Pediatric Decision-Making

Pediatric decision-making is a special kind of surrogate decision-making that involves a child (if old enough to understand treatment choices), their parent or guardian, and their health care provider.

Children under the age of 18 are generally considered as not having the capacity to make health care decisions for themselves and cannot give informed consent. Parents or legal guardians are presumed to be the appropriate decision-makers for their minor children.

Best Interests of the Child

When making medical decisions for minor children, parents/guardians should do so according to what is in the child’s best interest. Best interest is determined by a number of factors including, but not limited to:

  • The needs of the child and their health related interests
  • The effectiveness of any proposed medical treatment(s) relative to the benefits and harms of those treatments
  • The risks to the child with or without the treatment
  • The psychosocial components of the child’s life

If there is an inability to reach consensus about what is in the child’s best interest, the wishes of the parents/guardian generally are given preference. There are, however, limits on parental discretion with decision-making when there is evidence that parents’ actions or decisions likely represent serious harm to the child.

Involving Minors in the Decisions

  • Children become capable of expressing their own preferences as they get older. By age seven, many children are capable of engaging in decision-making discussions and agreeing to (assenting) or disagreeing with (dissenting) a parent’s/guardian’s decision. As they become mature enough to articulate preferences and the reasons for them, they are entitled to increasing respect for those preferences.
  • In many states, adolescents have the capacity to make medical decisions and may be recognized as emancipated minors in accordance with state law. Some states have a “mature minor doctrine,” where a patient under the age of 18 is allowed to make medical decisions if deemed mature either by a doctor or a judge (depending on the state). Vermont has no specific statute nor relevant case law regarding “mature minors”.
  • By law, children cannot execute legally recognized advance directives. However, for pediatric patients who are seriously ill or dying, portable medical orders (Vermont DNR/COLST) may be completed.

Advance Care Planning Conversations with Children

The Conversation Project has developed a Pediatric Starter Kit to help families have conversations with a seriously ill child. The goal of these conversations is to understand your child’s wishes as much as possible so you can ensure that their wishes are honored.

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