Medical Consent - Role of the Medical Consenter
The medical consenter for a child in DFPS custody should:
- Know the child or youth’s healthcare needs, conditions and history.
- Help explain health information to child or youth in plain language.
- Prepare them to consent on their own in the future.
- Participate in medical and other health appointments with the child or youth.
- Provide a summary of child or youth’s medical care to CPS regularly or upon request.
- Immediately share information about significant medical conditions with CPS.
- Read, sign and follow instructions in Form 2085-B (Designation of Medical Consenter).
- Present Form 2085-B to all health-care providers.
- Provide emergency contact information.
- Acknowledge in writing by signing DFPS Form 2759 that the medical consenter has:
- Completed DFPS Medical Consent Training for Caregivers.
- Understood informed consent and the importance of considering non-pharmacological interventions (non-medication options) before or along with psychotropic medications.
- Completed DFPS Medical Consent Training for Caregivers.
Children who are removed from their homes suffer emotional stress, and some may act out in unhealthy ways. Most children slowly heal and learn to control their behavior with patience, understanding, and clear consistent rules. Some children may need medication to help them get better. Some may need it only briefly to relieve stress and deal with trauma. Others may need psychotropic medications long-term to treat mental health disorders. Psychotropic medications help some children feel better and function at home, in school, and in their daily lives.
If a child is having serious symptoms that are not getting better or is a danger to self or others, the medical consenter must always talk to a doctor. If psychotropic medications are prescribed, the medications must always be part of a plan that considers other help such as therapy, consistent house rules, and teaching positive behavior.
The brochure, Making Decisions about Psychotropic Medications, helps medical consenters prepare for a conversation with the provider. Taking the brochure along to the appointment can help guide the discussion.
Medical Consenters must:
- Attend appointments with any provider when psychotropic medications may be discussed or prescribed.
- Discuss with the provider the elements of informed consent and ask questions when needed.
- Consider the use of non-medication options prior to or along with psychotropic medication.
- Take the child being treated with a psychotropic medication to follow-up appointments with the prescribing provider at least every 90 days. (For more about follow-up appointments, see Initial Psychotropic Medication Appointments and Follow-up Appointments below).
- Provide information about new psychotropic medication prescriptions and dose changes in writing to CPS by the next business day.
- Complete and sign Form 4526, Psychotropic Medication Treatment Consent, for each initial psychotropic medication.
- Obtain the signature of the prescribing provider or designee, and send a copy to the CPS caseworker within five business days.
Considering Non-Pharmacological (non-medication) Options Before or Along with Psychotropic Medications
All children and youth should be given safety, praise, nurturing, consistency and support from a caregiver knowledgeable of Trauma-Informed Care. Therapy or professional counseling will also help children heal. The child or youth may receive professional counseling with a focus on Trauma-Informed Care and evidence based treatments such as Trauma-Focused Cognitive Behavioral Therapy. Find more information about trauma treatment at the National Child Traumatic Stress Network. The medical consenter should talk to the child's CPS caseworker, child placing agency case manager, therapist or treatment team about behavior strategies to help manage difficult behavior and help children deal with stress.
The medical consenter must participate in each medical appointment and attend any appointment in which psychotropic medication is prescribed or monitored, according to CPS policy, but healthcare providers may require greater participation. The minimum participation guidelines are below:
- Preventive Care: The medical consenter or backup medical consenter may provide written consent for a residential provider or another person to take a child to a healthcare appointment, unless the health-care provider requires the consenter to come in person or call by phone.
Each child in DFPS conservatorship must get the preventive care required by Texas HealthSteps:
- Well child examinations
- Sensory screening (e.g., vision or hearing)
- Developmental/behavioral assessment
- Laboratory testing for screening purposes (e.g., blood work, urinalysis, TB testing, STD screening, pelvic exam)
- Anticipatory guidance
- Dental check-ups
- Ongoing Behavioral Health Therapy: The medical consenter or backup must approve the behavioral health treatment plan and follow closely the progress of the child. The medical consenter is not required to attend every appointment or to be present during the entire therapy session, unless requested by the behavioral health provider. However, the medical consenter must work jointly with the behavioral health therapist to try additional non-pharmacological interventions (non-medication options) for the child when needed. For example learning to relax through breathing exercises.
- Allied Health Services: (Dietary services, occupational, physical, speech or other therapy). The medical consenter must approve the allied healthcare treatment plan and follow closely the progress of the child's treatment. The medical consenter is not required to attend every appointment but should attend when requested by the allied health-care provider.
- Initial Psychotropic Medication Appointments and Follow-up Appointments. Medical Consenters must attend appointments with any provider when psychotropic medications may be discussed or prescribed. Medicaid approved telemedicine appointments meet the requirement for attendance. The medical consenter must attend follow-up medication review appointments with the child and the provider at least every 90 days. During the appointment, the provider may also spend some time with the child alone. The follow-up appointment is needed to allow the provider to:
- Appropriately monitor the side effects of the medication.
- Decide whether the medication is helping the child achieve the treatment goals.
- Decide whether continued use of the medication is appropriate.
- Other Medical Care: The medical consenter or backup medical consenter must attend the appointment or participate by phone with the healthcare provider, as specified by the healthcare provider, for all other medical care. This medical care includes medical appointments for:
- Physical health treatment, (e.g., acute care).
- Dental treatment (e.g., fillings, crowns).
When the child's medical consenter is a live-in caregiver, participation in medical appointments should not be a problem. However, this can be difficult when the child's medical consenter is an employee of an emergency shelter or CPS. DPFS recognizes that health-care providers also have busy schedules and appreciate any attempt by health-care providers to accommodate CPS employees who are required to participate in children's appointments.
In an emergency, state law allows a child in DFPS conservatorship to receive medical care without a medical consenter's permission. The Texas Family Code §266.009(a) defines an emergency as a situation in which:
It is immediately necessary to provide medical care to the foster child to prevent the imminent probability of death or substantial bodily harm to the child or others, including circumstances in which: the child is overtly or continually threatening or attempting to commit suicide or cause serious bodily harm to the child or others; or the child is exhibiting the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the child's health in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.
In an emergency, the child's caregiver or caseworker is required to take the child to an emergency room or healthcare provider. If no medical consenter is available, the doctor decides if the child's condition is an emergency under the law. If the doctor provides medical care without consent, he or she must notify the medical consenter no later than the second business day after providing medical care.
The court must review a summary of each child's medical care at each hearing held under Chapter 263, which includes the status, permanency, and placement hearings. DFPS includes this medical care information in its reports to the court. In addition, Guardians ad litem and Attorneys ad litem are required to get a response from the child or youth, in a developmentally appropriate way, that expresses the child's opinions about the medical care they receive and report this information to the court.
When a child is prescribed a psychotropic medication, DFPS is required to notify the child's parents of the initial prescription and any change in dosage at the first scheduled meeting between the parents and the caseworker after the medication is prescribed or the dosage is changed.
DFPS must notify parents if their child has a significant medical condition. Examples of a serious medical condition include injuries or illnesses that are life threatening or have potentially serious long-term health consequences, including hospitalization for surgery or care other than minor emergency care.
As long as children and youth are in conservatorship, DFPS staff, residential child care providers, and medical consenters should provide developmentally appropriate education to children and youth about their health conditions, medical care, medications, and how to access medical services.
Medical consenters should encourage children to participate in decisions about their medical care to the greatest extent feasible, depending on the developmental capability of each child. This process, called assent, empowers children, helps prepare them to make medical decisions as a 16 or 17 year-old youth or an adult, and may improve long-term health outcomes.
Assent involves the following elements (adapted from “Informed Consent, Parental Permission, and Assent in Pediatric Practice,” Pediatrics, Volume 95, Number 2, Pages 314 – 317, February 1995.):
• Helping the child or youth achieve developmentally appropriate awareness of the nature of his or her condition.
• Telling the child or youth what he or she can expect with tests and treatment.
• Helping to prepare the child for adulthood.
• Assessing the child or youth’s understanding of the situation.
• Asking for the child’s willingness to accept the proposed care.
As children develop, they should assume more responsibility for their health-care decisions. The medical consenter should consider the wishes of the child in making the decision, although the medical consenter (for the child) makes the final decision.
Talking with children and youth about their health-care and encouraging children to participate in the decision making process of informed consent helps prepare children for the time when they will begin to make health-care decisions on their own. If a youth may make some but not all of his or her healthcare decisions, the medical consenter should continue to prepare the youth to take on the remaining health decisions when he or she either reaches age 18 or the court authorizes that the youth may consent to all health-care.