A 35-year-old man comes to the office in late October to follow up on asthma. He has long-standing mild-intermittent asthma treated with an albuterol inhaler as needed. Over the last 6 months, the patient has had more frequent symptoms; however, he started an inhaled corticosteroid 4 weeks ago and has had no further asthma symptoms since then. Medical history is notable for type 1 diabetes mellitus treated with an insulin pump. Vital signs and cardiopulmonary examination are normal. The influenza vaccine is recommended, but the patient declines, stating, "I got the flu shot last year and got sick anyway." Which of the following is the most appropriate response to this patient?

Question

A 35-year-old man comes to the office in late October to follow up on asthma.  He has long-standing mild-intermittent asthma treated with an albuterol inhaler as needed.  Over the last 6 months, the patient has had more frequent symptoms; however, he started an inhaled corticosteroid 4 weeks ago and has had no further asthma symptoms since then.  Medical history is notable for type 1 diabetes mellitus treated with an insulin pump.  Vital signs and cardiopulmonary examination are normal.  The influenza vaccine is recommended, but the patient declines, stating, "I got the flu shot last year and got sick anyway."  Which of the following is the most appropriate response to this patient?

Quizplus · Accepted Answer

To allow a patient to make an optimal informed decision regarding a recommended intervention, the clinician should respectfully provide patient education, including a balanced assessment of the intervention and a realistic presentation of likely benefits, risks, and limitations. Giving an accurate and thorough explanation to the patient can reinforce patient autonomy and improve patient decision-making. This patient with asthma and type 1 diabetes is at particularly high risk for influenza and related complications and should be strongly encouraged to receive influenza vaccination. However, he has experienced previous apparent vaccine failure, which has discouraged him from accepting future vaccination. In this case, the patient's past illness could have been due to a different flulike infection, which would not represent true vaccine failure. In addition, there may be differences between the strains in the vaccine and those in circulation. Even if the patient acquired influenza despite vaccination in a prior flu season, he is still likely to benefit from seasonal influenza vaccination because it reduces both the risk of infection and the severity of illness. (Choice B) Using scare tactics or quoting worst-case scenarios, even if factually correct, does not truly give the patient a fair or balanced assessment of the benefits of vaccination. Such an approach undermines, rather than supports, patient autonomy. (Choice C) Although accepting the patient's decision without any discussion seems to respect patient autonomy in a superficial sense, it does not provide the relevant information the patient needs to make an informed decision. (Choice D) A simple reiteration of the clinician's initial rationale for recommending vaccination does not provide the patient with any additional information to facilitate decision-making. (Choice E) During influenza outbreaks, oseltamivir can be given prophylactically to exposed, high-risk patients (eg, patients in skilled nursing facilities, family members of confirmed cases). In such situations, it is administered in short courses, not through the whole season. Educational objective: In cases in which a patient declines a recommended service based on inaccurate or incomplete information, the clinician should provide a balanced assessment of the recommended intervention, including the likely benefits, risks, and limitations. Giving a more accurate and thorough explanation can reinforce patient autonomy and improve decision-making.

A 35-Year-Old Man Comes to the Office in Late October