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A 4-Step Framework for Shared Decision-making in Pediatrics
1Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute; and Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington douglas.opel@seattlechildrens.org.
Insights
This study introduces a 4-step framework to improve shared decision-making (SDM) in pediatrics. It guides physicians on when and how to involve parents in medical decisions for children.
Area of Science:
- Pediatric healthcare
- Medical ethics
- Patient-centered care
Background:
- Shared decision-making (SDM) is crucial for patient-centered care but its pediatric application is unclear.
- Existing SDM models do not fully address pediatric decision-making nuances, particularly surrogate decision-makers' limited authority.
Purpose of the Study:
- To present a practical 4-step framework to enhance SDM in pediatric practice.
- To address the gap in understanding SDM application when parents act as surrogate decision-makers.
Main Methods:
- A 4-step framework is proposed for physicians to determine the appropriate SDM approach.
- Key decision points include the existence of multiple medically reasonable options and the benefit-burden ratio of each option.
- The framework incorporates preference sensitivity and decisional characteristics to calibrate the SDM approach.
Main Results:
- The framework differentiates between physician-guided and parent-guided SDM based on medical factors.
- It offers strong and weak versions of each approach, tailored by preference sensitivity.
- The framework provides a structured method for applying SDM in pediatric clinical decisions.
Conclusions:
- The proposed 4-step framework offers a practical approach to optimize shared decision-making in pediatrics.
- Further research is needed to integrate adolescent participation into this SDM model.
Abstract:
Shared decision-making (SDM) is a well-established component of patient-centered care, and yet, its application in pediatrics is poorly understood. Common features of pediatric decision-making are not completely addressed in current SDM models, such as the fact that the principal SDM participant is the patient's surrogate, who, unlike competent adult patients deciding for themselves, has limitations on decision-making authority. To address this gap and improve the practice of SDM in pediatrics, a practical 4-step framework is presented. In step 1, physicians are posed the following question for any discrete decision: does the decision include >1 medically reasonable option? If the answer is no, SDM is not indicated. If the answer is yes, physicians proceed to step 2 and answer the following question: does 1 option have a favorable medical benefit-burden ratio compared with other options? If yes, physician-guided SDM is appropriate. If no, parent-guided SDM is appropriate. For each SDM approach, the physician proceeds to step 3 and answers the following question: how preference sensitive are the options? This helps to determine the specific SDM approach in step 4, which ranges from a strong or weak version of physician-guided SDM to a strong or weak version of parent-guided SDM. Several decisional characteristics, if present, can also help calibrate the version of SDM used. Additional analyses are needed to consider the inclusion of adolescents into this SDM framework.
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