Guidance for confronting the caregiver
The report includes a number of recommendations for pediatricians to use in dealing with impaired caregivers. The first is to conduct a safety audit of the practice, and to train staff on how to recognize and intervene as needed. Reporting any confrontation is another task that must be considered. In cases wherein confrontations or concerns about a caregiver’s impact on patient safety, a clinician’s duty to the patient overrides any considerations for confidentiality in regard to the parent or caregiver.
Even when a confrontation is required, Bondi says his hope is that pediatricians confront impaired caregivers as he hopes they would approach anyone—with kindness and respect.
“The conversation with an impaired caretaker may be quite difficult for the pediatrician, for the parent, and for the child,” Bondi says. “It's best to find a discreet but safe area where the conversation can be had. I think framing everything as concern for the child is a great way to get through to the caretaker.”
Another consideration is the fact that impaired caregivers may be unable or unwilling to give consent for medical treatment. The report suggests that nonurgent treatments be delayed until consent can be obtained, and that the pediatrician should be sure to document conversations and concerns in regard to delayed care.
Overall, Bondi says he hopes pediatricians realize how often they will face impaired caregivers and to be prepared for it.
“Encountering an impaired caregiver is something many pediatricians likely have never thought about. Having to react in the heat of the moment and not having previously considered this problem could result in a less than ideal interaction,” Bondi says. “It is my hope that at a minimum clinicians will read this report and tuck away the points that we raised. Thus, they won't be completely blindsided when it comes up. Of course, ideally practices would consider these issues thoroughly and train staff based on the issues we raise.”
1. Bondi, SA, Scibilia J; Committee on Medical Liability and Risk Management. Dealing with the caretaker whose judgment is impaired by alcohol or drugs: legal and ethical considerations. Pediatrics. 2019;144(6):e20193153. Available at https://pediatrics.aappublications.org/content/144/6/e20193153#ref-1. Accessed February 11, 2020.
2. Lipari RN, Van Horn SL. Children living with parents who have a substance use disorder. In: The CBHSQ Report. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2013. Available at: https://www.ncbi.nlm.nih.gov/books/NBK464590/. Published August 24, 2017. Accessed February 11, 2020.