00:01
So it may also be the case that we
need to make decisions for minors.
00:05
So minors are generally considered
children less than the age of 18.
00:10
It's going to depend
on the jurisdiction
about how this is defined.
00:13
But in that case,
we're you're generally assuming
that that child cannot make
decisions on their own.
00:19
They don't have the
capacity to make decisions.
00:22
And generally we're
going to rely on parents
to be the authority to make
decisions on their behalf.
00:27
They have the responsibility
to make decisions for the minor.
00:32
It is the case the
parents can factor
in family issues or family
values into the decision
they might make
for their particular child,
when they're going through
the informed consent process.
00:43
But there may be
circumstances where
that parental decision
can be challenged.
00:49
So if the clinicians feel
that the decision by the parent
is potentially dangerous
to the child's health.
00:55
They might say, "No,
we don't accept your decision.
00:59
We want to have more
discussion about this."
Classic example might be
a child with leukemia.
01:05
Chemotherapy is recommended,
has a high chance of success.
01:09
And the parents are saying
no to the chemotherapy.
01:12
There you think is potentially
dangerous to the child's health.
01:15
Here's an effective treatment
that has a high success rate,
You really think that
they should have the chemotherapy,
That parental decision to say no
to the treatment
of the chemotherapy
can be challenged.
01:27
There may be times when
you think the parental decision
is imprudent or neglectful.
01:32
So a parent making decision to use
alternative medicine practices,
rather than a tried
and true established
effective medical treatment
for their child.
01:43
Again, the clinicians can challenge
that decision by the parents.
01:47
If it's outright abusive,
if either there's neglect of
the child in the home situation,
or the parents were actually
abusive to the child,
there may be additional
reporting requirements
to the health department,
to state authorities,
Child Protective Services,
to report that
separate from any kind
of medical decisions
that the parents might make.
02:10
And maybe the court
would decide that
the parents can't make decisions
on behalf of the child,
if there has been abuse or neglect.
02:19
Now, if there are no parents,
if there is no parental involvement,
the child is estranged
from their parents
or their parents are deceased,
then when you do need to find
an authorized decision
maker for the child.
02:31
That might mean that you go
to the court to get a guardianship,
and then the guardian
will make medical decisions
on behalf of the minor.
02:38
There was also the case
that there may be minors,
so those that are under the age
of 18, that are treated as adults.
02:45
So they're called
emancipated minors.
02:47
They have the same
authority as an adult
to make their own
treatment decisions.
02:51
Again, this is going to depend on
the jurisdiction where you practice.
02:54
So you have to check on that.
02:57
But often, the list of
things that would qualify
as being an emancipated
minor would be
the minor gets married,
they have a child of their own,
so they become a parent.
That makes them emancipated.
03:10
They join the military, again,
that depends on the jurisdiction,
or they've demonstrated that
they are financially independent
and living apart
from their parents.
03:21
They've shown to the court
that they are independent,
and therefore the court has
deemed them as emancipated.
03:31
There's also the case that
there may be conditions
that are treated for minors
were for those actual
conditions or those treatments
they are considered what's
known as statutory adults.
03:46
So they can make decisions
about these conditions
or these treatments,
even in all other respects
they're considered minors,
and need someone else
to make decisions for them.
03:56
Again, check your jurisdiction
about how this applies.
04:01
So what are the possible options
for where this might happen?
So it could be for treatment or
advice for substance use disorder,
the miner might be able to
seek treatment on their own
and consent to treatment without
any kind of parental involvement.
04:18
It may be for mental
health services,
it may be for reproductive
health issues,
which could range
from contraception,
to sexually transmitted
diseases to pregnancy,
all of those times for
reproductive health issues,
that the minor might be able to make
treatment decisions on their own.
04:38
One that's been recently
controversial is
whether minors could
consent to vaccinations.
04:44
So in the COVID pandemic,
there are some jurisdictions
that would only allow parents to
make decisions for a COVID vaccine
on behalf of their child,
but in other places
the minor could
consent on their own.
04:58
So open to debate, I think
it's an important enough issue
that maybe this should be
something to consider as
we're patient or a minor is
considered a statutory adult.
05:09
But check your jurisdiction.
05:13
Alright,
why would we allow this to happen
for these conditions in particular?
Well, they do involve some
element of confidentiality.
05:22
So we want to have
adolescents seek care
and be forthcoming about
their health concerns.
05:28
If they didn't have
this possibility,
if they were concerned about their
parents learning what's going on,
maybe they wouldn't
be so forthright about
what's happening with their health,
or if they they're having
symptoms and so on.
05:41
So this is a means of them
getting the care that they need,
while maintaining confidentiality.
05:48
And maybe the case that
patients who need help care,
if they are not considered
statutory adults,
they'll not receive
the care they need.
06:00
And that's going to be negative
consequence for themselves.
06:05
They're not getting their
substance use disorder treated,
they're not having their
depression treated.
06:10
All of these things might have
bad consequences for them,
but also as a public health issue,
bad for the community
if these adolescents didn't
have the care provided to them.
06:24
So when might you consider
or things that you need to
consider for statutory adults.
06:29
So there are a few factors that
you have to take into account.
06:33
First of all, what's the
patient's chronological age?
So a 12-year-old making decisions
compared to a 16-year-old,
there may be differences in their
ability to process information
and understand it
to make decisions.
06:49
You might need to take into
account their maturity.
06:52
So what is their cognitive
and psychosocial development,
in terms sort of
understanding their condition,
and taking the treatment
that you're recommending.
07:06
You want to make sure
that there's been no abuse
or exploitation of the minor.
07:11
So you need to sort of
understand the circumstances
of why they're seeking
care for the condition.
07:16
If there are concerns about
abuse or exploitation,
you may need additional
safeguards put in place for them.
07:25
If you are taking care
of a patient over time,
how do you see them handling
other health behaviors?
Have they been keeping
their appointments?
Do they take medications
for conditions
other than these ones
that we've mentioned.
07:41
So is that sort of a demonstration
that they are mature enough
to be able to handle taking care
of the condition themselves.
07:49
It's also important,
in pediatrics, especially,
the therapeutic relationship
is really tripartite.
07:56
It's the child, the parent,
or guardian, and the clinician.
08:02
So all three generally
working together.
08:04
So you want to know,
what's been the involvement
of the parent or the guardian.
08:09
What have been the prior
communications within the family?
Is this something that you
really try to encourage
this minor to share
with their parent,
because you think it's important
for them as a family unit
to handle this condition together?
If you really have concerns
about parental involvement,
then this might be an instance
where you would consider
them statutory adults
and being able to make
their own decisions.
08:35
So these are additional
considerations
when you are getting consent
as statutory adults.
08:41
So one, as I said, you might
want to try to persuade them
that maybe it's a good idea to talk
to your parents or your guardian.
08:48
That you're seeking this
advice or this treatment.
08:51
Would it be okay with you minor
for me to ask these questions
or inform your parents,
this is what you're going through.
09:01
Again,
they can say yes or no to that.
09:06
What's going to be the outcome, if
they don't get the care they need?
Are they going to have any sort of
serious mental health
or other concerns?
where that's going to
really put them in jeopardy?
So how important is it of an issue
that you really need to
get them to treatment?
If you think it's important,
it's really going to be
in their best interests,
and it should be done
without the parents consent,
then you can proceed.
09:33
And, again, some of this is going
to depend on the particular minor
have they understood
the advice being given?
Do they understand the
advantages, the disadvantages,
the potential long term impact?
All the things that we would
normally do in a consent process?
Are they able to process
that information and say,
"Yeah, this is going to be
best for me."
And part of that is also
checking their understanding.
09:57
Can they give a rationale
around their reasoning,
in their decision making?
So, sort of demonstration
that they've given
that expressed consent?