Taking care with pediatric radiation risk communication

Special attention to communicating radiation risk in an effective and balanced manner is particularly important in the pediatric setting, according to an article published in the March issue of the Journal of the American College of Radiology.

Many medical imaging techniques that employ ionizing radiation are diagnostically beneficial, but pose potential risks for patients, especially those in the pediatric demographic. The article’s authors, Joshua S. Broder, MD, and Donald P. Frush, MD, both of Duke University in Durham, N.C., assert that communication with pediatric patients about radiation risk must be well considered and developed.

“Discussions must include relevant content, such as risk estimations, risk comparisons, radiosensitivity, the longer life expectancy of children compared with adults, diagnostic and management benefits of CT, alternatives to CT, and tactics to reduce risks,” they wrote. “Equally important are the process and style of communication, including the choices of why, how, when, and with whom to discuss risks.”

The authors propose physician communication with pediatric patients and their families regarding radiation risk for procedures at the upper end of the diagnostic imaging radiation exposure range to ensure practicality and feasibility. However, they warn that this tenant may vary with patient factors such as age and the presenting medical condition's associated risks. They also suggest consulting the ACR Appropriateness Criteria for further guidance.

Not only must physicians consider when to communicate this information, but they must also effectively relay their points to their audience. According to Broder and Frush, dialogue should be accurate, understandable, sensitive, courteous, compassionate, appropriate, honest and open. They have to choose between the multiple roles available to them, including advocate, informer and adviser. They should additionally be sure to perpetuate patient autonomy. Listening to patients and families is a vital part of understanding their experiences and opinions. 

When it comes to radiation risk, there are still many unknown elements. “Given the uncertainties around indications for imaging and risk estimations, physicians must be comfortable saying ‘we don’t know’ when information truly is uncertain,” explained the authors.

Furthermore, physicians must sometimes agree to disagree with patients in order to respect patient autonomy. However, this is not always as simple to do in the pediatric realm. “This situation is more complex with pediatric patients, for whom the decision makers who assume risk for the patients will not personally bear the adverse outcomes if risk materializes,” explained Broder and Frush. “In some cases, legal advice may be required to determine if the decision of a caregiver can be respected, for example, if a caregiver refuses what the physician believes to be potentially lifesaving diagnostic testing in a minor.”

Importantly, physicians need to possesss an accurate understanding of radiation risks, enabling explanation of the types and ranges of risks at a level of patient understanding. They should be open to changing their diagnostic plans after the patient discussion rather than entering the conversation with the intention of persuading patients to adhere to their plans.

Overall, the goal of the communication should be to determine the safest course of action for the patient. Reasonable alternatives to CT should be presented, and the possibility of performing CT in the future if the patient’s condition changes should be addressed as well.