A previously healthy 9-year-old boy is evaluated for a deep puncture wound to the foot. He was walking barefoot on the beach when he stepped on a rusty nail. His parents cleaned the wound with soap and water and applied pressure to it. The boy takes no medications. He has not received any vaccinations due to parental preference. The boy's parents are divorced and have joint custody of him. The indications, benefits, and risks of tetanus vaccination are discussed with both parents. The mother consents to the proposed tetanus vaccination and requests that it be administered immediately. However, his father refuses to agree to the vaccination as he prefers to explore herbal remedies. Which of the following is the most appropriate next step in management of this patient?

Question

A previously healthy 9-year-old boy is evaluated for a deep puncture wound to the foot.  He was walking barefoot on the beach when he stepped on a rusty nail.  His parents cleaned the wound with soap and water and applied pressure to it.  The boy takes no medications.  He has not received any vaccinations due to parental preference.  The boy's parents are divorced and have joint custody of him.  The indications, benefits, and risks of tetanus vaccination are discussed with both parents.  The mother consents to the proposed tetanus vaccination and requests that it be administered immediately.  However, his father refuses to agree to the vaccination as he prefers to explore herbal remedies.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d74b_d299_bc81_db2d8c98d9f7_MD0003_00 This patient is an unemancipated minor, defined as an individual age <18 years who requires consent by a parent or legal guardian for medical or surgical treatment. In all states, minors may receive acute care without consent if obtaining it would delay treatment. The parents or legal guardians must be notified as soon as possible. Many states also allow minors to consent without parental notification for contraception, treatment of sexually transmitted diseases, prenatal care, mental health services, and substance use rehabilitation (Table). According to the American Academy of Pediatrics Committee on Bioethics, a parental decision to decline routine immunization for an unvaccinated child is often tolerated as the risk of acquiring infection in a community with herd immunity is relatively low. In contrast to elective vaccination, this patient is at high risk of tetanus infection from the deep puncture wound and administration of tetanus vaccination is urgent. In patients with divorced parents, only parents with custody may give consent for medical care. Parents with joint custody are each able to consent, but consent from only one parent is all that is necessary to proceed with treating the minor, especially when the decision is clearly in the child's best interests. In all cases, treatment is ideally discussed with both parents to reach an agreement that will help the child and facilitate cooperation between the treatment team and the parents. (Choice A) Unemancipated minors do not have the legal authority to consent for procedures; consent must be obtained from at least one parent. (Choice B) It is appropriate to consult the hospital's ethics committee if an ethical dilemma is present. This is not the case with this patient as tetanus vaccination is in his best interest and the mother has already provided consent. (Choice C) If both parents refuse to consent to life-saving treatment, the physician would need to seek court approval before administering necessary but nonurgent treatment (eg, chemotherapy for acute lymphoblastic leukemia in a stable patient). (Choice E) Withholding the proposed treatment is inappropriate as the mother has already consented, which is considered legally sufficient to proceed. Parents cannot deny their children life-saving treatment unless the benefits are minimal or would not alter the prognosis. Educational objective: When caring for an unemancipated minor, informed consent from one parent or guardian is considered legally sufficient to justify proceeding with therapy. Physicians should also provide care in urgent situations without waiting for parental consent. References: Consent for emergency medical services for children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/12612264) Childhood immunization: when physicians and parents disagree. (http://www.ncbi.nlm.nih.gov/pubmed/22045859)

A Previously Healthy 9-Year-Old Boy Is Evaluated for a Deep