CPS Statement: Treatment decisions regarding infants, children and adolescents

CPS Statement: Treatment decisions regarding infants, children and adolescents

The following was adapted from the Canadian Pediatric Society’s statement on the “Treatment decisions regarding infants, children and adolescents”. Please see the full statement for the detailed recommendations.

Treatment decisions should be the result of a joint conversation between your patient, their parent(s), and the members of the health care team. Furthermore, the patient’s degree of involvement in the decision increases as they age and develop. Unlike with adults, it’s not always assumed that children and adolescents have full decision making capacity. Therefore, many of our paediatric patients need proxy decision-makers. The overall focus of the proxy decision maker should be on what the patient would have wanted and what is in their best interest. 

Children should be recognized as having some authority over their own health care even if they are not the primary decision maker. This brings up the concept of assent. Children are given information and an age appropriate choice for their treatment. An example would be to give a child the choice of arm in which to receive an injection, rather than to give a choice about whether or not to receive the injection. Therefore, the child is respected as an individual, is given age-appropriate information, and is allowed to demonstrate a degree of voluntariness in accepting the decision. 

The health care team can use the following three categories to help guide how much involvement the paediatric patient should have in decision making.

  1. Infants and young children: Children in this age group have no significant skill to participate in decision making. Therefore, decisions should be made by the surrogate decision maker in what they believe is the child’s best interest.
  2. Primary school age children: Children of this age should should be provided with age-appropriate information and are able to provide assent or dissent. The child’s parents authorize or refuse treatment however.
  3. Adolescents: many, but not all, adolescents are developing the decision-making capacity of adults. The adolescent should be able to understand and communicate relevant information, think and choose with some degree of independence; assess potential benefit, risk or harms of multiple options, and consider their consequences.

There are situations where the values and beliefs of the caregivers differ from those of the health care team. Clear communication tends to resolve these conflicts. Regardless, a clash in values can occur. In such a scenario, the parental decision making should be accepted unless it is clearly not in the patient’s best interest. If an agreement cannot be reached, a physician should provide a second opinion, involve institutional ethics committees, and, if necessary, local child protection authorities.  Practitioners may not withdraw from a patient’s care without providing a referral.

End-of-life decisions can be particularly difficult. It is recommended you read the full CPS article for details on such a sensitive matter. The comfort of the patient should be the focus of all of your decisions. Without exception, the health care team has an obligation to provide palliative and comfort care, including attention to symptom control and the emotional, psychological and spiritual needs of the patient and their family.

 

Last updated by PedsCases: January 01, 2015

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