Should guardians always be present during patient examinations?

Guardian Presence During Patient Examinations

The option of family member presence should be encouraged for all aspects of patient care, but this must be balanced with respect for patient privacy, evolving independence, and specific clinical circumstances. 1

General Principles for Guardian Presence

Benefits of Guardian Presence

• Enhances patient-family-centered care (PFCC)
• Provides emotional support for patients
• Improves communication between healthcare providers and families
• May actually improve care during procedures 1
• Studies show most parents observe quietly from a distance and rarely interfere with medical care 1

When Guardian Presence is Recommended

• During initial evaluation and examination 1
• For minor procedures (IV placement, laceration repair, etc.) 1
• For invasive procedures including resuscitation efforts 1
• When engaging family to help prepare children for procedures 1

Exceptions and Special Considerations

Adolescent Privacy

• Respect for the privacy of the patient and acknowledgment of the pediatric patient's evolving independence is essential, especially regarding reproductive issues 1
• Adolescents may need confidential care without guardian presence in certain situations 1
• When applicable laws allow adolescents to consent to specific services without parental consent, pediatricians generally may withhold resulting information from parents 1

Highly Consequential Infections

• For patients with highly consequential infections (like Ebola), adaptations and limitations may apply to parental/guardian presence 1
• A care team conference should be convened to determine appropriate level of guardian involvement 1
• Consider available hospital resources to support caregiver presence or provide alternative support via video-conferencing 1

Emergency Situations

• Unique ED situations require thoughtful advanced planning:
  • Arrival of child by ambulance without family
  • Unaccompanied minor seeking care without family knowledge
  • Visits related to abuse or violence
  • Time-sensitive invasive procedures including resuscitation
  • Unanticipated death of a child 1

Best Practices for Implementation

Communication Approach

• Provide clear information to guardians during interventions regardless of their decision to be present 1
• Use family-centered communication, promoting guardian engagement 1
• Ensure guardians feel valued and engaged during procedures 1
• Provide clear and concise descriptions of examinations in age-appropriate manner 1

Institutional Policies

• Develop institutional policies for PFCC through environmental design, practice, and staffing in collaboration with patients and families 1
• Ensure proper EHR systems to protect adolescent privacy regarding protected information 2
• Recognize state-specific laws allowing minors to access certain medical care without guardian consent 2

Common Pitfalls to Avoid

• Failing to maintain confidentiality of sensitive information 2
• Neglecting to address the needs of diverse patients and families 2
• Criticizing guardians' anxiety or difficulties in calming children 1
• Not providing guardians with clear instructions on how they can support their child during examinations 1

Remember that while guardian presence is generally beneficial and should be encouraged, each situation requires thoughtful consideration of the patient's privacy, developmental stage, and the specific clinical context.