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So I'm sitting here working at Urgent Care and just finished getting yelled at over the phone by a grandmother.  Basically the grandmother called asking if we could see her 3yo grandchild.  The mother is in Colorado, and the patient is not a current patient in our hospital system.  The grandmother had NO paperwork showing any legal custody of said minor.

I basically said that I could not provide care to the minor because there was no way to obtain verified consent from the minor's legal guardian, therefore recommended emergency room evaluation for any emergent needs.  The grandmother was irate...and honestly understandable.

Just curious how others would handle this situation?  Am I wrong on the concern for consent and medical battery (honestly in this situation it doesn't actually matter because we had no way to create a patient chart without legal guardian present to sign paperwork...policy matter)?  If it matters I'm in Michigan.

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Let me rephrase this: a lady, who claims to be the grandmother, but has no written relationship or permissions on record, wants you to perform an exam -and treat- someone who can neither consent nor assent?  
Sorry, Charlie.  The clinic should have a protocol in place for this.  Is the ED the most appropriate place?  In that they have the capability to determine ethicality and or need, yes.  Let grams bitch and moan, I think you did the right thing.

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So the ED is the place to commit medical battery?  Better to just tell Grandma to get written permission from parents then come back, don't send to the ED unless you think kiddo is having a medical emergency.

 

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1 hour ago, thinkertdm said:

Let me rephrase this: a lady, who claims to be the grandmother, but has no written 
Sorry, Charlie.  The clinic should have a protocol in place for this.  Is the ED the most appropriate place?  In that they have the capability to determine ethicality and or need, yes.  Let grams bitch and moan, I think you did the right thing.

Interesting, what makes an ED provider more able to determine the ethics, need and/or legality of treating an individual? 

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Not sure what the OP's state laws say, but in CA we could get the parent/guardian on phone and verbally get consent from them.   The RN and I would document we got verbal authorization to treat the patient. 

I whole-heartedly agree about the lameness of turfing the problem to the ER.  Only send to the ER if it's medically necessary.  

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51 minutes ago, Boatswain2PA said:

So the ED is the place to commit medical battery?  Better to just tell Grandma to get written permission from parents then come back, don't send to the ED unless you think kiddo is having a medical emergency.

 

It's not that the ED is the place to commit medical battery, but in MI (and most states) the ED is able to provide emergent care with assumed consent.  The ED is also attached to a hospital that has resources to obtain consent from the appropriate guardian.

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4 minutes ago, dfw6er said:

I whole-heartedly agree about the lameness of turfing the problem to the ER.  Only send to the ER if it's medically necessary.  

Again, it's not that I turfed to the ER.  It was that the ER can assume consent and provide emergent care if that is needed.

4 minutes ago, dfw6er said:

but in CA we could get the parent/guardian on phone and verbally get consent from them.

This was considered, but how do you confirm the identity of who you are speaking to on the phone?  I will be honest, I don't know the specific legality of doing this in MI, but that would be my main hesitation.

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4 minutes ago, mgriffiths said:

It's not that the ED is the place to commit medical battery, but in MI (and most states) the ED is able to provide emergent care with assumed consent.  The ED is also attached to a hospital that has resources to obtain consent from the appropriate guardian.

I spent half an hour to say this exact thing.  it’s difficult to determine medical necessity if you can’t evaluate the patient.  Just looking at temp and bp you’ve created a relationship.  A quick google search shows lawsuit on lawsuit of craziness.

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We'd get the child's name, SSN, demographics, insurance info and mom's/dad's/insured's info....generally then the RN and registration staff could look it up and see if the info adds up.  With the internet, this information is verifiable 24 hrs/day generally.

As for the ER....they can provide care if there's an imminent threat to life/limb.  If it's something like a rash or pink eye, generally the ER isn't able to provide emergent care without prior consent from the parent/guardian.

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I believe screening with vitals doesn't create an obligation to treat, nor is it illegal without consent.  EMTALA actually mandates you medically screen all patients who present to your ER and makes NO EXCEPTIONS FOR MINORS.  If vitals or what you're observing are off enough to give you concern, then you're obligated at that point to stabilize at a minimum.  If you at any time feel a life/limb threatening condition may exist, then it needs to be dealt with regardless of lack of consent.   And parents aren't allowed to refuse care in emergent situations, even if their religious beliefs are contrary to the care the child needs.  

Lastly, you have to do what's right for the patient.  If you document the direness of the situation, unsuccessful attempts to obtain consent from legal guardian/parent, and your belief the child has an emergent life/limb-threatening injury/condition, a jury is quite unlikely to return a finding against you. However, if you refuse to treat something that was potentially life/limb threatening because you didn't have consent, you may be in violation of both EMTALA and be open for a malpractice lawsuit.  

The American Academy of Pediatrics and the American College of Emergency Physicians have position papers which reflect my beliefs as well.

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40 minutes ago, dfw6er said:

I believe screening with vitals doesn't create an obligation to treat, nor is it illegal without consent.  EMTALA actually mandates you medically screen all patients who present to your ER and makes NO EXCEPTIONS FOR MINORS.  If vitals or what you're observing are off enough to give you concern, then you're obligated at that point to stabilize at a minimum.  If you at any time feel a life/limb threatening condition may exist, then it needs to be dealt with regardless of lack of consent.   And parents aren't allowed to refuse care in emergent situations, even if their religious beliefs are contrary to the care the child needs.  

Lastly, you have to do what's right for the patient.  If you document the direness of the situation, unsuccessful attempts to obtain consent from legal guardian/parent, and your belief the child has an emergent life/limb-threatening injury/condition, a jury is quite unlikely to return a finding against you. However, if you refuse to treat something that was potentially life/limb threatening because you didn't have consent, you may be in violation of both EMTALA and be open for a malpractice lawsuit.  

The American Academy of Pediatrics and the American College of Emergency Physicians have position papers which reflect my beliefs as well.

Completely agree...but that is an ER, not an UC.  Furthermore, patient wasn't in the office.  Grandmother called...don't even know the concern.

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Urgent cares are office visits...that’s why they aren’t emtala covered.  Vitals are fine.  The second you look at them and make a decision based on them, you have a relationship.

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1 hour ago, Boatswain2PA said:

Grandmother (or anyone) screaming over phone = I hang up and see next patient.  

This is the correct answer.  “Ma’am, if you don’t stop screaming, I’m going to hang up...click”

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ER has implied consent 

Urgent care does not

 

front a hint to everyone - let the front office staff handle this stuff - it is just a time and energy sink and the only thing that is going to come out of it is that someone is pissed, files a complaint, and employee gets in trouble (esp in corp USA) - so let the admin types handle this.   if they ask you how to handle it give them a brief 30 sec guide then move on.....

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This is not a job for Super PA but the job of all those clerks, administrators and nurses who she will have to get past before ever seeing you. Remember that old answer we used to hear? "It's not my job."

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1 hour ago, surgblumm said:

This is not a job for Super PA but the job of all those clerks, administrators and nurses who she will have to get past before ever seeing you. Remember that old answer we used to hear? "It's not my job."

Except if you just get a chart and treat the kid, when the real mother shows up and finds out YOU the PA treated the kid without accurate consent?  Guess who gets sued.  Not the 22 year old front office person.  You the provider.

 

I would have sent them out as well.

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I think not. The hospital is responsible as you were the final disposition of a case that they cleared. Perhaps a PA JD would like to make comment since we are divided in our response.

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I'm speaking about an Urgent Care (which is where the poster said he was...).  Not a hospital and as the provider who saw the patient you would 100% be named which even if thrown out down the road would haunt you.  Every credentialing packet and state license I have ever completed does not ask, "have you ever been successfully sued...".  They all ask, "have you ever been *named* in a lawsuit".  I have also been told time and time again by Locum agencies (when I did locums full-time) that they will not take any PA who has been named in a lawsuit regardless of outcome.  They said it was too much hassle with their group insurance.  

Sucks, but this is the reality we live in.

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Personally, I believe if you do what it right for the patient, everything else will fall into place. Not saying people shouldn’t protect themselves and document well, nor am I saying that the people who told the patient to seek care elsewhere are wrong. I just can’t go about it this way. I would get downright depressed thinking of patient encounters as “how might this get me sued”. Now if you can’t treat the patient but this system doesn’t allow them to have a chart generated, that’s different.

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I dunno LT.... how this might get me sued is just a part of the gestault these days. Someone once said working in the UC is a daily exercise in license protection. Generally I agree. We don't have the same rules as an ER but most people struggle to make the distinction.

In the case sited I would have declined to see the patient and directed them to the ER if they felt they had an emergency. Some of the UCs I cover are in (start the banjo music) rural areas and we get some of the dumbest people with some of the most bizarre complaints and concerns but every one of them is angry and knows a lawyer. I'm not relying on a bunch of people who have a bumper sticker on their car that says "we don't turn anyone away" to decide if I am legally protected in any given scenario. In general they act like I don't have an individual license and don't get a vote.

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7 hours ago, sas5814 said:

. I'm not relying on a bunch of people who have a bumper sticker on their car that says "we don't turn anyone away" to decide if I am legally protected in any given scenario.

LOL I thought my boss was the only one with that bumper sticker....

Edited by Cideous

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In the 90's  in the hood, I owned a practice that was 75% peds.  single mothers, grandmothers, foster mothers, etc.  I treated the patient w/o questioning who brought them in.  I guess my front staff sorted out who brought them in.  I just treated the child period!!!  Sometimes for free!  That's just the way it was.  NO one was turned away.  Not on my watch!!  I slept really well in those days.  Today .......sucks!!!  IMHO

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