6024 Using ‘shared decision-making’ to improve the ‘best interest standard’ when making medical decisions concerning children

Objectives Making decisions in paediatric medicine is rarely 'black and white'; they can be ethically challenging due to the inevitable triadic patient-parent-doctor relationship. The Best Interest Standard (BIS) is the leading model used in paediatric decision-making.¹ It is however under constant criticism. The model encourages deciding for the child and family as appose to with, whilst keeping the child's best interest at the absolute centre. This paper explores whether BIS decision making in paediatric care should and can be improved by integrating Shared Decision-Making (SD-M), a newer but widely advocated model that emphasises the child/adolescent's autonomy and shared understanding of all parties, in practice.² Methods Whilst acknowledging the strengths and successes of the BIS, this paper identifies three main problems with the standard: ambiguity, paternalism, and demandingness. 19 sources of literature were used to present these limitations (literature search details below in table 1). SD-M is reviewed in the context of the three themes ambiguity, paternalism, and demandingness; and thus, interplay between the two models is explored. Results The results section will cite literature to explain why these are serious limitations that need to be addressed. It is presented as three themes covering the three major issues: ambiguity, paternalism, and demandingness. Each section identifies a clear reason to review the BIS. These findings are enhanced by a discussion structured by the same three themes, on whether and how SD-M can address these specific issues to improve the BIS. SD-M was found to be beneficial as it allows for a multi-facetted approach accounting for factors such as about family values, brings clarity whilst keeping the child at the centre, and overall widens the 'tunnel vision' that is linked to the BIS. Conclusion This paper concludes that whilst the BIS is suitable and should continue to be used when making ethically challenging decisions in paediatric medicine, its current form is not fully sufficient, given the problems presented. It has been demonstrated that SD-M directly addresses the three main limitations of the BIS found; hence can and should be used in combination with the BIS to better current practice. References Loretta M Kopelman. The best-interests standard as threshold, Ideal, and standard of reasonableness. The Journal of Medicine and Philosophy, 1997. Birchley G. Deciding together? Best interests and shared decision-making in paediatric intensive care – health care analysis, 2013.