AAP speaks out on dismissal of vaccine-refusing patients, vaccine hesitancy




For years, pediatricians have sought a blessing from the American Academy of Pediatrics that acknowledged it was valid for members to dismiss families from their practice if they refused to vaccinate despite all attempts to persuade them. Now, a new clinical report has essentially delivered just that.

The report does not represent an official policy change from the AAP, but it does for the first time acknowledge that “firing” patients who persistently refuse vaccination is “an acceptable option” (Pediatrics. 2016 Aug. doi: 10.1542/peds.2016-2146).

Dr. Kathryn Edwards

Dr. Kathryn Edwards

“A number of pediatricians feel so strongly that if they don’t agree on vaccines, which are so basic to the delivery of care and have made such a big difference in children’s lives, how will they agree on a number of other things they’ll need to discuss?” Kathryn M. Edwards, MD, director of the Vanderbilt Vaccine Research Program, Nashville, Tenn., and a coauthor of the report, explained in an interview.

The AAP has received pressure from its members over recent years as increasing numbers of pediatricians choose to dismiss some or all of their patients whose parents were resolved not vaccinate, coauthor Jesse M. Hackell, MD, a practicing pediatrician and managing partner at Pomona Pediatrics, an affiliate of Boston Children’s Health Physicians, said in an interview.

In fact, a new study has revealed that 12% of pediatricians reported dismissing vaccine-refusing families in 2013, up from 6% in 2006. At the same time, the proportion of families refusing vaccines has nearly doubled in the same time.

“There was a groundswell of opinion that enough is enough and we can’t provide quality care if we can’t provide something we know is so important,” Dr. Hackell said. “We felt the Academy needed to stop being so adamantly opposed to the possibility of dismissal – not to recommend dismissal but simply to state it is an acceptable option.”

The AAP responds to fellows’ concerns

While the AAP continues to recommend doctors attempt to persuade families as long as possible to vaccinate, the new report discusses dismissal as a viable option as long as it adheres to relevant state laws that prohibit abandonment of patients.

“The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view,” the report states. “Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option.”

The report does note that some practice settings, such as hospitals or large health care organizations, may not allow dismissal of patients, and that pediatricians “should carefully evaluate the availability of other qualified providers for the family” if they live in an area with limited access to pediatric care.

Dr. Stuart A. Cohen

Dr. Stuart A. Cohen

But the report finally acknowledges those pediatricians who are “just philosophically wired to not accept vaccine refusals,” Stuart A. Cohen, MD, an assistant professor of pediatrics at the University of California, San Diego, and chair of AAP District 9 in California, said in an interview.

“It really interferes with your physician-patient relationship,” Dr. Cohen said, who was not a coauthor of the report.

Now, if pediatricians feel it necessary to dismiss nonvaccinating patients, “then the Academy understands because of concerns for other patients, but it must be done in a way that’s respectful and tries to ensure patients understand the safety and necessity of vaccines,” Dr. Edwards said.

The report still includes the AAP recommendation that “pediatricians continue to engage with vaccine-hesitant parents, provide other health care services to their children, and attempt to modify their opposition to vaccines.” And a number of members of the AAP’s infectious diseases and bioethics committees were uncomfortable with dismissing patients, Dr. Edwards said, but “there were certain people who needed this, who needed some blessing that this was not inappropriate after all the other things the pediatrician had done.”

Vaccines undergo thorough testing for safety and effectiveness

But the report also aims to provide pediatricians with strategies for doing everything possible first.

“We needed to address enabling the clinician to have some very specific talking points to use and not get involved in a philosophical discussion that can take an hour,” Dr. Hackell said. “They need to make a clear statement that vaccines are important, and if you don’t get them, bad things like death can happen.”

The report therefore provides a comprehensive overview of vaccine development, from the initial identification of the need for a vaccine through the various phases of clinical testing and ongoing postlicensure monitoring. This background information can arm pediatricians with foundational knowledge that’s helpful in talking with patients.

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