Patient dissent during those awkward teenage years

“NO! NO! NO!” Two-year-old Chloe cried, thrashing on the operating table. The team of nurses and anesthesia providers attempted to soothe the girl with songs and distracting toys. Despite their efforts, the team was unsuccessful in calming the young toddler and ultimately had to restrain the child until the anesthesia gases could take effect.

While preferential to have a calm and cooperative patient, it is understood that such a young child lacks capacity to understand what is “medically best” and ultimately, we, the medical team, proceed with having only parental consent.

In this scenario, moving forward with only parental consent is generally undisputed as the most ethical course of action because the child is too young to fully understand and appreciate the consequences of medical decision making (or in this case refusal of care). Similarly, it would be both unethical and unlawful to forcibly sedate an adult patient against their will.

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But how should a clinician respond to the dissent of their adolescent patients, especially for teens, preserving and cultivating the development of autonomy while balancing the duty to provide medical care and respect for the guardian’s consent?

We recently published a piece in Pediatric Anesthesia Journal highlighting ethical and patient assessment (principles surrounding an adolescent that withdraws agreement for a medical treatment). In this scenario, the 15-year-old patient withdrew her assent once in the operating room and away from her parent immediately prior to the anesthetic.

While not precise, a basic framework, referred to as the ‘rules of 7s’ presents a strategy that can be used to address the presumption of capacity as the child develops. It denotes that “children under the age of seven have no capacity; between seven and 14, have a rebuttable presumption of no capacity and between 14 and 21, a rebuttable presumption of capacity.” The reasoning is based primarily on the idea of preserving the developing autonomy of the adolescent patient and the psychological consequences of forced medicalization.

The framework guides that a non-emergency procedure, which most are, should be delayed to invite continued discussion in the presence of the parents. This would allow discussion of a plan agreeable to the adolescent and may include: Child life involvement, distraction therapy, and/or patient counseling. This will respect the developing teen’s autonomy as well as ensure trust in the medical providers, which is crucial in the clinician-patient relationship and encourages compliance.

However, this simplistic approach in dividing pediatric patients into three groups does not provide the complete picture. Development, specifically with respect to decision making capacity, is highly variable and guided by four elements: Understanding, reasoning, appreciation and expression of choice. These standards are more difficult to assess, particularly though brief clinical interactions.

At what age should patient dissent be taken seriously? Forcibly medicalizing a 7 or 8-year-old can induce psychological trauma with long-term impact on the child. It’s important to introduce the concept of assent in the treatment of young patients and to involve children in the medical decision-making process with increasing levels of autonomy to match the patient’s growing maturity and independence.

Of course, this is easier said than done. Each case is individual, and clinicians should use available tools (e.g. sedation, child life specialists, distraction techniques) to provide the optimal patient experience regardless of age.

We hope our paper and invites thought on the expanding complexities of pediatric assent as the field of developmental psychology progresses to tackle the awkward teenage years. And we hope it does so in a way that’s anything but awkward, but in fact inviting and cooperative.

–By Brittany Bryant, B.S., fourth-year medical student and Adam Adler M.D., MS, FAAP, assistant professor of anesthesiology at Baylor College of Medicine

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