Parent/guardian refuses

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First, ensure the parent or legal guardian understands the proposed care. Using the teach-back method$^{26,27}$ will help in this scenario. Once it has been ensured that the care plan is understood, ask what their concerns are, to gain an understanding of why they are refusing. This may allow for the opportunity to further discuss and clarify. Often, taking the time to perform these steps allows better understanding and agreement to care.

If consent to treatment has not been obtained after this, clinicians can consider alternatives and their consequences. For example, what is the risk to the patient if the care is not provided? If the risk is low and does not require immediate attention, discussing this with the family and the patient’s pediatrician in terms of next steps and follow-up may be all that is required. This should be documented in the chart. If the risk to the child’s health is high and, despite the previous steps mentioned, the parent or legal guardian is still refusing care, the emergency physician is obligated to take further action to protect the child’s health, including contacting local Child Protective Services, law enforcement authorities, and institutional legal resources.$^{3,15,31}$ In coordination with the legal team, steps may be taken for the child to be taken into temporary custody of the state.

Emergency clinicians may face situations in which the health risk to a child may lead to loss of life or limb and the parent or legal guardian attempts to leave with the patient. In this scenario, inform the guardian of the need for the child to stay and receive appropriate care. If the family will not comply with the recommendations, institutional security or police may be helpful. In addition, social work and risk or legal teams should be made aware of the situation. Child Protective Services will also need to be made aware of the situation and the steps required to ensure appropriate care. Physicians and staff should avoid any action that would lead to further harm to the child, such as an attempt to separate a child from a parent that would cause physical harm to the child. If the parent or legal guardian leaves with the child, notify the local police department and Child Protective Services of the elopement and obtain their assistance in returning the child to the ED for care. Again, clear documentation of these events and the steps taken must be included in the clinical care notes. The bottom line is that, in most cases, parents’ rights are limited in refusing life-saving or life-sustaining interventions for their children, and consultation with legal teams is needed in such instances.$^3$