No guardian present

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F0nzie

F0nzie

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Getting pressured by my CMHC to do a psych eval on an 18 year old who has a guardian but the guardian cannot make the appointment. Should I see this patient?
 
Why does the 18 year old have a guardian? (meaning, is she DD or in any way not considered competent)
 
sunlioness said:
Can't they just reschedule it?


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I am booked out 6 months and 2 doctors just transferred to another clinic. They will have to reschedule or kick someone off the schedule. They're talking about bringing in a legal representative by phone who will be covering the guardian.
 
Totally unclear to me if this differs by state or compared to child psych, but at least for us, kids can be seen for up to 6 sessions for therapy/evaluation without parental consent. Curious if there is a similar law for DD folks with guardians?
 
Pick an alternative day when the guardian can be present, schedule the patient and guardian at the end of the day and have the clinic pay you extra for the hour longer you're staying. Of course all support staff needs to stay longer too.
 
F0nzie said:
Getting pressured by my CMHC to do a psych eval on an 18 year old who has a guardian but the guardian cannot make the appointment. Should I see this patient?
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of course.....just see the patient. it just seems like you are being difficult for a rather trivial thing here.
 
vistaril said:
of course.....just see the patient. it just seems like you are being difficult for a rather trivial thing here.
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You can't provide services to someone with a guardian without the guardian present b cause the patient does not have the capacity to provide informed consent.


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Also, when you want to discuss the plan, how can you do that without the guardian there? The person who lives with the patient and consents to all pieces of their care should definitely be at the visit.
 
Which I ran into once. I saw a developmentally disabled adult for an evaluation without his parents (who were guardians) present. An employed caregiver was with the patient and she had most of the history. Now the caregiver was raising various concerns and said that she felt the patient needed a medication adjustment. So I recommended an adjustment, but asked her to clear it with the parents first. And when permission was obtained, I'd send over the script.

Well, the parents were furious that I'd recommend changing anything. Very furious. Demanding to talk to supervisors furious. And their take on things was very different than their hired representative's even though she claimed to speak for them.

Nuh uh. Not doing that again.

If you do see the patient without the guardian, I'd hold off on even voicing any recommendations until you can talk to him or her on the phone directly.


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there must be a reason that mom is not legal guardian. I wouldn't see this patient without legal guardian present in some form. If they are available over telephone during the time of the consultation that would also be acceptable. Otherwise this is just a waste of your time and creating more problems. If they have to reschedule in 6 months well that is not your problem. If they cant make the appt by some method I would count that as the same thing as a no show.
 
notdeadyet said:
You can't provide services to someone with a guardian without the guardian present b cause the patient does not have the capacity to provide informed consent.


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surely fonzie could touch base with the guardian by phone towards the end of the intake and go over plan. That would be simple. It just seems like he is coming at this like "whoa, there is some possible problem and now I can't see the patient because of it" rather than "there is a minor problem we have to find a solution for so I can do my job"
 
vistaril said:
surely fonzie could touch base with the guardian by phone towards the end of the intake and go over plan. That would be simple. It just seems like he is coming at this like "whoa, there is some possible problem and now I can't see the patient because of it" rather than "there is a minor problem we have to find a solution for so I can do my job"
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Wasn't available by phone either. Luckily my intake today canceled and they were able to fit the pt in.
 
F0nzie said:
Wasn't available by phone either. Luckily my intake today canceled and they were able to fit the pt in.
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if thats the case(that the guardian wasnt available for a quick phone call), then I think you were right to balk. Because that would mean you are willing to work to find a reasonable solution but the guardian was not(jesus how hard is it to make time for a quick phone call?)
 
Why not talk to the patient only and then talk with the guardian over the phone at a later
time? Does merely asking questions of someone require a risk/benefit discussion and consent? I'm not CAP, so I have no clue about the legalities, but practically, it seems that making treatment recommendations and just talking to the patient represent two very different levels of "intervention." Of course, I'm not sure how helpful your evaluation will be without the parallel history from the guardian, but that's a whole other (perhaps more clinically important) can of beans. In any case, you probably wouldn't want to talk to the mother without consent from the guardian.
 
Is all this true for children too? Or only people who are assigned a guardian because of some specific reason? I feel like I saw doctors without my parents probably starting around 12 years old or so.
 
vistaril said:
surely fonzie could touch base with the guardian by phone towards the end of the intake and go over plan. That would be simple. It just seems like he is coming at this like "whoa, there is some possible problem and now I can't see the patient because of it" rather than "there is a minor problem we have to find a solution for so I can do my job"
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I would want to talk to the guardian first actually. I get periodic referrals from DFS for "psych evals". I have really begun to hate that term because of these types of referrals. If I don't have a referral question, then I don't really know what the purpose of the eval is and the patient doesn't know why they are there either. "They told me I had to come." Also there are significant legal issues involved and the caseworkers at DFS don't know or care much about my own ethical and legal obligations. If a parent has lost custody, they won't be honest with you about it either because it was always because DFS was being unreasonable or overreacting, etc.
 
Why would a physician walk into a known career-killer-if-sued situation? Especially being child trained? NOPE. Good call initially to not see the patient, especially if they can't give informed consent. The legal road isn't a long and winding one when the law is as clear-cut as it is in these situations.
 
Be vigilant. I caught one parent who signed every form at an intake EXCEPT the form giving consent to evaluate and treat their child. It was clearly not an accident. It was a setup for a lawsuit.
 
HooahDOc said:
Be vigilant. I caught one parent who signed every form at an intake EXCEPT the form giving consent to evaluate and treat their child. It was clearly not an accident. It was a setup for a lawsuit.
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Curious as to why you were so sure that wasn't an oversight?

Also, it might be tough for them to contest that they were not consenting to treatment when they are the one bringing them to the appointment. Every child psychiatrist that I have worked with meets with, or at least talks to, the parent at every appointment. If it is a divorced parent situation might be a bit different story. The consent form is more of a cya than an actual legal requirement has always been my understanding. It would be pretty tough for them to argue in court that they didn't want treatment, but they showed up to the appointment and then filled the prescription that you ordered.
 
smalltownpsych said:
Curious as to why you were so sure that wasn't an oversight?

Also, it might be tough for them to contest that they were not consenting to treatment when they are the one bringing them to the appointment. Every child psychiatrist that I have worked with meets with, or at least talks to, the parent at every appointment. If it is a divorced parent situation might be a bit different story. The consent form is more of a cya than an actual legal requirement has always been my understanding. It would be pretty tough for them to argue in court that they didn't want treatment, but they showed up to the appointment and then filled the prescription that you ordered.
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Everything else about the parent, past random and frequent threats to sue over nothing, frequently complains and generally wreaks havoc on the clinic. I get the idea of implied consent, but it's easy enough for a parent to argue they didn't understand that their child was actually going to be evaluated in some way. And you're right, the consent form is not a legal REQUIREMENT, but it's a good idea. The more hard proof you have, the better off you'll be in court. Unless, of course, the hard proof supports malpractice.

I always check in with parents of younger kids. I always talk to parents at the initial appointment. Depending on the clinical situation and history, I don't always check in with the parents of adolescents unless I feel the need to, at least at every appointment. I will still check in occasionally but it all depends.
 
HooahDOc said:
Everything else about the parent, past random and frequent threats to sue over nothing, frequently complains and generally wreaks havoc on the clinic. I get the idea of implied consent, but it's easy enough for a parent to argue they didn't understand that their child was actually going to be evaluated in some way. And you're right, the consent form is not a legal REQUIREMENT, but it's a good idea. The more hard proof you have, the better off you'll be in court. Unless, of course, the hard proof supports malpractice.

I always check in with parents of younger kids. I always talk to parents at the initial appointment. Depending on the clinical situation and history, I don't always check in with the parents of adolescents unless I feel the need to, at least at every appointment. I will still check in occasionally but it all depends.
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I agree completely and with the communication with parents part, I have a fairly similar setup. I also have noticed that whenever my spidey sense tingles on one of these types of documentation issues with kids, it is because someone is trying to game something and then I usually ask for more documentation rather than less.
 
smalltownpsych said:
I agree completely and with the communication with parents part, I have a fairly similar setup. I also have noticed that whenever my spidey sense tingles on one of these types of documentation issues with kids, it is because someone is trying to game something and then I usually ask for more documentation rather than less.
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Many parents have a way of creating new problems for you, even if the patient is doing great and has no concerns and demonstrates improvement and stability. Sometimes it's easier to just not go looking in the first place, to avoid getting into more discussion and education about the dynamic and need for parent to create a problem in the presence of improvement and the patient doing well, and that not every little thing they observe warrants clinical attention.
 
In residency I once saw a kid who was brought in by either her uncle or grandfather, but he wasn't her legal guardian. Because of this, we required that they reschedule and bring the legal guardian to the first appointment. At subsequent visits it was allowed for other family members to bring her in if they had documented permission from the parents. I would imagine that adults with a guardian should be handled in a similar manner.
 
HooahDOc said:
Imagine how fun all of this gets when a minor patient turns 18 between appointments and the parents cannot seem to understand why they can no longer have anything to do with the patient's care without his permission.
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I have had times where that is a definite benefit for the patient and for me. I don't get paid for phone calls to anxious over-involved parents so it's always good to tell them I can't talk to you anymore and the kid can really start working on their own autonomy that was held back cause of mommy and/or daddies own fear and need to control. It gets a little dicier when kid has severe problems and then the discussion with kid is more about making a choice to have continued parental involvement.
 
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