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Opening the Door to Shared Decision-Making in Pediatrics

October 11, 2022

Editor’s Note: Krista Roncone, MD, is a second-year resident physician in pediatrics at the University of Virginia. She is interested in medical education and health disparities research, and is considering integrating these components into a career in pediatric hospital medicine or critical care.
-Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

Each of my clinic visits begin with a knock, followed by a careful pause as I wait to hear a voice on the other side reassuring me that I am a welcomed guest. To me this has never been a formality or empty action, but a grounding moment where I pause and bear witness to the biggest privilege of our profession: being invited to cross the threshold into the lives and families of our patients.

With this in mind, shared decision-making (SDM) is a vital part of the field of pediatrics. As a resident, SDM can at times feel intimidating as it shifts the focus from picking the “right” answer from a list of multiple choice questions that we are accustomed to in our medical school training, to a continuum of possible options that relies on family values to determine the best choice. The emphasis on SDM is only becoming more common and formalized in pediatric practice, and is shaping expert guidelines at a national level. For example, this past year’s release of the new AAP Clinical Practice Guidelines on febrile infants underscores SDM as a key component of the management pathway.

While it is clear that SDM is a fundamental part of the delicate relationship triad between the pediatrician, parent, and patient, there is a lack of structured guidelines and training on this important process. A study by Sarah Eaton and colleagues from Switzerland and the US, being early released this week in Pediatrics, utilized a panel of experts from various countries to formulate several consensus opinions about the role of SDM and ways to appropriately employ it (10.1542/peds.2022-057978).

The framework that the authors lay out focuses on several factors that involve:

1) clinician preparation

2) making an assessment of the family unit involved

3) ways to execute and redirect SDM conversations

With regards to clinician preparation, the authors stress the importance of logistical preparation (collecting information about related treatment options, outcomes, etc.), but also appropriately note the importance of acknowledging any implicit biases and identifying strategies to mitigate these. The authors then highlight several factors that go into the assessment of the family in a SDM process. It is important to gauge a family’s understanding of the situation at hand, estimate health literacy, and proactively seek to understand the family’s specific values by asking clarifying questions.

There was expert consensus that making recommendations is a fundamental part of the process. They note the art of making a recommendation that is clinically sound, ethical, and well-received relies on reflecting on personal biases, ensuring that the recommendation is consistent with the family’s values, and providing the opportunity for the family to reject the recommendation without any perceived repercussions. Interestingly, the experts differed on whether a family should be asked if they desire a recommendation before one is provided.

One notable strength of the study was that parents were included on the expert panel. As this article touches on how important family-specific values are in SDM, it would be interesting to see future studies that include experts from Latinx and Asian countries in order to strengthen our understanding of SDM across a variety of cultural backgrounds.

In this blog, I have summarized the general concepts from this expert panel, but I would recommend that you read the entire article to learn more.

When done in a structured and thoughtful manner as outlined by this study, shared decision-making allows us to come to proper medical decisions in a manner that respects the gravity of the relationship that pediatricians have with families and patients. With a knock at the door we don’t just enter physical spaces, we enter as humble guests in a home of choices that a family makes for their child.

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