Dr Sara Jamieson and Dr Lucy Hanington, both Medicolegal Consultants at Medical Protection, share how to navigate this tricky situation.
Case study
Dr Y is a consultant psychiatrist in private practice. He sees an 11-year-old patient, Amy, whose mother has brought her for an ADHD assessment. Amy struggles to focus at school, and there has been some challenging behaviour at home. Amy’s parents are divorced. She lives with her mother but regularly spends time with her father during the holidays.
Dr Y conducts an assessment, which includes an interview with Amy’s mother and review of reports from school. He concludes that the diagnostic criteria for ADHD are met and suggests that Amy may benefit from medication. He discusses the risks and benefits of his proposed management plan, and explains the need for ongoing monitoring. He provides a prescription for a low dose of slow-release methylphenidate and arranges a follow-up appointment.
A week later Dr Y receives a message from Amy’s father stating that he does not agree with the ADHD diagnosis. He says that Amy is well-behaved when with him. He asks Dr Y to revoke the diagnosis and amend the medical records accordingly. He demands that no further medication should be prescribed, and threatens to report Dr Y to the Medical Council of Hong Kong (MCHK) if he does not comply with his wishes.
Dr Y contacts Medical Protection for advice. Despite being confident in his assessment, he is concerned about the implications of being reported to the MCHK. He notes that medication has been beneficial for Amy, but asks whether it is reasonable to continue to prescribe, given that Amy’s father does not consent to treatment.
Medical Protection’s advice
Dr Y is advised that it may be helpful to meet with the father to discuss his concerns and the diagnosis in more detail. ADHD is a neurodevelopmental disorder that can present differently between genders and through life. Affected individuals may be able to mask their symptoms in certain settings, and a parent who has not witnessed the challenges may question the validity of a diagnosis.
Further, it is not unusual for parents to be reluctant to medicate their child. A holistic assessment is key, and in such a situation it is important to take the father’s account into consideration too. Dr Y is advised to bear in mind his duties in relation to confidentiality, and to check with each parent before sharing any updated report.
Consent
The MCHK’s Code of Professional Conduct outlines clinicians’ professional obligations in relation to consent when treating children. If under the age of 18 years, a child can only consent to their proposed treatment if they have the competence to do so. They would need a degree of maturity and intelligence to understand the nature and implications of the treatment. It is the clinician’s obligation to assess and confirm this before relying on a child’s own consent. Even if the child does meet criteria to be able to provide their own informed consent, parental involvement in the decision-making should be encouraged for important or controversial procedures.
If the child is not competent to consent to their own treatment, then consent must be obtained from a parent or legal guardian. The MCHK state that, except for major or controversial procedures, it is "usually sufficient to have consent from one parent" (MCHK 2.12.4) and legal advice should be sought if a parental dispute cannot be resolved as an application for a court order may be required. Even if both parents are not required to consent to the treatment, the ideal situation would involve both parents agreeing with and understanding their daughter’s management plan.
Medical records
Medical records must be true, clear, and contemporaneous, and, according to MCHK, "material alterations to a medical record can only be made with justifiable reason which must be clearly documented" (MCHK 1.1.3). Although under the Personal Data (Privacy) Ordinance Cap.486, data subjects have a right to access and correct their own personal data, what is being requested here is the removal of information that Dr Y had received from a family member - ie the record was an accurate reflection of what was discussed in the consultation, and had played a role in Dr Y’s diagnostic decision-making. The MCHK state that, "Material alterations to a medical record can only be made with justifiable reason which must be clearly documented" (1.1.3 ). It would not be appropriate to remove reference to information that was actually received. Dr Y’s clinical opinion also should not be amended purely because a patient or parent disagrees with it.
Dr Y can listen to Amy’s father, and document the information he receives in the medical records. It would be appropriate to note the different viewpoint of each parent and state how each of the accounts received has played into the diagnostic process and any disagreement. The new information may, or may not, influence the overall assessment and recommendations for management, however it is at least likely to assist in understanding the circumstances for Amy overall. In addition, ensuring that the father feels heard may help to prevent any escalation of the matter from a medicolegal perspective.
Learning points
Medical Protection often advises doctors who find themselves embroiled in a dispute between parents regarding the care of their child. It is important to maintain professional boundaries and to stress to the parents that any decision-making should be in the best interests of the child. It is not appropriate for medical professionals to act as mediators or conveyers of information, but ensuring that both parties are heard can be key in ensuring the right outcome for the patient and resolution of a potentially difficult situation.