Informed Consent and Scope of Practice for a Minor Procedure
A 16-year-old presents with an ingrown toenail and paronychia. He is accompanied by his mother, who consents to a partial nail avulsion with matricectomy. The teen is anxious and says he 'doesn't want it done.' He is otherwise healthy, takes no medications, and has no allergies. The mother insists the procedure is necessary and says she will sign for him. The clinic is busy, and the procedure is scheduled in 20 minutes.
1. How do you approach consent and assent in this situation?
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This is a consent and assent issue for a minor.
- Parental/guardian consent is generally required for a minor, and the mother can consent.
- Assent from the adolescent should be sought; his refusal matters and should be explored, not overridden.
- Explore his concerns: fear of pain, needles, or the procedure itself. Address with explanation, topical anesthetic, or a support person.
- Do not proceed against his wishes if the procedure can be safely deferred; document the discussion.
- If the paronychia is severe and limb-threatening (it is not here), emergency treatment may proceed under emergency provisions.
Respect the teen's developing autonomy while keeping the parent informed.
2. What if the mother demands the procedure immediately and the teen continues to refuse?
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Balance parental authority with the adolescent's emerging autonomy and the best-interest standard.
- Defer the procedure if it is not urgent - the paronychia can be managed conservatively (soaks, antibiotics if indicated) while addressing his anxiety.
- Explain to the mother that forcing a procedure on a distressed, refusing adolescent risks harm and is not in his best interest; offer a follow-up visit with anxiety management.
- Document the refusal, the discussion, and the plan.
- Involve a colleague or ethics consultant if conflict persists.
- If the condition worsens (spreading cellulitis, systemic signs), reassess and treat under emergency provisions with appropriate documentation.
3. What documentation and communication steps are essential before any procedure?
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- Document the indication, risks, benefits, and alternatives discussed.
- Document who consented (mother) and the teen's assent/refusal and the discussion.
- Confirm identity and allergies.
- Explain aftercare and warning signs to both patient and parent.
- Ensure privacy and a chaperone as appropriate.
- Record the time-out and procedure details.
- Communicate the plan to the care team and schedule follow-up.
Clear documentation protects the patient and the clinician and supports continuity of care.