It could be as big as a school bus accident with multiple injuries, major and minor. Or, it could be as small as a child getting hurt on a playground or at a park. But, one of the most difficult and frustrating circumstances on an EMS call occur when the patient is a child and there is no parent or responsible adult around to either authorize or refuse treatment and transport.
Undoubtedly, the child is scared. In some cases, he or she may be uncooperative. In every case, we as emergency personnel are confronted with complex decisions about the actions that we take. There may be no clear answers.
Every state has laws regarding the authority of children to make decisions for themselves. State laws, however, differ in their details, and those details can be important. There may be differences with respect to which children can make their own decisions, or under what circumstances they can make a decision. For example, the age of majority varies. While there are some general principles, it is important to know your state's laws and practices.
Some cases are easy. There is an implied consent to treat and transport whenever the life or health of the child is at risk. The law presumes this consent for treatment even if the child is unable to give it by presuming that the parents would want the care to be provided.
Generally, there are two requirements to apply this rule. There must be an emergency requiring an immediate response and there must be an illness or injury that is life threatening or disabling. But, it is the less serious cases where the answers are less clear. What do you do when called to the scene of a child who has minor injuries after falling off a bicycle? Medically, you may recognize a potential head or abdominal trauma due to mechanism of injury, or perhaps the need for sutures. But, there is no decreased level of consciousness, and the child wants to go home, instead of with you to the hospital. It is the marginal case in which you must know the details of your state's law, and your own medical protocols. Also, you need to know what resources are available.
In many states, a minor is allowed to refuse treatment when the parent or guardian is not immediately present. But, the child must have the maturity and intelligence to make an informed choice. Perhaps most important, the child must have the clarity of thought under the circumstances to understand the consequences of either being treated or refusing treatment.
Regardless of the specific words in any law or policy, the decision ultimately must be based on the totality of the circumstances. An important part of the provider's assessment must be consideration of the circumstances. That may include the severity of pain, mechanism of injury, weather and other environmental factors. The location of the call, and its proximity to the child's home, school, hospital or other resources are important. The child's age is a consideration, but never an absolute one. A younger child may be better able to make a decision about treatment than an older one who has a different type of injury. In most states, the only age absolute is the age of majority, at which the patient is treated as an adult, with complete authority to refuse treatment.
If, after considering all of the circumstances, you conclude that the child is not able to understand the nature of the illness or injury, and the potential outcomes of treatment, then you may conclude that he or she is not able to make an informed decision. If the child is not able to make an informed decision, then you should act. The next step is to evaluate whether there is a substantial risk of death or serious harm. This should be done in consultation with an attending physician if possible. If the answer is yes, then treat and transport the patient. Seek to contact parents or guardians for treatment instructions if it is not.
Another approach is to ask what would "reasonable" parents want done with their child if they were on the scene? In essence, the law puts us in the place of the parents and expects us to make decisions as if we are reasonable parents. Unfortunately, the definition of "reasonable" is often vague, and always depends on the specific circumstances. When there is no immediate threat of life-threatening or disabling injury, take extra time. Try to contact the family or some other responsible adult. Ask for assistance from law enforcement or family services officials.
It is especially important to document your assessment and actions. It must be clear from your documentation why you concluded that the child was (or was not) able to make a decision. Parents should be notified promptly. If the child refuses treatment, documentation of the refusal is especially important, as well as documentation of the parental notification. It also is important to document where the child goes, and with whom.
Make use of all the available resources in the difficult cases. This may include using whatever communication resources are available to contact the parents. Law enforcement officials may have additional legal authority to enable transport of a reluctant child. Consult with your medical control or emergency room physician, if that is available.
What is perhaps the most important legal advice for these difficult cases is to plan ahead. Calls for unaccompanied sick and injured children are inevitable. Because of uncertainties in the law, EMS programs should consult with local attorneys and develop policies for handling such cases. Firefighters and EMS providers should know the policies, and consider how they would apply to specific cases that are likely to occur in the community.
Perhaps the best practical advice comes from a paramedic friend (who also is an attorney), who said, "I'd rather be sued for transporting a kid to the hospital than for leaving him on the street."
Steve Blackistone, a Firehouse® contributing editor, is an attorney and a member of the Bethesda-Chevy Chase Rescue Squad in Montgomery County, MD.