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New report addresses caretakers with impaired judgment in pediatric settings :

November 25, 2019

Your office manager calls to discuss an urgent concern. She tells you that when checking in your 17-year-old patient Chad, she smelled alcohol on his father’s breath and saw that he was unsteady on his feet. How should you handle this situation?

Almost 9 million U.S. children live with a parent who has a substance use disorder. It is likely, therefore, that pediatricians will interact with child caretakers whose judgment is impaired by drugs or alcohol. These circumstances present an array of professional, ethical and legal obligations.

An updated clinical report from the AAP Committee on Medical Liability and Risk Management offers suggestions when establishing anticipatory procedures and training programs for staff in such situations to maximize the patient’s well-being and safety and minimize the pediatrician’s liability.

The report, Dealing With the Caretaker Whose Judgment Is Impaired by Alcohol or Drugs: Legal and Ethical Considerations, is available at  https://doi.org/10.1542/peds.2019-3153 and will be published in the December issue of Pediatrics. It discusses safety, privacy and confidentiality; mandated reporting; and consent for treatment.

Safety

The safety of your patients, visitors and staff is essential. Interactions with an impaired caregiver should be discrete and nonthreatening. If there is acute risk to the child or others because of the caretaker’s condition, it is appropriate to contact law enforcement and child protective agencies to maximize safety and obtain treatment for the impaired caretaker.

Office policies and staff training should address management of visitors with impaired judgment. A safety audit is a valuable tool to assess your workplace, its policies and procedures.

Privacy and confidentiality

When discussing your concerns with the caretaker regarding risks to the child, do so in a compassionate, nonjudgmental fashion. Use your established professional relationship to show that the concern is for both the child’s and the impaired person’s welfare. 

Unless your state law indicates otherwise, the physician’s duty to the patient should take precedence over the caretaker’s expectation of confidentiality. As possible, it is appropriate to assist the caretaker in obtaining assistance to address his or her substance use and its effect on the child. 

Mandated reporting

A caretaker’s impairment may constitute abuse or neglect of the child. Be knowledgeable of your state’s laws governing reporting child abuse, standards of abuse and consequences of failing to report for mandated reporters. Act accordingly.

Permission for treatment

If the caretaker is under the influence of drugs or alcohol, he or she may not be able to give permission for the child’s medical treatment. In such situations, it would be prudent to postpone nonurgent care until permission can be obtained. Document the encounter and your inability to render care because valid and sufficient consent/permission could not be obtained.

You direct the patient’s father to a quiet space with the office manager and find out that Chad “desperately” needs his sports physical to start football practice later that day. The patient’s father returned from a friend’s retirement party early that morning and was not expecting to take his son to the office that day. Your patient, not his father, drove to the office.

After assessing the situation, you believe Chad is safe and that he can get himself and his father home safely. Neither you nor Chad is able to reach his mother. In absence of permission from an unimpaired guardian, you tell Chad that you cannot perform his physical but would be willing to fit him in the next day.

Dr. Bondi is a lead author of the clinical report and a member of the AAP Committee on Medical Liability and Risk Management.

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