Confidentiality and consent when a young adult asks you not to tell her parents

Sophie is 19 and is presumed competent to make her own health decisions. The starting point is confidentiality: I cannot disclose her clinical information to her mother without Sophie's consent, even if her mother is paying the bill. Payment arrangements do not create a right to clinical information.

• I would explain this clearly to Sophie and ask what she wants her mother to know, if anything. I could discuss fees or payment with her mother only with Sophie's consent and only the minimum administrative information needed.
• I would not discuss the suspected diagnosis, refraction, topography or referral with her mother.
• If Sophie wants her mother involved later, I would record that consent.
• A request for her own records should be handled under the Health Information Privacy Code. She is entitled to access her health information. I would confirm identity, explain the process and provide the records within 20 working days, with any reasonable copying fee disclosed in advance. I would withhold information only in the limited circumstances allowed by the Code, such as where disclosure would pose a serious threat to someone's safety, and I would document the reason.
• I would document the confidentiality discussion and her instructions.

I would not issue a contact lens prescription yet. A prescription implies that a lens has been fitted, assessed for fit and safety, and that the patient can handle and care for lenses. Sophie has not been fitted, and keratoconus makes lens selection more complex. Giving a prescription for online ordering before fitting could lead to a poorly fitting lens, corneal insult or wasted money.

I would:

• explain the difference between a spectacle prescription and a contact lens prescription;
• state that I can provide a spectacle prescription now, but that her corrected acuity and keratoconus mean spectacles may not give the best vision;
• refer for corneal topography and ophthalmological assessment, because inferior steepening with high astigmatism suggests keratoconus;
• explain that contact lens fitting, if appropriate, would usually be a specialist or experienced keratoconus fitting process after the diagnosis is confirmed;
• document that she requested a contact lens prescription and that I declined with reasons, and document her understanding.

If she chooses to order lenses online anyway, I would explain the risks without being punitive, and offer review if she has problems.

I would explore her concerns rather than simply repeating the referral. Cost and privacy are real barriers, and keratoconus can progress, so refusing referral is not a neutral choice.

• Clarify what she is worried about: the cost of consultation, the possibility of surgery, or her mother seeing a bill. Explain what the referral involves and that a public hospital assessment may be available depending on triage.
• Discuss options for confidentiality, including whether she can be contacted directly and whether she wants to pay in instalments.
• Explain the natural history: keratoconus can progress, and timely cross-linking or specialist contact lens management may protect vision. Do not exaggerate, but do not minimise the risk.
• If she still refuses, document informed refusal, the risks discussed, the advice given and the offer to review. Provide a safety net: return if vision changes, if glasses no longer help, or if she changes her mind.
• With her consent, I could write to her GP to ensure another route to review exists. Without consent, I would not disclose.
• I would not abandon her. I would offer monitoring and repeat the referral discussion at review.