What exactly is shared decision making and why is it important to know? As a starting point to understanding the new vaccine guidelines, the public needs to comprehend the terminology. Shared decision making is not a new term to the medical community. The federal government, in reference to new vaccine guidelines, describes it as a discussion between families and health care providers. Shared decision making, as a method of care for providers, has been reintroduced to the nation as guideline for previously recommended routine vaccinations.
A new survey showed that although 68% understood that it involved review of medical history with health provider, 40% believed it meant just making your own decision. There were 10% who had no idea what it meant and 25% thought it meant a discussion with a family member. The survey showed that many interpret the change as a sign of uncertainty about vaccine safety and efficacy.
These misunderstandings undermine confidence in the long established, safe children’s immunization schedule. Recommending shared decision making in evidence based vaccine efficacy and safety suggests there are doubts where there are none.
The concept of shared decision making started in 1982 in the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. The report described it as “a process based on mutual respect and partnership between the patient and clinician considering all options together accounting for patient values and best interests.”
There are many definitions associated with shared decision making but they all elude to collaboration, individualized care, partnership, patient education and participation. It is a step beyond informed consent “by assisting patients through a process that cultivates an enhanced understanding of the risks and benefits of the various treatment and non-treatment options.” Besides education of the disease, vaccine and or treatment — risks and benefits are shared, questions answered and a plan of care mutually decided upon.
Shared decision making is more useful in situations where there is more than one right plan of care and no single correct answer. Vaccines that have been proven to save lives, communities and health care dollars for many years require education and information but not mutual decision making. Experts on vaccine laws and regulations who have studied the ramifications of vaccine policy change support shared decision making in certain situations but disagree with its in use in vaccines. There is concern for the burden to be shifted on clinicians and parents. They also stress it is useful when there is more than one reasonable choice.
For example, like the treatment for strep throat, these vaccine’s efficacy and safety is proven. If a patient is diagnosed with strep throat, the evidence based proven treatment is penicillin (or other antibiotic if there is an allergy.) This does not require shared decision making.
I can hear the argument as I type that last sentence as there is trend in this country of distrusting the experts and academic conclusions. When people decide things with feelings and opinions rather than years of experience and field work, we see things like the rolling back of tried and true vaccine schedules morph in disease outbreaks.
However, if a patient is diagnosed with cancer, shared decision making regarding genetic testing, radiation, surgery and chemotherapy is highly beneficial to make a plan that is best for the patient’s biology, biography, goals and priorities.
Presently at a routine pediatric wellness appointment, a vaccine alert pops up and is a normal part of the check up. Most providers and some more than others are on an extremely tight and timely schedule. Time allotted for each visit is limited. In many lower income clinics where there are limited resources, exam time is even shorter. This is considered to be one of the reasons there is a gap in vaccine rates socioeconomically.
The pediatric provider must fit it an exam, address wellness, growth and development issues and parent/child concerns while all the while making sure the parents and patient feel heard. Adding shared decision making for routine vaccines adds on discussing all aspects of the disease the vaccine is for, risks and benefits, allowing for questions and for parents to understand the wealth of information delivered and then still have to document everything. Many times the parents may not be certain and want more time to decide. This means homework and effort for patients or parents.
If they choose to wait, they may not be able to return, forget to return and the opportunity to vaccinate is lost. More choice can equal less access. Data may show that they chose not to get vaccinated when they actually couldn’t get time off for work or other reasons to not return.
The childhood vaccines that have been eliminated from the routine schedule have prevented many thousands of hospitalizations, disabilities and deaths. It is necessary to improve public understanding and advocate for the public health benefits of routine vaccines. Thankfully it is not a mandate, states do not have to alter their school vaccine requirements. It is also fortunate that some states and medical organizations are advocating and educating about vaccines for the health of children and the national community.
A shared decision making analogy can be likened to parenting styles. No matter what your parenting style, safety comes first. If a child wanted to touch a hot stove, the answer is unequivocally no. No amount of discussion will alter the outcome of an injury occurring if the child touches the hot stove. The nation and its children are already experiencing the harm of decreased vaccine rates with the measles outbreak.
Take care of yourself and someone else.
Juanita Carnes is a nurse practitioner with 39 years of experience in a hospital emergency department and urgent care facilities. She served 30 years on the Board of Health in Westfield, Massachusetts.