Today’s young people have access to more information via the internet and the media than their caregivers ever had as teenagers. This includes access to factual and misleading information about their healthcare, especially vaccines. In this post, we cover the key terms, tools, and strategies pediatricians can use to support adolescents’ vaccine and healthcare rights, including resources for finding accurate vaccine information and for advocacy.
Why Safe and Effective Vaccine Information Remains Key for Adolescents
As the COVID-19 pandemic continues and immunizations for children remain vital to preventive care, offering information and support to families as they weigh vaccination decisions can help make communities safer and strengthen the bonds between pediatric practices and their families. A 2020 report by the Centers for Disease Control & Prevention (CDC) found that adolescent vaccine rates dropped significantly during the pandemic, and pediatricians have a major role in getting patients back on track.
Pediatricians have opportunities every day to be a young adult’s support system, informational guide and advocate for rights and responsibilities teens begin to embrace as they gain autonomy and weigh the risks and benefits of their healthcare decisions. Legal and ethical standards for adolescents’ privacy, confidentiality, and rights can get tricky quickly, so it’s essential to research your state’s laws before advising families. This infographic by the Kaiser Family Foundation gives an overview of consent laws for COVID-19 vaccines in U.S. states.
Making Informed Medical Decisions in Pediatric Primary Care
Who makes medical decisions about vaccines and when does an adolescent get a say? Medical staff can support kids and caregivers in making sensible medical decisions for every individual by being a supportive source of information and a guide for young people learning to do their own healthcare research. Here are some resources pediatricians can have on hand to start the conversation of informed medical decisions.
The correct vocabulary can help clarify a sometimes overwhelming new world of information for patients and their caregivers exploring the unique responsibilities of medical decision-making. Here are some key terms:
- Informed consent is a process that engages patients in their healthcare and affirms parental permission and patient assent or refusal before, during, and after conducting medical procedures. According to the AAP, “Encouraging pediatric patients to actively explore options and to take on a greater role in their health care may promote empowerment and compliance with a treatment plan.”
- In most U.S. states, the age of majority is 18, which means that a patient usually needs parental permission to consent to medical treatment if they are an unemancipated minor. For example, the CDC lists the age of consent for a patient to receive STD and HIV treatment as 18, with some patients qualifying for exceptions when they are as young as 12 years old. Exceptions are depending on state statutes, such as prenatal care, for treatment of sexually-transmitted diseases, or for immunizations.
- Confidentiality keeps medical information safe between physicians and patients. Pediatricians have the responsibility to know their state’s laws for patient confidentiality. The HIPAA Privacy Rule recognizes parents in most cases as the patient’s personal representative with some important exceptions.
- Mature minor laws enable physicians to determine whether a patient is “mature” enough to make informed medical decisions on their own, despite being younger than the age of majority (18 years in the US). The laws also protect physicians from legal claims. Laws vary by state and may not offer confidentiality protection for minors. Documentation is crucial in these cases.
These terms are useful tools in beginning conversations about decisions in adolescents’ medical care -- they are a starting point to a long term care plan. Just as informed consent continues as a process throughout treatment, conversations about medical decision-making are great ongoing topics for teens as they mature to adulthood. For more information about guiding adolescent patients to making their own care decisions and eventually transitioning to adult healthcare, be sure to check out our previous post.
Strategies for Patient Engagement: Vaccines
In regards to vaccines, there are three possibilities where informed medical consent and the question of adolescents' medical decision-making rights come into play. First, the caregiver and patient could both assent or refuse vaccination; the patient could refuse while the caregiver assents; or the patient could assent while the caregiver refuses.
Scenario 1: Caregiver and Patient Both Assent/Refuse
In the first scenario, the united front of patient and caregiver makes actionable steps reasonably straightforward for the physician -- in the case of assent, vaccines can be given. In case of refusal, the physician’s chosen steps for addressing vaccine hesitancy can be introduced. Some strategies for addressing vaccine hesitancy are:
- Compassionate listening. What are the families’ fears, concerns, and assumptions about vaccines and can any be addressed during the visit?
- The CASE response, recommended by the AAP. This method includes four steps: Corroborate, About Me, Science, and Explain/Advise.
- Verbal, material, or online resources explaining the safety and efficacy of vaccines, including the testing process.
- Strong recommendations for vaccines. The AAP states that the current vaccine schedule is the only accepted vaccine schedule.
- Providing clear guidance about the risks and consequences of choosing not to vaccinate.
For more professional resources on addressing vaccine hesitancy, the CDC offers both patient education and provider information.
Scenario 2: Patient Refuses, Caregiver Assents
Ethically and emotionally, a patient who refuses a vaccine, even if their parents assent, is a challenging case for pediatricians, and the patients’ concerns and refusal must be weighed respectfully and carefully. The AAP states that the provider’s responsibilities include giving the patient developmentally-appropriate information about treatment, consequences, and resources for more information, as in the case of a vaccine-hesitant parent.
Options and ideas should continue to be exchanged between physicians and the family to evaluate the best course of action for the patient in this case, including physical health as well as the needs of the patient’s social, emotional, and family needs. See the AAP’s complete list of recommendations here.
Scenario 3: Patient Assents, Caregiver Refuses
In many states, the parent or legal guardian’s role as medical decision-maker means that a caregivers’ choice to refuse one or more vaccinations is final until the decision is reversed or the patient reaches the age of consent.
There are however several states that allow for exceptions to this general rule. For example, patients in Alabama can self-consent for the COVID-19 vaccine at age 14. Pediatricians should be aware of their state’s regulations to provide patients with resources to vaccinate without parental consent as requested, while taking into consideration the importance of maintaining both appropriate confidentiality and the trust of both caregivers and patients.
Adolescents may request treatment without the consent of a parent at Title X clinics. According to the U.S. Health Resources & Services Administration, “Title X Family Planning clinics receive funding from the Title X Family Planning Program to provide individuals with comprehensive family planning and preventative health services.” This would allow patients to receive vaccinations related to reproductive health and family planning, such as the HPV vaccine. Title X programs in the U.S. were reduced by 50% after a revision in 2018 by the Trump administration -- learn more about the current state of Title X here.
Other resources for adolescents include websites such as vaxteen.org, which gives information on states’ consent laws and avenues for vaccination, and guides on various vaccines and talking to parents about vaccinations.
Overall, communication about vaccines and medical decision-making are some of the most important conversations pediatricians have adolescent patients. By knowing state regulations and arriving prepared with resources to encourage questions and conversations, pediatricians can help close the gap in vaccination rates and empower adolescents’ growth into healthcare autonomy.
When you're finished with adolescent well visits, be sure to give your practice its own well visit, too. Check out this webinar from PCC to learn how a financial well checkup can get your practice prepared for the months and years ahead.