Legal and Ethical Issues in Pediatric

Intensive Care

Mrs. Anisha Mane

 AIM

• At the end of the seminar students are able to

understand about ethical and legal issues in
pediatric intensive care unit and apply this
knowledge in clinical area.
OBJECTIVES
 Principles of ethics
• Ethical dile
Malpractice in the Pediatric Settings
• Negligence is defined as an occasion when a
person owes a duty to another and, through
failure to fulfill that duty, causes harm.
• Malpractice is professional negligence
 For a court to recognize a claim of
malpractice or negligence, four legal
elements must be present:
1. There must be a duty owed to the client by
nurse
2. The nurse must breach the duty
3. The breach of duty must be the cause of
the damage
4. There must be actual damage to the client
 Breach of Duty: 5 R Rule

Right Client

Right Route Right Medication

Right Time Right Dosage

 Statutory Law: State Statutes
• State Nursing Practice Act and Board of
Nursing Rules & Regulations
• Define the scope and limitations of professional
nursing practice
• It is vary from state to state but have common
elements
• Penalties for violations
• Formal reprimand
• Period of probation
• Fines
• Limiting, suspending, or revoking license
 Statutory Law: Reporting
Statutes
• Child Abuse Prevention and Treatment Act and
Reporting Statutes
• Mandate reporting specific health problems and
suspected or confirmed abuse
• Health professionals must report under penalty of fine or
imprisonment for failing to do so:
• Infant and child abuse
• Dependent elder abuse
• Specified communicable diseases
 Civil Law

• Negligence: Failure to act in a reasonable

and prudent manner
• Malpractice: Failure of a person with
specialized education and training to act in a
reasonable and prudent manner
 What is Informed Consent?
In 1914, Justice Benjamin Cardozo stated, “ Every
human being of adult years and sound mind has
a right to determine what shell be done with his
own body…” (Schloendorff v. Society of N.Y.
Hospital).
 Definition
• Informed Consent (IC) is the duty of a health
care provider to discuss the risks and benefits
of a treatment or procedure with a client prior
to giving care
 IC must include the following:
1.The nature of the procedure
2.The risks and hazards of the procedure
3.The alternatives to the procedure
4.The benefits of the procedure
 When IC is Not Required
• In case of emergency situation (for minor or adult) A
MINOR is defined as a person who has not yet
obtained the age at which she or he is considered to
have the rights and responsibilities of an adult
(Alabama , Nebraska and Wyoming – 19 y.o., all other
states – 18 y.o.).
• It is prudent to obtain the IC from the adolescent in
case if health care providers have made a reasonable
attempt to contact the child parent
 When IC is Not Required
• Many states allow the evaluation and treatment
of a child for suspected physical or sexual abuse
without the informed consent of a parent or
guardian.
• Photographing and taking an X-Ray (Utah)
• In case of forensic examination (do not force or
restrain the child to perform genital or rectal
examination)
 When a minor can consent for care?
• Care involving pregnancy, contraception, or
treatment of STD
• Drug and alcohol treatment
• In some states – emancipated children can make
their health care decisions by themselves
 Emancipation
Emancipation is the legal recognition that the minor lives
independently and is legally responsible for his or her
own support and decision making.
• Can occur through an official court proceeding
• In some states, a minor can automatically become
emancipated by marrying, joining the military, or
becoming a parent before the age of majority
• Some states do not officially recognized any form of
emancipation
 When a minor can consent for care?
• Mature Minor Doctrine (in case if the minor has
not achieved emancipation) – “a minor can
consent to care as long as the individual
demonstrates the maturity to understand the
risks and benefits of the treatment”
 Parental Consent after Divorce
• After divorce, the ability to consent for medical
care rests with the parent who has been granted
legal custody by the divorce decree ( the legal
document approved by the court that grant
divorce, divides marital property, and specifies
child custody)
• Legal custody v. physical custody
 Refusal of Medical Care by Parent
or Child
• Religious beliefs - state can make legal
decision for the child
• PARENS PATRIE is a legal rule that allows
the state to make decision in place of parents
when they are unable or unwilling to provide
for the best interest of the child.
 Refusal of Medical Care by Parent
or Child
• Some states use child abuse statutes that make
medical neglect a form of abuse as legal
justification to take custody of a child who
needs medical care.
• The religious exemption clause only prevent the
parents from being prosecuted for medical
neglect.
 Obtaining IC under Special
Circumstances
• Consent for donation of tissues or organs
• Consent for genetic testing
• Consent for medical experimentation with
children
 Consent for Donation of Tissues or
Organs
• If a child is too young, the parent or legal guardian
may consent for the child
• Three requirement for the minor to be a donor:
1. The parent who is consenting must be aware of the
risks and benefits
2. The child primary caregiver must be able to provide
emotional support for the child
3. There must be a close relationship between the donor
and the recipient
 Consent for Genetic Testing
• Dilemma created by new technology
• The benefits and the risks should be discussed
with a child if appropriate
• Parents or guardian can consent for the testing
• Genetic testing should not be performed on a
child unless the results of the test will serve the
best interests of the child
 Consent for Medical
Experimentation on Children
• All research facilities that receive federal funds must
comply with federal regulations that require review of
all experimental protocols by an Institutional Review
Board (IRB) (Code of Federal Regulations, 1983).
• Federal regulations require the consent of one or both
parents and the assent of the child, depending on the
amount of the potential risk and benefit associated with
the treatment or procedure.
 Confidentiality
• The right to confidential health care is protected
by the US Constitution, federal and state laws,
and the ethical codes of health care
professionals.
• Confidentiality is an essential part of the
relationship between client and health care
provider
• Nurse has a duty of confidentiality (disciplined
by both employer and state board of nursing)
 When a Minor can Receive
Confidential Care
• Contraception, treatment of
STD DEPENDS
• Drug and alcohol treatment ON
• Mental health care STATE
• HIV testing LAWS
AND
REGULATIONS
 When a Health Care Provider Can
Breach Confidentiality
There are 4 exceptions:
1. Mandatory reporting laws for child abuse
2. Mandatory injury reporting laws that apply to all
clients who are injured by a weapon or criminal act
3. Public health law that require reporting infectious
diseases to the local health department
4. A duty to warn third parties
 Research
• Understanding the private worlds of physicians, nurses, and
parents: A study of life-sustaining treatment decisions in Italian
paediatric critical care (Franco A Carnevale, Monica Benedetti,
Amabile Bonaldi)

• This study’s aim was to describe: (a) How life-sustaining

treatment (LST) decisions are made for critically ill children in
Italy; and (b) How these decisional processes are experienced by
physicians, nurses and parents.
• Focus groups with 16 physicians and 26 nurses, and individual
interviews with 9 parents were conducted.

• Findings uncovered the ‘private worlds’ of paediatric intensive

care unit (PICU) physicians, nurses and parents; they all suffer
tremendously and privately. Physicians struggle with the weight
of responsibility and solitude in making LST decisions.

• Nurses struggle with feelings of exclusion from decisions

regarding patients and families that they care for. Physicians and
nurses are distressed by legal barriers to LST withdrawal.
• Parents struggle with their dependence on physicians and nurses
to provide care for their child and strive to understand what is
happening to their child.
 Bibliography
1) Lippincott, W.,& Wilkins. (2010). Essentials of pediatric
Nursing. New Delhi: Wolters Kluwer pvt Ltd. Pg.no. 106-132.

2) Wong’s,Clinical Manual of Pediatric Nursing (7th edition).

Mosby : Elsevier Publications.

3) Marlow, R. Dorothy.,& Redding, A. Barbara. (2008). Textbook

of Pediatric Nursing. (6th edition). Philadelphia: Elsevier
publications.
The End