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CONSENT, CONFIDENTIALITY AND CONUNDRUMS

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Mature Minor ... Mature minor. 12 states allow but do not require parental ... An 18 y.o. woman is brought by her parents for treatment of her eating disorder. ... – PowerPoint PPT presentation

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Title: CONSENT, CONFIDENTIALITY AND CONUNDRUMS


1
CONSENT, CONFIDENTIALITY AND CONUNDRUMS
  • Adolescent Health Care
  • Donna R. Perry, MD, FAAP, FSAM

2
Informed Consent
  • Understanding
  • Nature of the illness
  • Consequences of not treating
  • Consequences of treating
  • Pros and cons of the form of treatment

3
Confidentiality
  • Revealing information only to persons authorized
    by the patient, the law or regulation
  • Limits of confidentiality
  • Patient is an imminent danger to self or others
  • Legal requirements to report abuse or neglect,
    including statutory rape

4
Mature Minor
  • A patient who, in the estimation of the provider,
    is able to provide informed consent

5
Case 1Easiest
  • A 15 y.o. girl comes in for a school physical
    examination. In your risk behavior assessment
    the girl admits she has recently become sexually
    active with her 17 y.o. boyfriend. She had a
    scare when her menses was late, but a home
    pregnancy test was negative. You confirm the
    negative HCG and begin the discussion of
    contraception. The patient doesnt want you to
    tell her mother.

6
Case 1 Issues
  • What are the laws on discussing and providing
    contraception for teens?
  • Can you maintain confidentiality?
  • What if her boyfriend was 20 y.o.?

7
The Law on Teen Consent and Confidentiality
  • www.guttmacher.org
  • Monthly updated minors legal rights
  • State specific information
  • No sovereign Indian Nation law published on
    website

8
Consent for Contraception
  • 21 states and DC explicitly allow minors to
    consent
  • Arizona
  • New Mexico
  • 15 states have NO explicit policy
  • Wisconsin
  • 14 states permit minors to consent with some
    provisions
  • Alabama high school graduate or 14 y.o.
  • Kansas mature minor

9
Consent for STD Services
  • All 50 states and DC explicitly allow minors to
    consent to STD services
  • Some states have a lower age limit
  • 29 states explicitly include HIV testing and
    treatment
  • Except for 1 state that requires parental
    notification of a HIV, no state requires
    parental notification

10
Consent for Prenatal Care
  • 29 states and DC explicitly allow SOME minors to
    consent to prenatal care
  • Age restrictions
  • Mature minor
  • 12 states allow but do not require parental
    notification
  • 16 states have no explicit policy

11
Prenatal Care in NAIHS
  • Teen can consent to contraception
  • Teen can consent to prenatal care
  • Teen cannot consent to C-section or other surgery
    connected to pregnancy

12
Statutory Rape
  • Laws in each state are complex and vary greatly
  • Each state has an age limit under which a minor
    may not legally consent to sexual intercourse
  • Punishment in most states varies depending on the
    age difference of the partners, and the age of
    the minor

13
Conundrum
  • Mandatory reporting can interfere with a minor
    seeking needed health care
  • Not all states have mandatory reporting, or it is
    loosely covered under child abuse statutes
  • At least half of babies born to minors are
    fathered by adult men, often 3-6 years older
  • Exploitation
  • Abuse

14
Case 2--Trickier
  • A 17 y.o. high school student admits to drinking
    1-2 six-packs of alcohol on weekends. He is a B
    student and involved in basketball so tries not
    to drink during the season. He doesnt drive if
    he is drinking.

15
Case 3Also Trickier
  • An 18 y.o. woman is brought by her parents for
    treatment of her eating disorder. The girl
    initially agrees to share information with her
    parents and is doing well. Several months into
    treatment she has a relapse, confides she has
    discovered the ana-lifestyle and developed her
    own website. She doesnt want her parents to
    know. She is losing weight.

16
Confidentiality Issues
  • Underage
  • Unhealthy
  • High risk even though not driving
  • Enough danger to self to breech confidentiality?

17
Experimentation or Commitment
  • Confronting all high risk behaviors and advising
    on healthier behaviors
  • At what point does a behavior go from adolescent
    experimentation to committed behavior?
  • Drug and/or alcohol use
  • Eating style
  • At what point is the patient or others in
    imminent danger?

18
Case 3Danger zone?
  • A 17 y.o., recent high school graduate, comes for
    her second prenatal visit. She asks you if it is
    harmful to use meth during pregnancy. She
    recently tried it and it made her feel really
    good.

19
MethamphetamineStreet Names
  • Amp
  • Blue belly, black bear, black beauty
  • Crank, crystal
  • Ice
  • Meth
  • Speed
  • White cross, white crunch

20
Methamphetamine Causes Feelings of
  • Increased energy
  • Decreased appetite
  • Increased wakefulness
  • Euphoric, esp if smoked or injected

21
Methamphetamine Epidemiology
Past Month Illicit Drug Use among Youths Aged 12
to 17, by Race/Ethnicity 2002
22
YRBSS 2003 DATA
  • Ever used Meth Ecstacy
  • Navajo Nation HS 15 10
  • BIA schools (2001) 20
  • AZ Public schools 8.6 7.8
  • US High Schools 6.7 11.1

23
Methamphetamine Physiology
  • Onset of action
  • Oral 30-60 min
  • Nasal 15-20 min
  • Inhaled or injected 1-3 min
  • Elimination and duration
  • 4-6 hours

24
MethThe Rush
  • Adrenal gland release of epinephrine
  • Explosive release of dopamine
  • Intense euphoria
  • BP spike
  • Heart rhythm abnormalities

25
These people NEED HELP
  • There is both a physical and psychological
    addiction to methamphetamine
  • Users can be a risk to themselves and others
    during the withdrawal periods
  • Intensive therapy is the best hope, but the
    relapse rate is very high

26
Confidential Care or Not
  • Most patients woefully undereducated about
    Methamphetamine
  • Patient cared enough to ask
  • Will patient go into care?
  • Involve parent/family? Without patient consent?

27
Conclusions
  • Confidential care, with some limitations is
    recommended for adolescent patients
  • State law helps for some parts of reproductive
    health and STD care
  • Providers can be caught in care conundrums with
    adolescents
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