Physicians Perceptions of Shared Decision-Making in Neonatal and Pediatric Critical Care

作者：Richards Claire A.^*; Starks Helene; O'Connor M. Rebecca; Bourget Erica; Hays Ross M.; Doorenbos Ardith Z.

来源：American Journal of Hospice and Palliative Care, 2018, 35(4): 669-676.

DOI：10.1177/1049909117734843

• ICU/critical care issues in palliative care
• pediatric palliative care
• pediatric communication issues
• physician-patient communication
• shared decision-making
• pediatric bioethics
• family-centered care

Background: Most children die in neonatal and pediatric intensive care units after decisions are made to withhold or withdraw life-sustaining treatments. These decisions can be challenging when there are different views about the child's best interest and when there is a lack of clarity about how best to also consider the interests of the family.
Objective: To understand how neonatal and pediatric critical care physicians balance and integrate the interests of the child and family in decisions about life-sustaining treatments.
Methods: Semistructured interviews were conducted with 22 physicians from neonatal, pediatric, and cardiothoracic intensive care units in a single quaternary care pediatric hospital. Transcribed interviews were analyzed using content and thematic analysis.
Results: We identified 3 main themes: (1) beliefs about child and family interests; (2) disagreement about the child's best interest; and (3) decision-making strategies, including limiting options, being directive, staying neutral, and allowing parents to come to their own conclusions. Physicians described challenges to implementing shared decision-making including unequal power and authority, clinical uncertainty, and complexity of balancing child and family interests. They acknowledged determining the level of engagement in shared decision-making with parents (vs routine engagement) based on their perceptions of the best interests of the child and parent.
Conclusions: Due to power imbalances, families' values and preferences may not be integrated in decisions or families may be excluded from discussions about goals of care. We suggest that a systematic approach to identify parental preferences and needs for decisional roles and information may reduce variability in parental involvement.

• 出版日期2018-4