Overview
Definition:
Shared decision-making (SDM) is a collaborative process where clinicians and patients (in this context, adolescents and their caregivers) work together to make healthcare decisions, integrating the clinician's medical expertise with the adolescent's values, preferences, and life circumstances
It moves away from a paternalistic model to one that respects adolescent autonomy and promotes engagement.
Epidemiology:
Adolescents (typically defined as ages 10-19) represent a significant portion of the global population, often navigating complex health issues that require nuanced decision-making
The prevalence of chronic conditions and mental health concerns among adolescents further highlights the importance of SDM.
Clinical Significance:
Effective SDM with adolescents is crucial for improving treatment adherence, enhancing patient satisfaction, fostering health literacy, and promoting long-term self-management of health conditions
It respects their developing autonomy and prepares them for adult healthcare, leading to better health outcomes and reduced healthcare costs.
Age Considerations
Early Adolescence:
Ages 10-13
Increased reliance on parental involvement
Focus on understanding basic information and preferences
May require simpler language and more direct guidance.
Mid Adolescence:
Ages 14-16
Growing desire for independence and peer influence
May express stronger opinions and preferences
Balancing parental roles with adolescent input is key.
Late Adolescence:
Ages 17-19
Significant development of autonomy and decision-making capacity
Closer to adult decision-making patterns
Emphasis on informed consent and future planning.
Developmental Stages:
Understanding cognitive, emotional, and social developmental stages is vital to tailor the SDM process
Adolescents' capacity to understand complex information and consider future consequences varies significantly.
Clinical Presentation
Scenario Identification:
Situations requiring SDM often involve choices about treatment options for chronic illnesses (e.g., diabetes, asthma), decisions regarding reproductive health, mental health interventions, or lifestyle modifications
Presenting with uncertainty or multiple viable options signals a need for SDM.
Adolescent Readiness:
Signs of readiness for SDM include expressed desire to be involved, ability to understand information, articulating preferences, and willingness to take responsibility for decisions
Conversely, disinterest or confusion may indicate a need for a more guided approach.
Parental Involvement:
Parental or caregiver involvement is essential, especially in younger adolescents
SDM involves finding a balance where parents feel informed and supported, while the adolescent's voice is heard and respected, adapting as the adolescent matures.
Diagnostic Approach
History Taking:
Assess the adolescent's understanding of their condition and treatment options
Inquire about their values, preferences, fears, and goals related to their health
Explore their support system and any cultural or religious considerations impacting decisions
Gauge their perceived readiness for decision-making.
Communication Techniques:
Utilize teach-back methods to ensure comprehension
Employ open-ended questions and active listening
Use decision aids (e.g., brochures, videos, interactive tools) to present information clearly
Acknowledge and validate the adolescent's feelings and concerns.
Assessing Capacity:
Evaluate the adolescent's ability to understand the information presented, appreciate the situation and its consequences, reason through the options, and communicate their choice
This assessment is dynamic and may change over time.
Ethical Considerations:
Respecting confidentiality within legal and ethical bounds is paramount
Navigating parental rights and adolescent assent/consent requires careful attention
Understanding concepts like mature minor doctrine and varying state laws is crucial.
Management
Principles Of Sdm:
Ensure clear communication of risks, benefits, and alternatives for each option
Elicit preferences and values by asking questions like "What is most important to you?" or "What are you hoping to achieve?"
Agree on a plan and a follow-up strategy, clearly defining roles and responsibilities.
Decision Aids:
Utilize age-appropriate decision aids that present information in an unbiased, understandable format
These can help adolescents and their families weigh options more effectively
Examples include charts comparing treatment outcomes or videos explaining procedures.
Navigating Disagreements:
When disagreements arise between the adolescent, parents, and clinician, acknowledge the different perspectives
Facilitate a discussion to understand the underlying concerns
Seek common ground and explore compromises
If consensus cannot be reached, consider involving a mediator or ethics committee for complex cases.
Documentation:
Document the SDM process thoroughly in the medical record, including the information shared, the options discussed, the preferences elicited, the decision made, and the rationale behind it
This ensures continuity of care and legal protection.
Key Points
Exam Focus:
SDM is a core competency in pediatrics and adolescent medicine
Expect questions on balancing autonomy, parental rights, and ethical considerations in decision-making for common pediatric conditions
Understand how to use decision aids and assess capacity.
Clinical Pearls:
Start early with SDM even for routine care to build rapport and trust
Adapt your approach based on the adolescent's developmental stage and maturity
Always provide a safe space for the adolescent to express their true feelings and preferences.
Common Mistakes:
Overlooking or dismissing adolescent preferences, assuming equal capacity across all adolescents, failing to involve caregivers appropriately, using overly technical medical jargon, and not adequately documenting the SDM process
Rushing the decision-making process without ensuring understanding.