The NORCAL Risk Management department often gets calls describing treatment scenarios involving adolescents that do not neatly fit into one of the sensitive treatment categories. These situations often require the clinician to weigh the adolescent’s need for autonomy against the parents’ need to nurture, guide, and protect their child. When the line between what can and cannot be shared with a parent appears legally ambiguous, a physician’s discretion is often the best solution. Consider the following two cases.
Case File
Case One
A 16-year-old patient with intractable anorexia nervosa wanted her pediatrician to keep her weight confidential from her parents. The pediatrician called the Risk Management department to ask if he could honor the patient’s request.
Case Two
A 17-year-old patient came into the pediatrician advising that his parents were out of town and he was having intercourse and developed pain and numbness in his penis. The pediatrician, who told him to ice it and go to the emergency department if he had no relief, called the Risk Management department to ask if he should advise the parents of the treatment he had provided to their son.
Discussion
The need to notify parents in these two cases could be argued either way. For example, opinions may differ about whether intercourse-related penis pain is closely enough related to family planning services or STI treatment to withhold notification of the patient’s parents about his treatment. Similarly, an adolescent’s weight is not the type of medical information that usually triggers confidentiality. However, because the patient is being treated for a mental health condition that is significantly associated with her weight, the patient’s weight may have become confidential under the circumstances.
State laws rarely contain the detail necessary to provide guidance for every clinical situation. Most states with parental notification laws related to the provision of sensitive condition treatment permit clinicians to use their discretion as to whether a patient’s parent should be notified of sensitive treatment.1,2 For example, if the parents of the patient in case one did not know their daughter had anorexia, breaking confidentiality could be justified, not only because anorexia can be life threatening, but also because family therapy may be in the patient’s best interest.3 However, in the case described above, the patient, parents and pediatrician may have been able to come to an agreement about whether reporting the patient’s weight to her parents was necessary to achieve the patient’s treatment goals.
Similarly, the pediatrician in case two would have to determine whether the benefits of parental notification outweighed the risks. In case two, the insurance EOB would most likely alert the parents to their child’s visit to the pediatrician. The pediatrician, if he decided the information should be shared with the parents, could limit the details and leave explaining to the parents how the penis pain came about to the patient.
Medical Liability Risk Management Recommendations
Because every treatment situation is unique, it is important to carefully consider how breaching or sustaining confidentiality will affect your treatment goals for a particular patient. Consider the following questions in your analysis:1,4
- Does the patient have a life-threatening problem?
- Will breaking confidentiality irreparably damage the therapeutic alliance?
- Will breaking confidentiality put the patient in danger?
- Will a third party most likely provide the treatment information to the parents?
- If the patient is advised of this, he or she can be counseled about how to talk to his or her parents about the treatment before they are surprised.
- The patient can also be given information about contacting his or her parents’ health insurer to determine whether the insurer will uphold confidentiality.
- If the patient demands decision-making autonomy and privacy, will they be able to pay for necessary treatment without the involvement of their parents?
Once your decision is made, there are additional strategies to minimize the negative aspects of maintaining or breaking confidentiality. Consider the following recommendations:1,4
- When telling a parent about otherwise confidential information, disclose the least amount of information possible for necessary shared decision-making.
- If you decide to allow autonomy and maintain confidentiality, also provide age-appropriate decision-making support.
- Adequately document the reasoning that went into your decision-making autonomy and privacy determination.
- When the situation calls for your discretion, appropriately document the risk-benefit analysis that went into your decision-making autonomy and privacy decision.
References
1. Amy L. McGuire, et. al. “Keeping Children’s Secrets: Confidentiality in the Physician-Patient Relationship.” 8 Houston Journal of Health Law & Policy, 2008;315-333.
2. Melissa Weddle, et. al. “Confidentiality and Consent in Adolescent Substance Abuse: An Update.” Virtual Mentor, 2005. 7(3)
3. Jean Someshwar. “Adolescent Confidentiality: Where Are the Boundaries?” Pediatrics Consultant Live, 2009.
4. Xiomara M. Santos. “Protecting the Confidentiality of Sexually Active Adolescents.” Virtual Mentor, 2012;14(2)99-104.
