by Jonathan M. Fanaroff, M.D., J.D., FAAP
Pediatricians often are asked
to care for children when
the parent is not present. In
nonurgent situations, the pediatrician can take a number of practical steps
to maximize their patients’ access to care while
minimizing liability exposure.
These steps are discussed in the AAP clinical
report Consent by Proxy for Nonurgent Pediatric
Care from the AAP Committee on Medical
Liability and Risk Management. The report,
a revision of a 2010 clinical report, is available at http://dx.doi.org/10.1542/peds.2016-
3911 and is published in the February issue
The report makes the following recommen-
dations for pediatricians:
• Determine whether the practice will see
minor patients without a parent or guardian
present. It usually is best if all physicians within
the practice adopt the same policy; otherwise,
problems can occur during coverage situations.
• If the practice decides not to provide nonurgent
care to patients without a parent or guardian
present, then the office policy and an information sheet explaining it should be provided to
patients and their parent or guardian.
• If the practice decides to provide nonurgent care
to patients accompanied by someone other than
their parent or guardian, it should establish a
policy and procedural guide for the office as
well as a patient information sheet that explains
• It is advisable to create a template consent form
to be used in cases in which individuals other
than the parent or guardian may be expected
to accompany a child to the office. The report
suggests a number of items to include.
• The proxy relationship should be verified and
documented periodically. Additionally, when
the office or pediatrician does not know the
proxy personally, photo identification, such as
a driver’s license, may be required.
• Establish an office procedure for providing and
documenting informed consent for proxies with
limited English proficiency (LEP), hearing im-
pairment or limited health literacy. Similarly,
information sheets related to office policies
should be accessible for proxies with LEP and
limited health literacy.
• Pediatricians need to be aware of state and federal laws that affect the ability to give consent
by proxy (see www.plol.org). Additionally, it
is advisable to have legal counsel review office
policy and supporting documents to promote
compliance with applicable laws.
• It is recommended that informed consent,
including consent by proxy, be included in
residency training and continuing medical
education. Such educational efforts have been
effective in improving knowledge and attitudes
about informed consent.
• When in doubt about informed consent in a
proxy situation, pediatricians should use dis-
cretion in deciding whether to treat and should
base the decision on the child’s best interests.
Most important is for the pediatrician to recognize
and distinguish between appropriate and inappropriate proxy consent. It is perfectly appropriate to
perform a rapid test for Group A streptococcal infection in a patient with a sore throat with consent by
proxy. It would be inappropriate, on the other hand,
to perform genetic testing for Huntington disease.
Dr. Fanaroff is lead author of the clin-
ical report and chair of the AAP Com-
mittee on Medical Liability and Risk
How to minimize liability when providing
nonurgent care in parent’s absence
from the AAP Division of Quality
The Academy is working to ensure that quality
measures reflect the unique nature of care for children and demonstrate the value of care provided by
pediatricians. To that end, the Academy has partnered with the National Quality Forum (NQF) to
ensure the interests of children are at the forefront
of the national dialogue about quality measurement.
The NQF is a nonprofit, nonpartisan membership organization focused on improving health care.
It may be most well-known for its evidence-based
measure endorsement, which is considered the gold
standard in health care quality measurement. NQF
reviewed and endorsed many of the measures familiar to pediatricians, including numerous Healthcare
Effectiveness Data and Information Set (HEDIS)
measures and most of the measures in the Children’s
Health Insurance Program Reauthorization Act
(CHIPRA) Core Set. To date, NQF has endorsed
over 300 quality measures, which are used in a variety of federal, state and private quality programs.
To review all measures submitted for consider-
ation, NQF convenes standing
committees to focus on specific
topic areas. These committees are
comprised of subject matter ex-
perts from a variety of medical, al-
lied health and health policy fields.
For the last four years, Thomas K.
McInerny, M.D., FAAP, past AAP
president (2012-’ 13), has served as co-chair on the
NQF Health and Well-Being Project, which reviews,
evaluates and make recommendations regarding en-
dorsement of quality measures that address popu-
At the end of 2016, the Health and Well-Being
Standing Committee completed its review and rec-
ommendations for 23 quality measures. The com-
mittee recommended 15 for endorsement, four of
which included or directly impacted pediatric pop-
• childhood immunization status,
• preventive care and screening: influenza im-
• influenza vaccination coverage among health
care personnel and
• preventive care and screening: influenza immu-
As a member of NQF, the Academy participates in
public comment opportunities that include quality
measures specific to, or that directly impact, pediatric populations. The Academy also votes on the
standing committees’ final recommendations for endorsement. As of December 2016, over 30 FAAPs
had been appointed to standing committees for
about 20 different NQF projects.
AAP keeps children at forefront of dialogue on quality measures
• National Quality Forum (NQF) website, http://bit.
• NQF Health and Well-Being Project, http://bit.ly/2jfaDB8
• NQF Draft Report for Voting, http://bit.ly/2ig9oxl
It is imperative that pediatricians recognize and distinguish
between appropriate and inappropriate proxy consent in
nonurgent care, according to a new AAP clinical report.