ROUTINE AND EXTRAORDINARY HEALTH CARE SERVICES Frequently Asked Questions The purpose of these “Frequently Asked Questions” is to assist DCF staff with determining whether medical treatment is routine or extraordinary, because this determination will affect whether DCF can consent. In order to make decisions about whether to consent to a proposed medical treatment, it is necessary for DCF staff to obtain information from the physician about what treatment is being proposed and the reason for the treatment. DCF social workers should always consult with a supervisor or manager when determining whether a treatment is “extraordinary” or “routine.” The Health and Medical Services Team and legal staff are available for consultation in making these determinations. See also DCF Regulations 110 CMR 11.00, “Medical Authorization,” on the DCF Intranet site at Library/DCF Regulations. Q-1: Does emergency medical treatment require consent? A-1: For emergency treatment, a health care provider does not need consent in order to provide the necessary treatment. According to DCF regulations at 110 CMR 11.03 (1), a “medical emergency” means “any immediately life threatening condition, including but not limited to: severe profuse bleeding; choking, blocked airway; unconsciousness; cardiac arrest; cardio-vascular accident; any fracture; extensive burns; severe cuts; other similar severe injury; other signs of serious physical illness; any condition where delay in treatment will endanger the life, limb or mental well being of the patient.”
Q-2: Under what circumstances can DCF consent to medical treatment for DCF involved children? A-2: DCF is authorized under statute and regulation to consent to routine treatment for children who are in DCF care or custody. However, when a child is in DCF care, via a voluntary placement agreement or CHINS custody order, DCF generally promotes medical decision-making by the child’s parents. When routine treatment is being recommended for a child in DCF custody, DCF consents; when extraordinary treatment is being recommended for such a child, DCF is required by statute and regulation to request the court to consent.
Q-3: What information should DCF staff obtain from the physician to determine whether medical treatment is routine or extraordinary? A-3: The following information should be obtained from the physician to determine whether a treatment is routine or extraordinary:
For Medical or Surgical Procedures:
The name(s) and a brief description of each planned procedure/surgery;
Whether the procedure/surgery is the usual treatment for the child’s diagnosis or condition;
Whether the anesthesia or sedation is the usual type administered for the procedure/surgery;
The specific benefits expected from the procedure/surgery;
The child’s prognosis without the procedure/surgery;
The alternatives to the procedure/surgery;
The potential side effects and complications of the procedure/surgery; and
Whether the procedure/surgery is part of a research protocol (if so, the DCF policy on consent for participation in research must be followed). (See ”Policy for Approval of Research Proposals and Survey Participation Requests.”)
The name of each medication that is being proposed;
The name of all other medications the child is taking;
For each medication:
frequency of administration;
route of administration (e.g., oral, via tube, injection, intravenous);
the potential adverse interactions with another medication the child is currently taking;
the specific risks of stopping the medication abruptly; and
any other contraindications such as the child’s age, medical conditions, etc.
The reason the medication is being prescribed (i.e., the symptom, disorder or behavior being treated or prevented) and whether the medication is the usual treatment for the child’s condition or diagnosis;
Whether the medication is an antipsychotic. If so, it is considered extraordinary. Refer to DCF Regulations regarding the requirement for a court order to administer that type of medication and contact your DCF attorney. The child’s attorney needs also to be advised. (See DCF Regulation 110 CMR 11.14.)
Whether laboratory or other tests are required to monitor for side effects. If so, it is necessary to know the frequency with which these tests must be done and when the first one is scheduled.
If the information obtained is not sufficient to make a decision, DCF staff should call the physician directly to clarify the information. Then, if the situation is still not clear, DCF staff should call the Health and Medical Services Team for consultation during normal business hours. Q-4 provides information about helpful tools available to help collect the medical information from the physician.
Q-4: Is there a tool I can use to collect information that I need from medical providers? A-4: Yes. You can use the “Dear Doctor Letters” which may be found on the DCF Intranet Library tab under “Forms”; under “Non-FamilyNet Forms” choose “Medical.” There are two letters, one specifically for medical information (“Dear Doctor Attachment”) and another for medication information (“Dear Doctor Medication Information Request”). DCF staff may use these tools to gather information about what is being proposed to help determine whether the treatment is routine or extraordinary. If necessary, you should contact the medical provider for additional information that is not included in the form or is not clear.
Q-5: Once the information is collected, how is the decision made about whether the proposed medical treatment is routine or extraordinary? A-5: The decision requires careful and prompt administrative review, since extraordinary medical treatment may require a court order and could delay provision of necessary care. The following factors must be considered in deciding whether a medical procedure is routine or extraordinary:
Complexity, risk and novelty of the proposed treatment: The more complex the treatment, the greater the risk of death or serious complications or the more experimental the procedure, the more likely it should be considered extraordinary;
The possible side effects: The more serious and permanent the side effects, the more likely the procedure should be considered extraordinary;
The prognosis with and without the treatment: The less clear the benefit from the treatment, the more likely it should be considered extraordinary;
The clarity of medical opinion on the proposed treatment: The more divided the medical opinion, the greater the need to regard the treatment as extraordinary;
The presence or absence of an emergency: As noted in A-1, in a medical emergency a physician can act without anyone’s consent;
The extent of prior judicial involvement in medical decisions for the child: If a court has already been involved in past medical decisions, particularly regarding the specific diagnosis, the more likely the court should be consulted again; and
The extent of conflicting interests between decision-makers and the best interests of the child: Where the interests of the child conflict with the interests of decision-makers, the greater the need to seek a judicial decision.
(See DCF Regulations at 110 CMR 11.17 for further discussion of these factors.) Q-6: What medical treatments are considered ROUTINE? A-6: The following criteria are useful in determining that a medical treatment is routine:
Treatment which is the accepted or usual course of care for the child’s condition or diagnosis, is not experimental or part of a research study and the benefits of the procedure outweigh known or anticipated risks;
There is no disagreement between the medical providers who are involved with the child’s care about the treatment that is being proposed, and the medical providers involved believe that the proposed treatment is the best available alternative.
For medications: all of the above, as well as all of the following:
The medication and dose are the accepted course of treatment for the child’s diagnosis or condition;
The medications are not known to cause serious adverse interactions with other medications the child is taking according to available medical information and opinion; and
The child is not known to be allergic to the medication or anesthesia.
The following are examples of routine medical treatments:
Well child care including: medical history: physical examination, developmental assessment and guidance on development; immunizations and laboratory tests in accordance with standards published by the American Academy of Pediatrics and as outlined in Early and Periodic Screening, Diagnosis and Treatment schedules. (EPSDT – Link to site)
Examinations by a medical provider in response to a child’s illness or injury;
Immunizations if the child has no history of allergy or adverse reaction to the vaccine and parents do not oppose; and
Diagnostic testing and any necessary sedation recommended by the child’s primary medical provider that do not meet the guidelines for extraordinary treatment in A-4 above.
Q-7: What are examples of routine treatment that may appear extraordinary? A-7: The following are examples of types of medical treatment that are considered routine. There will be exceptions at times for some children, which is one reason that it is necessary to obtain the opinion of the child’s primary care physician in all cases.
Anesthesia or sedation for diagnostic procedures/surgeries where any body movement or activity by the child would compromise the ability to adequately perform the procedure or treatment, e.g., MRIs, CT scans, cast application, central line (special intravenous line), tooth extraction, insertion of a g-tube (also known as a gastrostomy or feeding tube);
A request for a child to have a circumcision;
A child with a condition that can only be repaired by a complex surgical procedure, such as a child with complex intestinal abnormalities where the only option is a complex and invasive surgical repair that involves many stages; and
Chemotherapy and/or radiation for a condition that requires this treatment.
Q-8: What are examples of circumstances under which normally routine medical treatment may be extraordinary? A-8: The following are examples:
A child with a bleeding disorder having an elective procedure such as a tonsillectomy or tooth extractions; and
A child who has had a serious life-threatening reaction to anesthesia and a non-emergency procedure under anesthesia is proposed.
Q-9: Is there any medical treatment that is alwaysconsidered extraordinary? A-9: Yes. Under DCF Regulations the following are always deemed extraordinary:
Antipsychotic medications (see 110 CMR 11.14);
Orders to forgo or discontinue life sustaining medical treatment (DNR orders) (see 110 CMR 11.12 and 11.13);
Electroconvulsive therapy (shock therapy) (see 110 CMR 11.15); and
Sterilization (see 110 CMR 11.11).
Q-10: Is there medical treatment that is likely to be considered extraordinary? A-10: Yes. These include:
Any treatment that is experimental;
Treatment that carries the potential for significant risk or very serious and permanent side effects and has unclear or minor benefits to the child;
Treatment about which available medical opinions are divided;
Treatment that is not the usual or accepted course of treatment for the child’s condition or diagnosis;
Anesthesia or treatment to which the child has had an adverse reaction in the past;
Transplants that are not an emergency; and
A treatment to which the family is opposed due to serious religious convictions.
Q-11: After collecting the medical information and considering the factors in A-4, and A-1 through A-9 above, if I cannot determine whether a recommended treatment is routine or extraordinary, what should I do? A-11: After a discussion with your supervisor and manager, consult with a DCF attorney and/or contact the Health and Medical Services Team staff for any unresolved questions regarding this determination.
Q-12: If I need assistance to understand or interpret the medical information I collect from the physician, what should I do? A-12: There are several things that you can do:
During normal business hours:
Call one of the members of the DCF Health and Medical Services Team; or
If the treatment is being done or will be done at Childrens’ Hospital, contact the DCF Nurse Liaison at 617-355-6755; or
Call the physician who provided the information to ask for clarification or further information.
After normal business hours:
Call the answering service for the physician who provided the information. If that person is not on call, ask to speak with the physician who is covering for that physician and ask for clarification or further information.
You may also call the Hotline and ask for the on call supervisor (OCS) who will direct your question to the appropriate on call manager.
Q-13: Where and how do I record all of the information I’ve collected? A-13: Each family member has a medical/behavioral information tab on FamilyNet where information should be recorded. To access this tab, choose the family member’s name under “Case Member”, click on Medical/Behavioral Information and enter the information you’ve collected on conditions, treatments and behaviors. The worker should also enter into dictation any contacts made to obtain the information and any meetings or conferences held to determine whether a proposed treatment is routine or extraordinary, including the date, who attended, the decision and reasons for it.