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Consent and Assent for Anesthesia in Infants and Children Consent and Assent for Anesthesia in Infants and Children

Consent and Assent for Anesthesia in Infants and Children - PowerPoint Presentation

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Uploaded On 2022-06-08

Consent and Assent for Anesthesia in Infants and Children - PPT Presentation

Clinton Fuller MD Texas Childrens Hospital Updated 102019 Disclosures No relevant financial relationships Learning Objectives Describe basic ethical theories and principles List the elements of informed consent in adults ID: 915035

ethics consent assent patient consent ethics patient assent ethical medical informed decision age capacity patients autonomy making treatment case

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Slide1

Consent and Assent for Anesthesia in Infants and Children

Clinton Fuller, MDTexas Children’s Hospital

Updated 10/2019

Slide2

Disclosures

No relevant financial relationships

Slide3

Learning Objectives:Describe basic ethical theories and principles

List the elements of informed consent in adultsRecognize differences of informed consent and assent in pediatricsApply ethical principles to clinical scenarios

Slide4

Case Scenario

14 year old female with no known medical history presents to preoperative area prior to scheduled dental restorations under general anesthesia.She failed dental procedure in clinic due to anxiety and lack of cooperation.

Slide5

Case Scenario

Upon entering the exam room, you note the patient sitting on a stretcher with both parents present.Patient begins to yell about not wanting procedure performed, stating she will fight anyone that touches her. She will not take any oral premedication.

Slide6

Case Scenario

How would you proceed?A: Premedication with IM KetamineB: Call for help for forced inhalational induction

C: Cancel the caseWhy did you choose that option?Are there any guiding principles to assist in this decision?

Slide7

What are Ethics?

The discipline dealing with what is good and bad, and with moral duty and obligation1The

study of actions taken by moral agents to determine if they are good or bad

2

Slide8

Who are moral agents?One who is

capable of knowing and understanding good and badHas the capacity

of choosing one over the other

Slide9

What is capacity?Ability to make moral distinctions and act on them

Moral agents are expected to act within the boundaries of ethical behaviorWe assume human adults

have capacityBut what about children?

Slide10

What are Clinical Ethics?Application of ethical theories, principles, rules, and guidelines to clinical situations

Allow for resolution to ethical issues or dilemmasSuch as consent and assent

Slide11

How to best act?

ConsequentialismCorrectness of one’s actions based on the consequencesDeontology

Correctness of one’s actions based on fulfilling the duties of the actor

Virtue ethics

If one acts

virtuously

, they will necessarily do the right thing

Slide12

Principlism

4 principles of equal weight:AutonomyBeneficenceNon-maleficenceJustice

Slide13

Autonomy

Patients have the right to make decisions about things that will effect their own livesFundamental concept in the western traditionOther cultures may hold other moral domains (ex: community, sanctity) at an equal or higher level3

Underlies the right to informed consent

Slide14

BeneficenceDuty to act in the best interest of the patient

Parents and Physician may disagree here

Slide15

Non-maleficenceRequirement to avoid harming patients

Expressed in the Hippocratic aphorism“First do no harm.”

Slide16

JusticeEquitability:

2 patients with same diagnosis should be treated similarly regardless of social standing or wealthDistributive justice: Distribute limited healthcare resources fairly among patients

Slide17

Bias in “Traditional Ethics”Male and Western bias

Historic male domination of academics and medicineDifferent ethical theories may better account for non-western cultural valuesEthics of Caring

Slide18

Ethics of Caring

Perspective based on relationships and caring for othersPrimacy of relationships is emphasizedIncorporates the complex web of relationships in which the patient is embedded and considers the perspectives of all those who truly care for the patient

Slide19

Informed Consent

Process of dialog with a patient about a planned course of action

45 parts:Disclosure of informationAssess understanding

Determine capacity

Obtain legal authorization

Ensure consent is voluntary

Slide20

Disclosure of Information

Nature of illness

Proposed procedure or treatmentProbability of successRisks and benefits involvedAlternative actions

Including refusal of all actions

Slide21

Informed Consent for Peds

Explain information in an age-appropriate manner

Patients should participate in decision-making appropriate to their developmentAssent

Slide22

Parental Duty

Obligation to protect and promote both the health-related and non-health-related interestsProvide “informed permission” with assent of the child as developmentally appropriate

Slide23

Duties

Physician

Beneficence: to act in the best interest, promote health-related interests

Parent

Parallel interests to Physician

Promote non-health-related interests

Family unit autonomy

Government

Societal interest in protecting the child from harm

Slide24

Model for consent by others

Adults:

Living will

Substituted Judgement

Children:

Best interest standard

Constrained Parental Autonomy

Shared family-centered decision making

Katz, A.L. and Webb, S.A. “Informed consent in decision-making in pediatric practice.” Pediatrics. 2016; 138(2): e20161485.

Slide25

Decision Making Models

Best-interest standard

Maximize benefitsMinimize harmsConstrained parental autonomyPrevent harm

Shared, family-centered decision-making

Collaborative communication and exchange of information between medical team and family

Family shares their goals and values

Katz, A.L. and Webb, S.A. “Informed consent in decision-making in pediatric practice.” Pediatrics. 2016; 138(2): e20161485.

Slide26

Assent

To express approval or agreement

Must include:Developmentally appropriate awareness of the nature of the conditionExpectations of tests and treatments

Assess understanding

Assure no undue influence

Solicit expression of approval or agreement

Assent should only be solicited if some element of refusal will be respected

Slide27

Rule of 7’s for assent

Younger than age 7

No capacityAge 7-14Assume no capacity, but may be refutedGreater than age 14

Assume capacity, but may be refuted

This is a simplified understanding of assent

Slide28

Some minors may consent

In United States, for care related to sexual activity:

Treatment for sexually transmitted diseasesContraceptionPrenatal care

Mature minor doctrine

Legally emancipated minors

Living separately from parents and financially independent

Married

Active military duty

These are general standards in the

United States

, and vary slightly state to state

Slide29

Age of minor consent may vary

South Africa:Children’s Act 38 (2005)

“…over the age of 12 years and is of sufficient maturity and decisional capacity to understand the various implications of the treatment including risks and benefits thereof.”

Ganya

W, Kling S, Moodley K. ”Autonomy of the child in the South African context: is a 12 year old sufficient maturity to consent to medical treatment?” BMC Medical Ethics. 2016; 17:66.

Slide30

Age of minor consent may vary

Europe

https://

fra.europa.eu

/

en

/publication/2017/mapping-minimum-age-requirements/consent-medical-treatments

Slide31

Mature minor doctrine

Some adolescents have the maturity and capacity to understand the elements necessary for consent

This is a judicial determination stating a minor is sufficiently mature to provide own consent

Slide32

Special situations

Patients with chronic illness often have enhanced capacity

Reasonable to respect refusal of nonurgent careShould make efforts to understand reason and clarify any misconceptions

May limit short-term autonomy in some instances to preserve long-term autonomous choice

Slide33

Guidelines

Slide34

Guidelines

Other local cultural or ethical considerations may impact the consent processDifferent ethical constructs may better account for these views

Ethics of caring emphasizes relationships between patient and caregivers or community

Slide35

Case 1

14 year old healthy female who does not want to undergo dental restoration under anesthesia

What to do?Cancel the case as the patient does not assent and care is electiveWork to understand why patient objects to treatment, address any misunderstandings

Continued care by dentist

Slide36

Case 2

14 year old female with diagnosis of acute lymphoblastic leukemia presents for retrieval of oocytes for fertility preservation prior to chemotherapy

Documented previous assent, but not assenting todayWhat do you do?

Slide37

Conclusions:

Ethics provides a framework for decision makingInformed consent involves 5 stepsAssent should be sought from pediatric patients if refusal will be respectedPediatric patients may consent in special situations

Slide38

References:

Ethics. Retreived from https://www.merriam-webster.com/dictionary/ethics

Taylor RM. “Ethical principles and concepts in medicine.” Handbook of Clinical Neurology, Vol. 118 (3rd series) Ethical and Legal Issues in Neurology, Elsevier B.V. 2013.

Minkoff H. “Teaching ethics: when respect for autonomy and cultural sensitivity collide.” Am J

Obstet

Gynecol. 2014; 210(4): 298-301.

Katz AL and Webb SA. “Informed consent in decision-making in pediatric practice.” Pediatrics. 2016; 138(2): e20161485.

Ganya

W, Kling S, Moodley K. ”Autonomy of the child in the South African context: is a 12 year old sufficient maturity to consent to medical treatment?” BMC Medical Ethics. 2016; 17:66.

Consenting to medical treatment without parental consent.

Retreived

from

https://fra.europa.eu/en/publication/2017/mapping-minimum-age-requirements/consent-medical-treatments

.

WMA Declaration of Lisbon on the rights of the patient.

Retrieved from https://

www.wma.net

/policies-post/

wma

-declaration-of-

lisbon

-on-the-rights-of-the-patient/.