Consent and confidential care for adolescents — formative SAQs

SAQ 1 — Consent, capacity and confidentiality (10 marks)

A 15-year-old presents requesting the contraceptive implant and asks that her mother not be told. She is otherwise well. [5] [6]

Questions

1. State the three pillars of valid informed consent and how they apply to this adolescent. (3 marks) [5]
2. Describe how you would assess her decision-making capacity at the bedside. (4 marks) [6] [7]
3. Give the conditional confidentiality script you would say aloud, including its lawful limits. (3 marks) [4] [2]

Model answer

Three pillars (3). Capacity — she can understand, retain, weigh and communicate the decision; information — she is told what the implant is, its benefits, risks, alternatives and the option of doing nothing; voluntariness — the choice is free of coercion. In an adolescent, distinguish the minor's own consent (if capable) from parental permission and the child's assent. [5]

Capacity assessment (4). Capacity is task-specific, not age-gated, using the Gillick/mature-minor principle. Walk her through the implant decision and check she understands and can restate (teach-back) the procedure, efficacy, risks and reversibility; that she retains it long enough to decide; that she weighs it in her own situation (for example future fertility, STI protection still needs condoms); and that she communicates a stable, voluntary choice. Check voluntariness and coercion. Document the reasoning. [6] [7]

Confidentiality script (3). "What we talk about privately stays private, unless I become worried you are not safe, that someone else is being hurt, or the law says I must act. If that happens, I will tell you what I need to do and we will plan it together." Limits: serious harm to self or others, abuse or assault, and other legal mandates. Encourage parent involvement where safe and she agrees. [4] [2]

SAQ 2 — Lawful override and electronic-record confidentiality (10 marks)

During the private interview the same afternoon, a 16-year-old discloses an active suicide plan for tonight. Separately, your clinic's patient portal is about to send an explanation-of-benefit that would expose a contraception visit to a parent. [4] [9]

Questions

1. Outline the immediate actions after the suicide-plan disclosure, including how you break confidentiality ethically. (5 marks) [4]
2. Explain the confidentiality risk posed by portals, billing and insurance records, and how to prevent it. (3 marks) [9]
3. How do you maintain the therapeutic relationship after an unavoidable breach? (2 marks) [1] [4]

Model answer

Immediate actions (5). Secure immediate safety — do not leave the young person alone, remove means if safe, escalate to ED or crisis teams per local pathway. Break confidentiality ethically: tell the young person what you must share and why; share the minimum necessary with the people who need it; involve parent or carer and crisis or safeguarding services as required. Document decisions, who was informed, and the safety plan. Treat under best interests while capacity is reassessed. [4]

Portal and billing risk (3). Electronic health records, patient portals, after-visit summaries, billing statements and insurance explanation-of-benefit letters can surface contraception, mental-health and sexual-health content to a parent by default. Prevent it with local sensitive-note and confidential-content workflows, confidential contact details, and careful checking of what the portal will release before it releases it. [9]

Preserving the relationship (2). An ethical override — told in advance, proportionate, and explained — can preserve trust. Acknowledge the young person's wish for privacy, explain the safety reason, and stay engaged for follow-up so the breach does not become abandonment. [1] [4]