Shared Decision Making in Complementary and Alternative Medicine Therapies

Abstract

In Minnesota, thirteen-year-old Daniel was ill and felt even worse after going to see his doctor. The experts said he could die without treatment for Non-Hodgkin's Lymphoma, but Daniel and his mother opted to pursue a seemingly natural healing therapy: an American Indian tradition called Nemenhah, for which the scientific community has little evidence of benefit. After an emotional battle with the Brown County District Court and a multi-state search for Daniel, chemotherapy was mandated and Daniel's parents were allowed to retain custody of their son, promising to adhere to the medical treatments recommended by Daniel's oncology team1. High profile cases like these illustrate the poignant interpersonal and legal challenges that arise when pediatric patients and families choose alternative therapies while rejecting conventional medical care for children. When the stakes are high, such as in cancer therapy, conflicting opinions can pose serious challenges for conventionally trained healthcare teams. Additionally, many clinician identify a lack of knowledge regarding alternative therapies and feel poorly equipped to discuss these issues with families2. Nevertheless, treatment decisions that utilize the principles of shared decision making (SDM) – collaborative deliberations informed by the best available evidence while accounting for patient values - remain the ideal in these complex situations3. Unlike the above example, the circumstances in which most pediatricians encounter complementary and alternative medicine (CAM) are thankfully less dramatic, but no less important. Recent data suggests that 1 in 9 children use some form of CAM4, 5. In most of these cases patients and families may not be fleeing conventional care, but rather are seeking ways to blend a variety of conventional and alternative health approaches, with the common goal of maximizing health, mitigating illness, and preventing disease. Thankfully, the American Academy of Pediatrics (AAP) recently published a report describing many common CAM therapies encountered by pediatricians6. Implicit in this report's brief concluding suggestions for discussing CAM was a commitment to SDM, advising physicians to “work together with parents as a team to consider and evaluate all appropriate treatments”. Despite the challenging nature of such discussions, we argue and develop in further detail that discussions of all treatment options in a collaborative manner can enable patients, families, and providers to strengthen the therapeutic alliance and encourage an active role in improving health, while avoiding conflict. SDM is an ethical and practical ideal of clinical conversations between patient, family, and provider that outlines benefits and risks of each available treatment option, solicits preferences of the patient/family, and deliberates about a practical solution7, 8. SDM has been proposed as the ideal model for the clinical relationship for choices considered to be “preference-sensitive,” where the evidence of benefit is uncertain and there is a large role for patient values9. The integration of CAM into discussions in pediatric care is a prime example of circumstances in which SDM should be employed in order to address the motivation and inclinations of the patient and family, while teaching children and adolescents about their active role in promoting health. How to best engage patients and families in constructive conversations about CAM treatment remains unclear10 Through use of a more participatory model, patients and families can increase their understanding of health care decisions and over time exercise discernment about alternative and complementary options. Here, we present a structured approach for responding to inquiries about CAM from the perspective of the pediatrician committed to SDM. The subsequent cases illustrate a range of scenarios in which CAM may enter the healthcare dialogue and as well as to highlight specific themes from the structured approach and how they can ultimately be resolved.