healthcare (Sixth session rule), as follows:
• Only applies to psychiatrist, psychologist, social worker,
•
•
•
•
•
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marriage and family therapist
notifying parent would cause minor to avoid care
clinically indicated and failure to treat would be detrimental
minor voluntarily seeking care; minor is mature enough to
consent
Provider must document the decision (reassess after six
session)
Minor financially responsible (not parent)
NO MEDS prescribed! (otherwise doesn’t fit the rule)
•
•
Inpatient: 16 & 17 can sign into (and out of ) psych
units without parental consent; 14 & 15 year olds can
sign in, but parents must be contacted within 72 hours.
Minors and Reproductive Rights
• Contraception/family planning. Two sources of
legal authority that give minors control over
their own reproductive care (in addition to
abortion/abortion counseling):
– Case law has developed over several decades
– Federal grant program and other payer
programs require patients are given
confidentiality (including minors)
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Mandatory Child Abuse and Neglect
Reporting
• Each healthcare must report, as soon as practicable (no later than
12 hours) to DCF (or the police) if, in the ordinary course of
employment or profession the provider has reasonable cause to
suspect or believe any child under 18 years old has been:
– abused or neglected (includes maltreatment, malnutrition, sexual
molestation or exploitation, deprivation of necessities, emotional
maltreatment or cruel punishment)
– has a non-accidental injury at variance with history given
– is placed at imminent risk of serious harm
– Oral report followed by written report. DCF has authority to follow up
and obtain any information it deems necessary for the child and his/her
siblings.
• Age of consent for sexual activity is 16, but decision to report 13, 14
and 15 year old as abused or neglected due to sexual molestation or
exploitation is NOT tied directly to statutory rape laws (but 12 or
younger should be reported)
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Record Access
• The power to authorize disclosure of records
generally belongs to the person who controls the
medical decision-making
– This is true for paper and electronic records
– Be aware of challenges for electronic record access, it is critical
to think through how to correctly honor minors’ and parents’
access, knowing that parts of the chart are meant to be
accessed by only the minor or only the parent.
– Ability of IT support for EMRs to ensure confidentiality still in
process
• Work toward a process that honors access rights and
does not allow parental access (to parent or minor
depending on the data involved) when it is not
appropriate
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Ethical and Professional
Considerations
• AMA, AAP, AAFP and other similar
organizations share the same perspective:
where law does not require otherwise,
physicians who treat minors must involve
minors in decision-making process
commensurate with abilities of the minor.
• Numerous studies confirm that 66-75% of
minors would be at risk of not accessing
necessary health services if they did not
feel the care could be kept confidential
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Application of Legal Considerations
CASE STUDIES
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Case 1 - Melissa
Part I
Melissa is a 16 yr. old female who has been followed
at your clinic since she was 10 years old. Today, she
is coming for her yearly physical and because her
school notified her that her “shots are not up-todate”. She is otherwise well. Her mother was unable
to come with her today, because she could not get
any time off from work, but Melissa assures you that
it is “ok with my mom that I get my physical”. You
are unable to reach mom by phone.
1.) Can you do Melissa’s yearly physical exam?
2.) Can you bring Melissa up-to-date on her
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shots?
Case 1 - Melissa
Part II
Melissa tells you that she has heard
from her girlfriends that there is a new
“wart and cancer vaccine”, and she
would like to get it. She doesn’t know if
her mother is ok with her getting it.
1.) Can you give Melissa the HPV
vaccine?
2.)How should you proceed?
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Case 1 - Melissa
Part III
In further discussion, Melissa discloses that she has
become sexually active with her long-standing boyfriend
and that they use condoms all of the time, but she
wants to be “sure she’s protected from the wart virus”.
She also shares with you that her sexual activity has
become a source of conflict between her and her mom
and she is very distressed about this and wonders if you
can recommend someone she can talk to.
1.) Can you refer Melissa to mental heath
counseling without the mom’s permission and can
Melissa go there on her own?
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Issues highlighted
• Mature minor doctrine
• Controversy around consent for vaccines.
• Ability to consent for specific types of care
sought
– Reproductive care
– Mental health care- outpatient
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Mature Minor Doctrine
ALL must apply
• Age 15 & up
• Capacity to provide informed consent
• Low risk service
• Care is for the minor’s benefit
• Medical care is in mainstream of
established medical opinion
• Vaccine provision – medical judgment
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Emancipated Minors
• Varies from state to state
–
–
–
–
Married*
Parent*
In the armed forces
Those living on their own, but financially
independent*
– Younger than 18 in some states
– Pregnant
*Applies in CT – very rarely
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Mental Health Services
• Falls under type of services adolescents
can consent to on their own
– 12 and older
– Generally out-patient – 6 visits
• Psychotropic medications – need parental consent
• Payment ability and notification may be issues
– In-patient care excluded
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Case 2 - Naomi
Part I
Naomi is a 15 year old daughter of
professional parents who work at Yale. She
has a private managed care insurance plan.
She comes to your office for a pregnancy
test, bringing her parents’ insurance card.
1.) Can you test Naomi for suspected
pregnancy?
2.) She does not want to have her parents
informed of this test. What do you do?
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Case 2 - Naomi
Part II
Her pregnancy test is indeed positive. Based on history
and clinical examination, you determine that she is
approximately 7 weeks pregnant. She wishes to have an
abortion. She does not wish to have her parents
informed.
1.) What can you do?
Part III
Naomi is now very concerned because her parents have
access to her medical record through MyChart, and is
afraid that her parents will find out about her pregnancy.
1.) What can you do to protect her confidentiality?
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Issues highlighted
• Initial ability of a teen to consent to care
on the basis of type of service
(reproductive, abortion), not status.
• Grey zone of electronic medical record
access vs. confidentiality
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Issues Highlighted
• Ability of a teen to consent for care on the
basis of type of care, not status of
individual
• Teen’s right to confidentiality
• Note: if < 13 yrs, need to explore issues
of abuse.
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Case 3 - Camille
• Part 1
– Camille is a 12 10/12 year old female who comes into
your office with her mom for her yearly physical. She
and her mom have no specific complaints and they
think that things are going very well. The mom
readily leaves the room so you and C. can have some
“private time”. During this time, C. discloses that she
has been having sex with two boyfriends and wants
to get checked for any STIs
• How do you proceed? Can you treat C.?
What more do you need to know?
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Case 3 - Camille
• Part II
– Camille reports that both of her boyfriends
are 15 years old and that she has had only
anal sex because she did not want to get
pregnant. She states that the sex has been
consensual. She thinks that maybe she should
start some birth control, especially since she
has very heavy periods.
• How do you proceed? Are you faced with
mandated reporting here? What are you able
to do for Camille?
• How do you include the mom in this visit?
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Issues Highlighted
• Consent for specific services sought
– Reproductive and mental health
– Lower age for treatment– 12 years
• Mandated reporting for sexual abuse
– Definitions
• Disclosure to parents
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Case 4- Jeremy
Part 1
Jeremy is a 13 year old boy who presents to your
office complaining of testicular pain, and a penile
drip. Based on the history and clinical findings you
surmise that he has gonorrhea, complicated by
epididymitis. Treatment would include Ceftriaxone
(250 mg) IM, Doxycycline 100 mg BID for 10 days,
and a follow-up visit in two days to determine
whether he is responding to therapy.
1. ) Can you treat Jeremy without getting
permission from his parents? Why? Why not
2. ) Should you notify his parents of his disease
or your treatment plan?
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Case 4 -Jeremy
Part II
Jeremy’s mother finds the bottle of Doxycycline,
which has your name and number on it, so she
calls to finds out what kind of medicine he is on,
and what you are treating him for.
1.) What do you do now?
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Case 5 - Tyrell
Part I
Tyrell, a 15 year old comes into the
emergency department complaining of a pain
in the right lower quadrant. He looks mildly
distressed. A quick history is compatible with
a diagnosis of appendicitis. He does not
know where his mother is, and you cannot
reach his father at work.
1.) Can you examine him?
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Case 5 - Tyrell
Part II
You determine that Tyrell has appendicitis. He
has been in the ED for 3 hours now and you are
still unable to reach his parents. You are
concerned that his appendix might rupture.
1.) Can you go ahead and operate?
2.)What if the diagnosis was equivocal?
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Issues highlighted
• Consent for care in emergency settings.
• Definition of emergency.
• Need for documentation regarding
attempt to reach parents.
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Emergency Conditions
All must apply
• A condition is present that requires prompt
treatment to alleviate pain, or anything
causing a child to be frightened or hurt
• There is immediate need for medical
attention
• Any attempt to get consent would delay
treatment AND increase risk to life or
health
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What’s an Emergency?
• If child/adolescent is in pain, frightened or
upset
• How persistent must one be to find a
parent?
– Severity of the injury
– The risks of intervening
– Degree of resulting disability
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