Protecting oneself when parents refuse vaccinations for their children entails documenting all discussions – including a conversation about how parents should respond to illness or fever – as well as creating a system in the office to identify incompletely immunized patients for proper triage and care should the need arise, Dr. James P. Scibilia said at the annual meeting of the American Academy of Pediatrics.
Pediatricians should also document that parents have received a vaccine information sheet at each relevant visit and ensure that parents sign appropriate and unaltered “informed refusal” forms, preferably the AAP’s Refusal to Vaccinate form, each time vaccination is refused, said Dr. Scibilia, who is not an attorney but serves on the AAP Committee on Medical Liability and Risk Management.
©dina2001/thinkstockphotos.com
“If patients bring their own form, make sure you read it properly. I received one that had an AAP logo and looked like our form but had a different set of information,” he said.
Physicians may be at legal risk if parents claim in the wake of a bad outcome that they weren’t informed of the risk of nonvaccination; courts have favored the plaintiffs in at least a couple of reported cases thus far, he explained.
Documentation of repeated vaccine discussions – with chart notes indicating that “you’ve reemphasized the risks of not getting a vaccine,” for instance – is important. “Have some little phrase to integrate into your records so you can show that each time the patient came in, you readdressed the issue with them,” said Dr. Scibilia, of Heritage Valley Health System, Beaver, Pa.
“Then make sure you tell your parents that their [unvaccinated] child may require more aggressive evaluation when ill,” he said. “And make sure you have some kind of triage in your phone protocol system.”
Not properly triaging or caring for an unimmunized or underimmunized child may be legally risky, he explained. “If you have a 10-month-old child who hasn’t had their pneumococcal vaccine and develops a 104° fever, you’re going to treat that child differently than one who had the vaccine,” he said. “You need to have some way to identify kids who aren’t immunized and triage them properly.”
Less clear is a situation in which a child infected with a vaccine-preventable illness is seen in the office and infects another child while there. “There is no case law in the U.S. on this. It may happen at some point, but there is nothing right now that suggests you’re at special legal risk [in such a case],” said Dr. Scibilia.
Just as vaccine refusal has been a growing problem, so have requests for altered vaccine schedules. In a recent survey of pediatricians and family physicians, 93% of physicians reported that some parents had requested altered vaccine schedules within the prior month. A significant number of physicians agreed to spread out vaccines, either always or often (37%) or sometimes (37%).
In a minority of cases, physicians decided to dismiss families from their practice: 2% said they “always or often” dismissed patients, and 4% said they “sometimes” did (Pediatrics. 2015 Apr;135:666-77).
“As a group, it seems like pediatricians are following the AAP’s guidance in that we’re trying to convince parents [that vaccination is in their child’s best interest], but it seems that we’re willing to alter schedules in order to get kids vaccinated,” he said.
Whether to agree to alternative scheduling requests is a “philosophical question” for the individual physician to answer, with the understanding that “when you alter the established vaccine schedule, you’re putting yourself at some risk if a patient develops a vaccine-preventable illness during the time frame when you’ve altered the schedule,” he said.
If a physician-patient relationship must be severed, the termination should be done properly and formally in order to avoid possible claims of abandonment. This means providing written notification and documenting that the patient received the notification in a timely fashion, usually with a return receipt. The notification must include an offer to provide emergency care for a specified period of time, Dr. Scibilia said.