5.3 Scenario Practice for Professional Responsibilities

5.3 Consent, Permission, and Assent

Pediatric consent is the single most tested professional-responsibility topic. Because minors usually lack the legal capacity to enter a contract, the AAP reframes the process as a triad rather than 'consent' alone:

• Informed permission is given by the parent or legal guardian after disclosure of the diagnosis, proposed treatment, risks, benefits, and alternatives. (Strictly, only a competent adult 'consents'; a parent grants permission for a child.)
• Assent is the child's affirmative agreement to participate, solicited when developmentally appropriate (commonly cited around age 7 and older, but capacity-based, not a hard age). Soliciting assent respects the developing child as a person.
• Informed consent by the minor applies when the minor is legally authorized to decide for themselves.

When a minor can consent for themselves

The exam-safe stance: the nurse knows their state statute and facility policy, advocates for the adolescent's access, and does not impose a blanket parental-consent rule when a recognized exception applies. A common trap answer demands parental consent 'in all circumstances' — that is wrong for emancipated/mature minors and statutory exceptions.

Assent, Dissent, and Confidentiality

Assent is more than a child not objecting; it is an affirmative, developmentally appropriate agreement. Soliciting it involves helping the child understand their condition, telling them what to expect, assessing their understanding, and asking whether they are willing to proceed. A child's dissent (refusal) should carry real weight in elective situations. , emergency or life-saving care), parental permission governs and treatment may proceed despite dissent — but the team should still prepare the child and minimize coercion. Never solicit assent if you have no intention of honoring a refusal; that is deceptive.

Emergency exception: In a true emergency, treatment necessary to prevent death or serious harm may proceed under implied consent without waiting for a parent.

Confidentiality with minors

Adolescents are more likely to seek care and disclose honestly when confidentiality is protected, so the nurse should provide private time with the teen and clarify the rules up front. Confidentiality is not absolute, however. The nurse must disclose when there is:

• Risk of serious harm to self (suicidal intent) or to others (homicidal intent).
• Suspected abuse or neglect (mandatory reporting overrides confidentiality).
• A legal mandate such as a valid subpoena or court order.

When served a subpoena, the correct action is to contact institutional legal counsel/risk management before responding — not to refuse outright and not to alter or destroy records. Tampering with the legal health record is never acceptable.

Ethical principles in play

Many scenarios map to the four bioethics principles: autonomy (the developing adolescent's voice), beneficence (acting in the child's best interest), nonmaleficence (do no harm), and justice (fair, equitable care). When parental wishes and the child's best interest collide, the nurse advocates for the child's best interest and escalates unresolved conflicts to an ethics committee rather than acting unilaterally.

Special Consent Situations

Several consent variations show up repeatedly on the CPN:

• Divorced/separated parents and custody: Verify legal custody before accepting consent. A non-custodial parent may not have authority to consent; in joint legal custody, either parent generally may consent. Foster parents and other caregivers often cannot consent to non-routine care without state-agency authorization.
• Surrogate decision-making: For a child without an available parent/guardian, consent comes from a legally authorized representative or, in emergencies, implied consent to prevent serious harm.
• Religious refusal of life-saving care: When a parent refuses essential treatment (e.g., a transfusion for a Jehovah's Witness child), the nurse respects the belief, seeks options, and escalates; courts can authorize treatment over parental objection because the state's parens patriae interest protects the child's life.
• Research vs. treatment: Pediatric research requires parental permission and the child's assent under stricter rules (federal regulations limit acceptable risk), in addition to IRB approval.

Documentation and the legal health record

Consent and assent discussions must be documented — what was disclosed, who gave permission, whether the child assented, and the use of an interpreter. The record is a legal document: late entries follow the late-entry/amendment policy, errors are corrected with a single line-through and initials (never obliterated), and the record is never altered or destroyed to change its meaning. Falsifying or deleting documentation is fraud and a reportable violation.

HIPAA and minors' protected health information

, a statutory exception), when the parent agreed to a confidential relationship between the minor and provider, or when state law says otherwise. In those situations the adolescent, not the parent, controls disclosure. The practical exam point: when a teen has legally consented to confidential care, the nurse does not automatically release that information to the parent. Share PHI on a need-to-know basis, verify the requestor's authority, and follow facility privacy policy and the minimum-necessary standard.