Opinion 10.016 - Pediatric Decision-Making
Medical decision making for pediatric patients should be based on the child’s best interest, which is determined by weighing many factors, including effectiveness of appropriate medical therapies, the patient’s psychological and emotional welfare, and the family situation. When there is legitimate inability to reach consensus about what is in the best interest of the child, the wishes of the parents should generally receive preference.
Physicians treating pediatric patients generally must obtain informed consent from a parent or a legal guardian. Certain classes of children, such as emancipated or mature minors, may provide consent to their own medical care. Physicians should give pediatric patients the opportunity to participate in decision making at a developmentally appropriate level. The physician should seek the patient’s assent, or agreement, by explaining the medical condition, its clinical implications, and the treatment plan in ways that take into account the child’s cognitive and emotional maturity and social circumstances. The physician should provide a supportive environment and encourage reluctant parents to discuss their child’s health status with the patient, in private themselves or with the physician. For HIV-infected children in particular, the physician should be sensitive to the fact that disclosure of health status can have implications for the child’s relationships with biological relatives, household members, and peers; adherence to a complex medical regimen; and participation in behaviors that put the child or others at risk. Physicians should also be sensitive that disclosure of HIV and other conditions (e.g., some inherited conditions) can also have implications for family members other than the child. If the patient does not or cannot assent, physicians should still explain the plan of care and tell him or her what to expect, without deception. In the case of an adolescent patient who has decision making capacity, the physician should encourage the patient’s active participation in decision making. The use of force such as with using physical restraints to carry out a medical intervention in adolescent patients who do not assent should be a last resort.
Parents and physicians may disagree about the course of action that best serves the pediatric patient’s interests, including how much to tell the child about his or her health status, when and how to do so, and who should lead the discussion. When disagreements occur, institutional policies for timely conflict resolution should be followed, including consultation with an ethics committee, pastoral service, or other counseling resource. If a health care facility does not have policies for resolving conflicts in a timely manner, physicians should encourage their development. Physicians should treat reversible life-threatening conditions regardless of any persistent disagreement. Resolution of disagreements in the courts should be pursued only as a last resort. (IV, VIII)