pediatric and teen cl care

Children and Informed Consent

BY JEFFREY J. WALLINE, OD, PHD, & MARJORIE J. RAH, OD, PHD

All patients should be informed about the potential risks and benefits of a treatment prior to initiation of that treatment. Although contact lenses are a relatively benign treatment, they still carry risks. You need to inform patients of the potential negative consequences so they can decide whether they want to be fitted with contact lenses.

But how much information is too much information? When do patients stop listening or understanding? Are we unnecessarily alarming our patients by telling them of the potentially devastating side effects that rarely occur?

The process of informed consent becomes even more difficult when children are involved. Children who have equal intellectual abilities aren't all capable of understanding abstract ideas at the same age.

When to Involve Children

Age 18 years is the legal age of consent. Children younger than 18 years typically require an adult to provide permission prior to initiating treatment. Children as young as 5 years may be able to understand the concept of risks and benefits of lens wear if explained properly. These children should provide assent prior to treatment.

Assent is active affirmation of the treatment obtained either in writing or verbally. Either way, the language must be easily understood by the patient. Short statements that can be pictured by the child provide the best information. Make written documents shorter than one page, use large print for young children and illustrations if appropriate. Figure 1 is not a legal document, but you can use it for assent by a child and it may help a child learn how to best care for lenses.

Children should also be able to "vote with their feet." Some children who don't understand future actions are very capable of letting you know on-the-spot when they are uncomfortable. If the child says "Stop!" then you must stop. You may talk to the child about alternate treatments or explain the process more clearly and begin again, but realize that the child has the right to discontinue treatment at any time.

Parents' Role

Parental permission is used for children who provide assent or for children too young for assent. Document parental permission more rigorously than a child's assent and provide more information about the potential risks and benefits of lens wear. Give parents time to ask questions prior to initiating the fit. Most practices obtain parental permission verbally, but some have parents sign a document that either lists the risks and benefits or says that the parents understand the risks and benefits as stated verbally.

Regardless of whether you choose to obtain consent and assent verbally or in writing, you should explain all potential risks, such as corneal ulcers, microbial keratitis, red eyes and irritated eyes, in terms of chance of occurrence, symptoms and eventual outcomes. Once these are understood by the patient (accounting for ability to understand) and parents, the fitting process can begin. CLS

Dr. Walline is an assistant professor at The Ohio State University College of Optometry, where he conducts studies of pediatric contact lens wear. Dr. Rah is an assistant professor at the New England College of Optometry where she works primarily in the Cornea and Contact Lens Service in patient care, teaching and research.