Small children, big dangers
Managing children is often more complicated than treating adults; knowing the legal dangers is essential. Dr Mónica Lalanda discusses the medicolegal risks for new doctors when dealing with children
Consent
it is important to allow children to be involved in the decision-making process
Seeking consent is a good way of communicating with children and their parents. It helps them all to understand their illness and the treatment options available. When appropriate consent is not obtained, a doctor is potentially at risk of legal actions. In children, the ability to take an informed decision depends on their age and their capacity; it is necessary to understand who can consent and who can’t.
Who can consent?
- Anyone aged 18 and over – When a person celebrates their 18th birthday in England a line is drawn between childhood and adulthood. In the medical world they are assumed to be competent adults and are capable of consenting or refusing treatment. It is different in Scotland where the age of legal capacity is 16.
- Aged 16–17 – When a young person celebrates their 16th birthday in England they can agree to treatment without needing parental consent and the parents cannot overrule their children’s decision. They can also withhold consent to treatment, but their parents have the right to overrule this decision. In these sensitive occasions doctors should allow the young person and his/her family to discuss the issue.
- Younger than 16 – Young people under 16 can consent to medical intervention if they understand what is proposed. It is up to the doctor to decide whether the child is mature and intelligent enough to fully understand the nature of the treatment. This is often referred to as Gillick competence. Remember that children may be competent to make one decision but not another. When a child is Gillick competent their parents cannot overrule the child’s consent; however if that child refuses treatment then their parents can override it. Children younger than 16 who are not Gillick competent and parental consent is required cannot consent or withhold consent.
Tips
- Whenever possible it is important to allow children to be involved in the decision-making process. So try to use words that they will understand.
- Deciding if a child is Gillick competent can be hard and requires experience. If in doubt always consult a senior.
- Always provide lots of information and document all conversations and the names of all those involved.
- The doctor’s overriding duty is to act in the child’s best interests.
Record keeping
Children’s medical conditions can change dramatically within a worryingly short period of time. So keeping good records is extremely useful for everyone involved in care delivery, and will be the basis of your defence should a case against you arise. It must be noted that there are differences in notekeeping for paediatric patients. Firstly, a general description of the child’s condition and attitude is needed. For an adult, you wouldn’t normally write: “Mr G stayed sitting on his chair smiling”, but for a child: “G looked very well and kept playing with my stethoscope” gives a lot of information. Secondly, it is important to document who accompanied the child, including names when possible.
Tips
- Write your notes clearly; record the date, time and sign your signature. Adding your bleep number and the name of your consultant might be helpful.
- Families can have complicated structures and some children can have two sets of parents. Document clearly who accompanies the child and who else lives at the child’s home.
- Avoid unusual abbreviations and do not write ones that will cause offence. FLC (funny-looking child) is unacceptable.
Prescribing
In addition to the usual hazards of prescribing, prescribing for children carries its own difficulties
In addition to the usual hazards of prescribing, which include using the right chart for the right patient, overprescribing, contraindications and allergy awareness; prescribing for children carries its own difficulties. Most dosages for children have to be calculated according to age or weight, therefore avoid prescribing from memory. Calculating infusions for premature babies can be complicated calculations; a tiny error in calculation or in positioning of the decimal point, could multiply the dose by 10 or even 100 times the dose you are meant to give.
Tips
- Use the BNF for children every time you prescribe. Do not trust your memory!
- Check and double-check with a suitably qualified colleague any calculations, particularly for infusions.
- Be particularly careful with medication that you are not familiar with. Drugs given in the wrong dose, or by the wrong route, can be lethal.
Child abuse
Following the tragic case of Baby P reported last year, the pressure to remain vigilant has never been greater. Spotting child abuse requires a unique awareness and you must always be alert to the possibility of child abuse. Missing the symptoms and the signs can have serious consequences for the child, care giver and the family involved.
Tips
- Be familiar with the common signs of child abuse and involve a senior immediately if the possibility of child abuse of any form crosses your mind. It does take courage and commitment to raise concern, but it is your duty.
- Be alert and record the general attitude of parents and carers towards the child. Write objectively and remain factual.
- Document who accompanies the child and who else lives at the child’s home. If the child is under foster care get as much detail as possible, including social workers involved in care.
Confidentiality
Children also have rights to confidentiality. However, finding out who you can communicate with is more complicated than with adults. For example, adolescents (children older than 16) have the right to keep their medical information confidential; so a doctor cannot inform the parents of their consultations or treatment without their agreement.
In general it is the same for Gillick-competent children under 16. This can be tricky; imagine a 14-year-old Gillick competent girl needs an urgent operation for an ectopic pregnancy and she doesn’t want her parents to know. The child’s safety is paramount and therefore there will be situations in which you may need to breach confidence in order to ensure the child’s safety, eg, if you have concerns that the patient is in an abusive relationship. (For the GMC’s 0-18 guidance, visit: www.gmc-uk.org).
Tips
- Competent children who want their medical information kept private should have this respected. However, you should explain why this decision is not the best option.
- Be aware that some families might have legal conflicts involving custody of the children and might be in the middle of a legal process. Be objective in any information you share as it might be used in the context of a family dispute.
- Informing parents and children is time consuming and you have to be prepared for it. The same information has to be given at different levels, appropriate for the child and for the adults. Be prepared for more emotional encounters.
- Anxiety and fear can make communication difficult. Extra explanations, reassurance and maintaining self-confidence can be draining; get senior help when needed.
- Be aware that parental responsibility can be revoked.
Who has parental responsibility?
- The child’s mother. The child’s father does not automatically have parental responsibility. He will have it if he is married to the mother, or has been given parental responsibility, or obtained a court order to that effect.
- For children whose births were registered from 1 December 2003 (15 April 2002 in Northern Ireland and 4 May 2006 in Scotland), parental responsibility rests with both parents, provided both are named on the birth certificate, regardless of whether or not they are married.
- A legal guardian appointed if a parent has died.
- Any other person who has been granted parental responsibility by court order.
- In an emergency situation, when the person with parental responsibility is not available to consent, the doctor must consider what is in the child’s best interests and then act appropriately.
Dr Lalanda works in emergency medicine and has a special interest in paediatrics.