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Medical Ethics Issues with Shared Decision-Making in Patient Encounters

July 5, 2017

The pediatrician in this interaction worked to build a therapeutic alliance with the mother of her minor patient. The mother responded. Later, the mother’s anxiety for her son’s condition caused her to discount the shared decision-making process and to cast blame on the pediatrician. The pediatrician’s documentation of her discussions with the mother clarified the events in this case, helping to get the lawsuit dismissed.

Allegation

Improper administration of vaccinations

Case File

Four Basic Principles of Medical Ethics3

  1. Beneficence — acting for the patient’s good
  2. Nonmaleficence — doing no harm
  3. Autonomy — recognizing the patient’s values and choices
  4. Justice — treating patients fairly

A mother brought her 11-year-old son to a pediatric practice for the first time for a check-up. The mother had been married, and she and her husband had been members of a religious community that avoided medical care and embraced prayer as a method for healing. Six months prior to this medical visit, the woman’s husband had been killed in a motor vehicle accident. She and her son had moved in with her mother (the patient’s grandmother), who did not belong to the religious community. At the grandmother’s urging, the boy’s mother had scheduled the appointment and brought her son to it. The grandmother was also in attendance. The visit was the boy’s initiation into the healthcare system. He had never before had any type of examination, medication or vaccine. He had been home schooled, so he had been exempt from immunization mandates associated with public school attendance.

The pediatrician examined the patient, and she found a well appearing 11-year-old white male with no immunologic, gastrointestinal, endocrine, neurologic, skeletal or hematologic issues. The physician discussed establishing an immunization schedule to catch up on childhood vaccines. The mother was unsure about this idea; she said she mistrusted the safety of vaccines.

The physician spoke to the patient’s mother about the benefits of immunizations. The patient’s grandmother, who was sitting in on the visit, expressed her strong support for setting up an immunization schedule and getting her grandson caught up on vaccinations. The patient’s mother said she would consider this, and at the end of the visit she allowed the office to schedule another appointment, when the first immunizations would be given.

The mother brought her son to the immunization visit, and he received a tetanus, diphtheria and pertussis (Tdap) vaccine; a meningococcal conjugate vaccine (MCV); a hepatitis B vaccine; an inactivated polio vaccine (IPV); a measles, mumps and rubella (MMR) vaccine; and a varicella vaccine. Three days after receiving the vaccines, the patient experienced a seizure at home. His mother took him to the emergency department, where he was treated and released with a referral to a neurology practice. The patient had several additional seizures before being evaluated by the neurology practice. The neurologist who saw this patient diagnosed benign rolandic epilepsy of childhood and recommended not medicating the patient unless he began experiencing frequent seizures.

The patient’s mother, however, believed the seizures were caused by the immunizations her son had received. She filed a lawsuit against the pediatrician alleging improper administration of vaccines. In depositions, the mother expressed her conviction that the vaccines, particularly the Tdap, caused her son’s epilepsy. She claimed that she was pressured by the physician to have her son immunized and that she was not appropriately educated about the risks associated with the immunizations. She also questioned why her son was given so many vaccinations at one time.

Experts who reviewed the case thought it was a coincidence that the patient experienced seizures soon after getting the vaccinations. They did not think there was a link between the two events. They noted that the patient’s EEG from the neurology work-up confirmed the diagnosis of benign rolandic epilepsy, a condition that often first appears in patients who are 10–12 years old. The reviewers accepted Centers of Disease Control (CDC) reports stating that the practice of giving multiple vaccinations at one appointment carries “no greater risk of adverse effects.”1 Eventually, this lawsuit was dismissed.

Discussion

In this case we see discord between the ethical principles of autonomy and beneficence. In addition, we see how autonomy and beneficence can come together as physicians and patients engage in shared decision-making. U.S. medicine has evolved from a physician-controlled approach to a “participatory style” in which “physicians and patients share authority and responsibility to build therapeutic alliances.”2

The pediatrician in this case educated the vaccine-hesitant parent about the risks and benefits of vaccines, gave her the required vaccine information statements (VISs) and documented the mother’s receipt of the VIS sheets. In fact, the pediatrician spent extra time in a dialogue about vaccines, because the mother was initially skeptical of their value and fearful that the vaccines would cause harm to her son. The pediatrician had explained her own perspective on vaccines and had listened to the mother’s opinions. Together, they had come to a mutual resolution that the vaccines should be administered. It was only later that the mother — worried about her son and searching for an explanation for his new-onset seizures — discounted the earlier shared decision-making process and tried to cast blame on the pediatrician. The physician’s well thought out and thorough discussion with the mother and documentation of the discussion were critical factors in getting the lawsuit dismissed.

Medical Liability Risk Management Recommendations

Interactions that Require Shared Decision-Making

  • Learn about and strive to practice “patient-centered medicine,” a model of care that emphasizes the importance of “empathic listening and communication” to build therapeutic alliances in which the patient’s medically appropriate preferences are taken into account.2
  • While collaborating with patients to reach shared decisions, be sure to give each patient the value of your training and expertise by clearly explaining your assessment of various treatment options.
  • Recognize that a patient’s poor health literacy can create barriers to effective communication, and keep in mind that fear can reduce a patient’s ability to grasp information. Use lay language when explaining medical concepts to aid patients’ comprehension.
  • Do not comply with patients’ wishes if doing so would cause you to provide substandard care.
  • In matters involving pediatric patients, such as in this case, recognize that the relationship is a tripartite one involving you, the parent(s) and the patient. This can hamper communication because information and descriptions of symptoms are often coming to you “by proxy” through a parent. Be aware that in such situations you may need to increase your listening and communication efforts.

This content from Claims Rx

References

1. Centers for Disease Control and Prevention. Multiple Vaccinations and the Immune System. (accessed 7/5/2017)

2. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. New York, NY: McGraw Hill; 2010:49.

3. Beauchamp TL, Childress JF. Part II: moral principles. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford University Press;2012:99-288.

Filed under: Medical Ethics, Patient Relationship, Case Study, Physician, Pediatrics, Family Practice

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