The Intersection of Evidence and Values in Clinical Guidelines: Who Decides What Constitutes Acceptable Risk in the Care of Children?

[摘要] Risk is implicit in all clinical decision-making. Whether a clinician refrains from ordering a head computed tomography scan for a patient with a headache or decides to obtain blood work on a child with a fever, each decision involves a balance between accepting and limiting risk. Ideally, clinicians strive to achieve this balance. Clinicians accept some risk (eg, the risk of missing a rare disease) to avoid placing undue burden on the patient and the health care system with invasive, expensive, and/or potentially unnecessary testing. Yet, clinicians also strive not to assume too much risk so that timely diagnoses are made and morbidity and mortality prevented.1Achieving this balance is difficult for a number of reasons. First, clinicians often lack precise estimates of the risks and harms for a given clinical scenario. There is simply an absence of or paucity of data to help quantify many of the risks, benefits, and outcomes associated with different possible therapeutic options. This confounds the ability to know whether pursuing 1 particular option corresponds to accepting too much or too little risk. As a result, decision-making is often intrinsically imperfect.Second, even if precise estimates of the involved risks are known, determining the threshold constituting acceptable risk (ie, the level above which too much risk would be assumed) is largely subjective. The issue of acceptable risk is inherently a matter of values, which, in pediatrics, includes not only the clinician’s values but also those of the parent and sometimes the child. Although there is general agreement that it is unacceptable for a parent to assume high levels of preventable risk and harm on behalf of his or her child, what constitutes a high level of risk and harm? Is it a 1 in 100 or 1 in 100 000 risk of the child …

[学科分类] 儿科学

[关键词] Campylobacter;proljev;dob