Decision Making in Plastic Surgery: A Blurred Line Between Autonomy and Shared Approaches
Kavitha Ranganathan, MD, Alexandra O. Luby, MS, Madeleine Haase, Michaella Baker, BS, Anne Patterson, Niki Matusko, BS, Katelyn Bennett, MD, Steven R. Buchman, MD, Jennifer F. Waljee, MD, MS, MPH.
University of Michigan, Ann Arbor, MI, USA.
PURPOSE: Although shared decision-making is an essential component of patient-centered healthcare, its role in pediatric patient populations is not well-defined. Particularly among children presenting to pediatric plastic surgery clinics, the extent of agreement between parents, children, and providers regarding the extent of autonomous decision-making remains unclear. The goal of the current study was to define the preferred level of autonomy in decision-making among the various stakeholders involved in cleft care.
METHODS: We surveyed children presenting to plastic surgery clinics (n=100) and their caregivers (n=100) regarding their preferences on autonomy during the process of surgical decision-making. Patients and their parents independently completed surveys on their preferred method of decision-making and autonomy. Fleiss' kappa was used to assess the extent of agreement between groups. Bivariate chi-square tests were used to assess the relationship between decision-making preferences and demographic factors such as age, gender, and socioeconomic status. Multinomial logistic regression was performed to assess the relationship between age and sex and child/parent preference.
RESULTS: Of the 100 children surveyed, 64 were female; the average age was 12.5 years. Children and their parents disagreed on their preferred style of decision-making (k=.0385). Overall, 40% of children and 67% of parents preferred the option of completely shared decision-making between the patient, parent, and provider; the minority of children (16%) preferred the doctor to be the main source of decision-making. Approximately 20% of children desired complete autonomy. The child's age was significantly associated with preference; the relative risk of children deferring to parents or surgeons over a completely shared approach was significantly lower for adolescents when compared to children younger than ten years old (RR=0.202; 95%CI:0.054-0.751; p=0.017). Parents' choices stayed constant with the child's age (χ=0.2051). Parents were more likely to choose the option that gave the child more autonomy when the child was male (χ=4.331).
CONCLUSION: While most parents preferred a completely shared approach to decision-making, children desired greater autonomy, particularly with increasing age. There was limited agreement between parents and children in this process. Providers must be cognizant of differing preferences among parents and children when discussing treatment plans and surgical algorithms; to optimize patient and parent satisfaction, differing methods of discussion may be required to respect the preferences of all stakeholders involved.
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