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Scenario 1
A 9 year old boy is brought to the ED by his parents. He has suffered a 5 cm laceration over his right knee. The child started screaming the place down when I mentioned 'stitches'. The parents also look concerned. They have refused to let me proceed with suturing. What do I do now? Would it amount to battery if I ignored the child's and parents' wishes and continued to suture by holding the kid down? (and, what would you do if this child is a Type 1 Diabetic??)

Scenario 2
A 16 year old girl booked into your ED complaining of heavy, painful bleeding PV. Urine pregnancy test was positive for bHCG. You have diagnosed an ectopic pregnancy and the obstetrician suggested urgent laparotomy. She however has requested you not to inform her parents. Would you breach confidentiality if you informed her parents?? What would you do?

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Scenario 1
Knee laceration is not a life threatening injury. Consent from the parents is necessary.
Give 2 options
1) Suturing will be done under adequate sedation Eg: Ketamine,
along with an anesthetist or another emergency physician. Follow the same procedure as day care surgery.

2) Suturing to be done under local anesthesia and an analgesic plus mild sedative Eg: Morphine plus or minus midazolam. Use this option if the parents are poor and cannot afford option 1.
Obviously the child will be distressed but the parents can be prepared well by adequate explanation of the procedure and counselling.
And i think you can take the 5 stitches in about 6-7 minutes.



Scenario 2
This is a little difficult situation. You need more input from others. But here is what I think. 16 year old is a minor. Consent is required from a parent or a guardian before undertaking the surgery.

If I had seen this patient, I would have throughly counselled the girl along with another lady doctor or social worker and convinced her to let me inform her parents. (I will do this even if it takes me a couple of hours - Provided the patient is stable)
Then I will counsel the parents before they meet the girl, to ensure they will be 100% supportive. Then take their consent for surgery and go ahead.

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A teenage girl will be highly disturbed in such situations and this is an ideal time for suicidal thoughts. It is of utmost importance to select the most senior & experienced person to proceed carefully with the counselling. Full trust of the patient MUST be achieved.
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Scenario 1

What do I do if the parents are still not convinced despite me offering LA/Sedation/GA? Am I right if I go ahead and suture the wound without the patient's/his parent's consent as I have the 'duty of care'?? Will I be liable to charges of 'battery' if I did?? What rights do the parent's have over their children in such situations to give consent? Has the child got 'Capacity' to get a valid consent? If not, at what age would you even start considering 'capacity' for a child? what does the law of the land say??

Scenario 2

Agreed that the patient may not be in an ideal state of mind. Though ideally you would want to involve her parents, does it not amount to breach of 'confidentiality'? At 16 years of age is she competent (has capacity) to make the decision of not informing her parents and go ahead with an emergency laparotomy?

Any ideas....

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Wait, I'll get some more experienced people to reply...

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Scenario 1

Reasons why parents not happy to get the suturing done

1.Worried that the child will be subjected to lot of Pain during the procedure.
2.May think that the benefits of sututing outweigh risks of the procedure.

---I think dealing with child is main issue here.
If the child is 9yr old he is old enough to know about suturing the pain.
I would start with child and spend good time with him explaining him the procedure(in his language and IQ level) and try and understand if he gets the concept.
I would reassure the child that there will be no pain during the procedure,try and alleviate his fears by demonstrating the small mock procedure.

---Dealing with parents
Good explanation of the procedure(I prefer Ketamine as it is short and quick)

I presume most of the parents want the procedure to be done as long as the child is not in distress.If still parents are adamant then we need to think of other aspects like financial issues or are they not happy with the overall care and would be nice to know what their expectations are.

Parents have got duty towards the child not rights.It is their duty to ensure that the child gets proper treatment and if the conflict is about the treatment(not life threatening)then there should be agreement and if they still adamant then i would involve the Socail services/Police.

Law of Land:
The age for consent for medical treatment is not officially laid down. There are obscure provisions made in Indian penal code section (IPC87 and 88), which refers to the validity of consent, which may occur from any act done in good faith and for individual benefit. Perhaps, these provisions are not specifically directed at medical treatment. When both the IPC (Sections 87 & 88) are combined, one can conclude that there is an implication that parental consent is necessary for medical treatment or surgical procedures on the minor.

Scenario 2
I think the answer for that question is in the above paragraph.

Looks like there is a majour overhaul needed in the LAW

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I agree with your statement that parents only have a duty towards the child but not its rights. But is there such thing as a proper social service back-up. Even the police for instance are not fully informed when it comes to such legalities as consent...
It would be interesting as to what stand the judiciary would take. I however wouldn't think that the rules would be the same in both the instances,as in the latter, the patient may be having the capacity to make a well informed, valued judgement ( a la the 'emancipated' child in the context of US and Gillick/Fraser guidelines in the UK).
However, in the context of our subcontinent, the socio-cultural background for most people is different. In most families, children depend (or shall we say it is expected of them!!!) to a great extent on their elders to make crucial judgements. Even if it means that the decision is wrong!!!