Parental rights:
Society has given the right of making medical care decisions to parent because they are viewed as uniquely capable of determining the child's best interest. This included authorizing treatments AND refusing treatments (even life sustaining treatments).
Limitations to parental rights:
If the parents' actions appear not to be in the child's best interest, the parents' rights can be challenged. You have the ethical responsibility to advocate for the patient if you believe the parents' actions are imminently dangerous, neglectful or abusive.

• Fully elicit parents' reasons for therapeutic decisions.
• Explore perceived differences in an open and accepting manner (even if you really disagree).
• Assess whether parents are capable/competent to make medical decisions
• Determine (through conversations with your resident and faculty supervisors) whether there are concerns about the parents advocating for the child's best interests.

Caregivers' legal responsibility:
Physicians who care for children have a legal obligation to report suspected child abuse. It is not your responsibility to determine whether the abuse occurred, what person may have perpetrated the abuse or any other specific details. This is a critical role to understand. There are often complicated social interactions and caring for abused children is a team effort. We work with nurses, social workers, other physicians and child protective services as a team to help determine what happened. If you do NOT report it and you suspect it you are legally liable.

• Be vigilant about this issue
• Be non judgmental-just because you suspect abuse doesn't mean it happened OR you know who the abuser might be.
• Be honest about what you see with the parents and ask for their explanation of your findings.
• Discuss your observations with your faculty supervisor
• Clearly document what you see and what you are told
• You SHOULD NOT disclose your concerns to the family before discussing this you're your supervisors…discussing these issues is the faculty/attending's responsibility.

General approach:
Adolescent patients are capable of participating and guiding their medical therapy. The extent of each patient's ability will depend on the developmental maturation of the patient. In general, parents retain the responsibility to direct care for patients less than 18 years of age unless there is disagreement about the course of therapy.
Special considerations:
As a caregiver for pediatric patients you should be able to define the following special categories of patients:

1. Emancipated minor
There are specific categories of adolescents who are legally capable of directing their medical care. The categories include: 1) married, 2) pregnant/parent, 3) in the military 4) self-supporting.
2. Mature minor
Courts can grant decision-making capacity to minors; this may be limited to specific categories of care (see below) or in some cases of chronic illness when the PHYSICIAN case determined that the patients is capable of informed consent.
3. Specific categories of care
Decision-making capacity is given to minors for the treatment/ care of pregnancy, drug or alcohol abuse and sexually transmitted disease. Laws vary by state.
For WA: http://www.bostoncoop.net/lcd/wiki?action=browse&diff=1&id=Washington
For AK: http://www.state.ak.us/courts/shceman.htm
For ID:
No emancipation except by marriage
http://www2.state.id.us/women/IdLaw/Ch4.html
For MT:
http://data.opi.state.mt.us/bills/2003/BillHtml/HB0647.htm

As a caregiver for pediatric patients you should be able to define the difference between:

1. Informed consent: requires that the patient be competent to make health care decisions, physician disclosure of relevant information, patient understanding of the information and a voluntary, un-coerced patient decision.
2. Parental permission: parents give permission for therapy provided to their children. The same standards and procedures for giving informed consent to a competent patient apply
3. Child Assent: helps patients acquire a developmentally appropriate understanding of her condition, telling the patient what he can expect from the treatment, assessing the patient's understanding of the situation, including determining whether they feel pressured to accept/reject the treatment. It also includes soliciting the patient's willingness to undergo the procedure (you can see how this is probably a team effort with the parents!) This approach is not limited to adolescent patients but is appropriate for ALL pediatric patients.

• Use appropriate language for the patient's developmental level when explaining medical care options.
• Respect the patient's privacy.
• Discuss sensitive issues when you are alone with older patients (e.g. drug or alcohol use, sexual practices/preferences, suicide risk etc.)
• Obtain parental permission about therapeutic interventions
• Obtain child assent from patients about therapeutic interventions.

A medical error or mistake is a preventable or unexpected outcome of a medical treatment. An adverse event is a side effect that is may occur in a certain percentage of cases that are treated.

Medical mistakes are usually not due to negligence. They arise from incomplete knowledge base, an error of judgment, lapse in attention or a "systems" error. You have a professional responsibility as a health care provider to disclose errors to your patients. Although it is difficult and uncomfortable disclosing errors, most patients appreciate honesty (wouldn't you?). Loss of trust usually arises from nondisclosure of errors.

When you identify a medical error:

• Determine the effect (actual or potential) on the patient
• Investigate/identify possible causes
• Explain in a calm, unhurried, truthful and apologetic manner that an error has occurred.
• Answer all questions the patient has and be open for additional questions in the future
• Provide information about follow up of the incident
• Accept responsibility and apologize if necessary

As a student is a common dilemma and each case should be approached on an individual basis. The primary conflict in these cases is the care for THIS patient vs. the need to learn to care for FUTURE patients. Balancing the risk to the patient you are caring for presently compared to what you will learn must be determined. There is an adage "see one, do one, teach one", that may or may not be appropriate based on the risk to the patient and your own unique abilities. You must be honest and provide adequate informed consent. An additional stressor for most students is also balancing care for the patient and being evaluated.

• Provide informed consent: - You should clearly indicate who will be doing the procedure and what the level of training is. You must answer additional follow up questions (like…how many of these have you done?).
• Know your limitations
• Communicate your abilities clearly with your supervisors
• First do no harm to your patients