An 8-year-old boy is brought to the urgent care clinic by his grandmother due to a fever, sore throat, headache, and nausea that began yesterday. His symptoms have worsened and he is now having difficulty swallowing. He is up to date on vaccines and has no chronic medical conditions. The grandmother cares for the child after school while his mother is at work. The boy's father died of leukemia 3 years ago, and his mother is healthy. Temperature is 39.4 C (102.9 F), blood pressure is 100/70 mm Hg, pulse is 112/min, and respirations are 14/min. Pulse oximetry is 95% on room air. The boy is awake, alert, and in mild discomfort. Examination of the oropharynx reveals pharyngeal erythema and exudate. The uvula is deviated to the right and the left soft palate is depressed downward. The patient has pooled oral secretions but is able to swallow. There is bilateral anterior cervical lymphadenopathy. Lung fields are clear to auscultation bilaterally with good air entry. A small peritonsillar abscess is suspected and the proposed plan, including transfer to the hospital for needle aspiration, is discussed with the grandmother. When asked if she has written consent to permit treatment, the grandmother replies that she has never been asked such a question before. Which of the following is the best next step in management of this patient?

Question

An 8-year-old boy is brought to the urgent care clinic by his grandmother due to a fever, sore throat, headache, and nausea that began yesterday.  His symptoms have worsened and he is now having difficulty swallowing.  He is up to date on vaccines and has no chronic medical conditions.  The grandmother cares for the child after school while his mother is at work.  The boy's father died of leukemia 3 years ago, and his mother is healthy.  Temperature is 39.4 C (102.9 F), blood pressure is 100/70 mm Hg, pulse is 112/min, and respirations are 14/min.  Pulse oximetry is 95% on room air.  The boy is awake, alert, and in mild discomfort.  Examination of the oropharynx reveals pharyngeal erythema and exudate.  The uvula is deviated to the right and the left soft palate is depressed downward.  The patient has pooled oral secretions but is able to swallow.  There is bilateral anterior cervical lymphadenopathy.  Lung fields are clear to auscultation bilaterally with good air entry.  A small peritonsillar abscess is suspected and the proposed plan, including transfer to the hospital for needle aspiration, is discussed with the grandmother.  When asked if she has written consent to permit treatment, the grandmother replies that she has never been asked such a question before.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Informed consent from a parent or legal guardian should be obtained prior to nonemergency medical interventions in a minor. Children often present with a caretaker (eg, relative, nanny) who does not have the legal right to consent for treatment (Choice B). For routine care, a written consent by proxy should be signed by the parent or legal guardian specifying who may consent to the child's medical care. Verbal consent is often accepted in cases of urgent intervention, as in this case of a child with a peritonsillar abscess. Because this patient is hemodynamically stable and not in imminent danger, proceeding without consent is inappropriate; the mother should be contacted and legal consent should be obtained (Choice E). (Choice A) Although the child may assent to treatment, he cannot legally consent. Emancipated minors, including those who are married, financially independent, or on active duty, can consent to treatment. (Choice D) If a parent refuses medically necessary treatment, a court order can be obtained to overrule the parental decision. If the boy's mother were to refuse consent for abscess drainage, petitioning the court would be appropriate and in the best interest of the child. Educational objective: In nonemergency situations, informed consent should be obtained from a parent or legal guardian prior to any medical intervention in a minor. References: Informed consent in decision-making in pediatric practice. (http://www.ncbi.nlm.nih.gov/pubmed/27456514) Consent by proxy for nonurgent pediatric care. (http://www.ncbi.nlm.nih.gov/pubmed/28115542)

An 8-Year-Old Boy Is Brought to the Urgent Care Clinic