Benevolent power

The nurse's ability to use "benevolent power" can be a very useful tool in relating to patients. Use of "benevolent power" takes advantage of the nurse's power and authority by virtue of positions. However, rather than focusing on the nurse's needs or manipulating the patient in a negative way, use of"benevolent power" allows the nurse to respond to the patient situation in a way which is beneficial and positive for the patient.

A critical analysis of criticisms of the Oregon Death with Dignity Act

This article critically examines the validity of common criticisms of the Oregon Death with Dignity Act, primarily through reviewing published research and analyses. After summarizing the law and recent developments, 11 areas of concerns are examined: (a) the amount of data collected, (b) the availability of the data, (c) the reporting process, (d) protection of physicians, (e) terminal illness as a requirement, (f) the amount of data on palliative care interventions, (g) data on lethal prescriptions, (h) data on psychological/psychiatric evaluations, (i) whether the decision to request medication is informed, (j) whether the request is voluntary, and (k) financial factors. The authors examine each of these areas of concern and find criticisms to be unfounded given the research and analyses conducted to date.

Ethical Considerations in the Recruitment of Research Subjects From Hospitalized, Cardiovascular Patient Populations

Cardiovascular research nurses play important roles in ensuring that subject recruitment is conducted in an ethically defensible manner. However, these nurses encounter many ethical challenges in the course of research. Sole reliance on regulatory mechanisms such as institutional review board oversight and adherence to legal requirements does not necessarily ensure human subjects' protection or the scientific integrity of researchers (J Law Med Ethics. 2002;30:411-419). Therefore, this article discusses 3 additional ethical considerations associated with recruiting hospitalized cardiovascular patients for research studies. These include (a) the role of the family and patient-delegated "gatekeepers," (b) the effect of transient and subtle mental status changes upon the consent process, and (c) the effect of conflicting patient priorities. This content is illustrated using the authors' experiences recruiting hospitalized coronary artery bypass graft surgical patients for a research study.

An assessment of the impact of informative dropout and nonresponse in measuring health-related quality of life using the EuroQol (EQ-5D) descriptive system

OBJECTIVES

To investigate the impact of imputing EQ-5D values to allow for informative dropout and nonresponse in a longitudinal assessment of the health-related quality of life (HRQL) of liver transplant recipients.

METHODS

The EQ-5D was administered at defined time intervals pre- and post-transplantation to all adults who were listed to receive liver transplants as National Health Service (NHS) treatment at each of the six Department of Health designated centers in England and Wales over a time-period of 36 months (12 month recruitment period and 24 month follow-up period). During the course of the study missing data arose for two main reasons, informative dropout and nonresponse. Informative dropout was accounted for by giving those patients who died an EQ-5D score of 0 and those patients who were too ill to respond to an EQ-5D score equivalent to the 5th percentile of respondents for each time point pretransplantation. Nonresponse was accounted for using relatively naive approaches (last value carried forward, and upper/lower 95% confidence interval around the mean) and contrasted with a more sophisticated multiple imputation method.

RESULTS

Adjusting for informative dropout in isolation resulted in a marked deterioration in mean scores over time pretransplant relative to the base case situation in which no such adjustments were made. Nevertheless, adjusting for informative dropout and/or nonresponders did not alter the base case conclusion of no statistically significant differences in mean EQ-5D scores over time pretransplant. In contrast, post-transplant data indicated highly statistically significant improvements in quality of life over time for the base case (P < 0.001) whereas no statistically significant improvements over time were found when informative dropout was allowed for in isolation (P = 0.402) or when informative dropout and nonresponse were allowed for simultaneously (P = 0.105-0.185).

CONCLUSIONS

It is important that future studies which purport to assess the HRQL over time of patients, such as these with end-stage liver disease, include an allowance for informative dropout and nonresponse within the analysis.

Withdrawal of ventricular assist device support

OBJECTIVE

Ventricular assist devices (VAD) are mechanical pumps implanted into patients with advanced heart failure who are at risk of imminent death. VADs are a treatment and not a cure, and mortality on device support remains high. Recognizing the dire nature of the decisions for patients and families and the associated high mortality rates, we actively included processes for device withdrawal as part of our program mandate.

METHODS

At Toronto General Hospital, from October 2001 to December 2004, 22 patients underwent implantation of a VAD. Seven patients died following device withdrawal.

RESULTS

The average time spent on support prior to device withdrawal was seven days. In four of the seven cases, family members initiated discussions regarding device withdrawal. Family-initiated discussions were more likely to occur if patients were implanted electively, as a bridge to transplantation. Disagreements occurred between the ICU and the transplant teams regarding the timing of device withdrawal and responsibility for stopping the pump.

DISCUSSION

Establishing a process for device withdrawal has been a key factor in the success of our VAD program. This process relies heavily on pre-implantation preparation, a strategy for resolving disagreements, and a process for withdrawing device support.

[A modified informed-consent procedure in which the complete information is given retrospectively: no objection from participating patients]

OBJECTIVE

To determine whether a modified informed-consent procedure, in which permission is requested to send a questionnaire and to provide all the information about the study only after it is completed, would raise objections from patients who were asked to participate in a study on satisfaction with the follow-up care after a cerebrovascular accident.

DESIGN

Descriptive cohort study.

METHOD

123 patients were approached for the randomised study. The patients who were included were interviewed by telephone two weeks after they had been sent the postponed information.

RESULTS

During recruitment, 5 patients refused to participate but this was not because of the modified procedure. Of the 112 survivors, 102 (91%) could be interviewed and 79 had read the letter. Nobody (0%; 95% CI: 0-5) said that their trust in doctors had decreased; one patient (1%; 95% CI: 0-7) indicated decreased willingness to participate in future studies; two patients (3%; 95% CI: 0-9) were dissatisfied about the procedure followed.

CONCLUSION

The participants in the trial had no major objections to the modified informed-consent procedure in which full information was given only after their participation had ended. Furthermore, patients did not refuse participation because of the modified procedure.

Capacity of forensic patients to consent to research: the use of the MacCAT-CR

The ability of psychiatric patients and prisoners to provide informed consent to participate in clinical research has given rise to much debate. Forensic psychiatric patients present a particular concern regarding their competence to consent to research, as they are both patients and prisoners. The primary goal of this research was to evaluate whether, by employing structured assessments of capacity to consent to research, we could determine if this combined vulnerability leads to differences in competence from the published abilities of nonforensic psychiatric patients. Subjects deemed incapable of providing informed consent scored differently and lower than the other consent groups on three aspects of the decision-making process. Diagnosis evidenced only a slight relationship to decision-making abilities, and this difference was only in the ability to understand the basic procedural elements of the research. Psychiatric symptoms were modestly related to decision-making. Positive symptoms were associated with poorer performance on the Understanding subscale of the MacCAT-CR, and negative symptoms were associated with lowered performance on the Reasoning subscale. These results are in accord with several published studies of nonforensic psychiatric patients and suggest that concerns regarding both forensic and nonforensic psychiatric patients' ability to provide informed consent may be unwarranted, especially in patients with few active symptoms.

Current practices and medico-legal aspects of pre-operative consent

BACKGROUND

Written informed consent is a pre requisite for surgical intervention as it provides the forum for the patient to appreciate implications of the procedure and the doctor to explain details and effects of the surgery.

OBJECTIVES

To evaluate the practice of obtaining informed consent pre-operatively by surgeons in Benin City and proffer solutions that would enhance its practice.

DESIGN

Cross-sectional study involving surgical patients or their relations or gurdian (in cases involving minors and unconscious patients) who were interviewed with structured ended questionnaires.

SETTING

Study was carried out at the University of Benin Teaching Hospital, Benin City, between 5th July and 6th September 2002.

RESULTS

One hundred and thirty-three respondents; 53(39.2%) males and 80(60.2%) females were interviewed. Documentations regarding consent were noted in 118(88.7%) cases. Of these, 74.6% felt they had enough time to reflect on the consent obtained while 48(36.1%) respondents were meeting the individual who obtained their consent for the first time. The content of information offered patients prior to obtaining consent was found to be significantly related to the levels of education (X2= 31.44; P<0.001). Over a hundred respondents were not informed of risk of procedure. Nonetheless over 50% of respondents felt satisfied with information supplied.

CONCLUSION

The quality of consent obtained from the average patient fell below expected standard. There is need for greater awareness amongst administrators of consent on the essence of improving quality of information given and mode of obtaining consent from patients.

Exploring the complexities of prostate cancer screening with a view to supporting informed consent

Men request to be screened for prostate cancer because they believe they are exhibiting responsible health promotion behaviour and there are definite benefits from the early detection of the disease. This belief about the benefits is in contrast to several national guidelines recommending that screening for prostate cancer not be done. Despite the guidelines men continue to request to be screened and doctors continue to supply screening tests to asymptomatic males. The lack of an appropriate screening test has been a key factor in supporting recommendations not to screen. However, recent studies show improved accuracy in the use of serum prostate specific antigens (PSA) as a screening tool. This implies that a revision of the guidelines might soon be appropriate. It is important that nurses and other health professionals are kept abreast of developments in prostate screening to assist men with their screening options to ensure their fully informed consent.

Increasing awareness of tissue donation: in the non-heart beating donor

Many healthcare professionals (nursing and medical staff) are familiar with asking families to consider organ donation in the brain-stem death patient. In contrast few healthcare professionals raise the subject of tissue donation with the newly bereaved non-heart beating donor (NHBD) families following cardiac death. The failure of healthcare professionals to approach theses families is strongly supported in the literature [Crit. Care Nurs. Clin. N. Am. 4 (1992) 63; William and Calif, 1996; Prof. Nurse 12 (1997) 482]. Coyle [Intensive Crit. Care Nurs. 16 (2000) 45] identified that for many nurses the conflict arises from the ethical principle of beneficence to do good and non-maleficence to do no harm. However, why is requesting organ and/or tissue donation an ethical issue, should it not be part and parcel of the care offered to bereaved families? Are healthcare professionals not making an issue of it? This article critically analyses the issues surrounding tissue donation and the role of healthcare professionals in raising awareness of eligibility for tissue donation. A tool of structured reflection [J. Nurse Manager 1 (1993) 9] will be used to highlight the use of reflective practice following a critical incident. On the basis of analysis of current practice consideration will be given for future theoretical arguments in development, research, and education.

Informed consent for ankle fracture surgery: patient comprehension of verbal and videotaped information

BACKGROUND

The purpose of our study was to evaluate the effectiveness of using a videotape to give patients information about the risks, benefits, alternatives, and treatment of a common orthopaedic procedure before they sign consent forms.

METHODS

During a 9-month period, 48 patients with isolated closed ankle fractures requiring surgical intervention were randomized into two groups that received either videotaped or conventional verbal information regarding consent for surgery. The study group watched a videotape containing information about the risks, benefits, and treatment alternatives, while the control group obtained this information verbally. To determine comprehension and retention, all patients completed a multiple-choice questionnaire immediately after receiving the information, and 37 patients (77%) were available to complete a questionnaire at an average of 10 weeks later.

RESULTS

The videotape group outperformed the verbal consent group by 40.1% on the initial questionnaire (p = .0002) and by 27.2% on the followup questionnaire (p = 0.0139). Patients with educational levels of less than or equal to the 12th grade performed 67.8% better on the initial questionnaire after watching the video than after receiving the information verbally. (p = .0001).

CONCLUSION

Patients who received information about their surgery on a videotape before giving their consent demonstrated a significant increase in comprehension compared to patients who received this information verbally. The benefit was even greater for patients with lower education levels.

Managing do-not-resuscitate orders in the perianesthesia period

Perianesthesia care often involves the use of pharmacologically potent drugs, increasing the risk of cardiopulmonary depression and arrest. For patients with terminal diseases, it may be difficult to decide whether cardiopulmonary arrest in the perianesthesia period is a result of anesthetic medications, surgical intervention, or the disease process. It is imperative that the patient maintains autonomy and is treated according to his or her wishes regarding do-not-resuscitate (DNR) orders. Some hospitals automatically suspend DNR orders for patients undergoing surgery, whereas others provide patients the option of no, limited, or full resuscitation. This article promotes the premise that all DNR orders should be reviewed and reconsidered with patients before consent for surgery.

Focus group interviews examining attitudes toward medical research among the Japanese: a qualitative study

OBJECTIVES

the purpose of ths study is to explore laypersons' attitudes towards and experiences of medical research, and to compare them with those of physicians in Japan. Designs and Participants: fourteen Japanese adults from the general public and seven physicians participated in one of three focus interviews.

SETTING

Osaka, Japan.

RESULTS

trust and distrust in the physician by whom the participants were invited to participate in research played a considerable role in their decisions about participation. That the participants felt an obligation to participate was also expressed. The lay participants perceived medical research as something entirely outside of their world. A greater willingness to volunteer for research was expressed if there were direct benefits to themselves or their families. Research methods such as use of placebos, double blinds, and randomisations seemed to cause negative attitudes to medical research. All physicians were convinced of the need for medical research, including double-blinded randomised control trials, and its significant role in medical progress. Most physicians thought that the greater awareness of the need for medical research in the community and a better understanding of the psychology of potential research participants were necessary and urgent.

CONCLUSIONS

there is a good possibility that the lay public and medical professionals have sharply different beliefs about and attitudes towards every aspect of medical research. Building up a better and equal patient-doctor relationship based on trust is a key issue in medical research, and it is mandatory to fill the gap in perception regarding medical research between them through fully informed debates.

Informed consent and biobanks: a population-based study of attitudes towards tissue donation for genetic research

AIMS

The procurement and usage of tissue samples has begun receiving increasing legal and ethical attention. The authors' aim was to develop an empirically based understanding of public attitudes to the use of tissue for research.

METHOD

A questionnaire was distributed to a randomized sample (n=1,000) of the population in the age group 18-85 in Västerbotten County, Sweden.

RESULTS

The response rate was approximately 60%. There was a general acceptance of genetic research based on biobank material (71%) but, though it is often a prerequisite for tissue-based research, a majority (62%) would not allow researchers to examine their healthcare records without specific consent. A majority (66.8%) accepted surrogate decisions by research ethical committees; 48% of the respondents estimated that they would feel respected if they were notified each time a sample was used. When compared and ranked with other issues, informed consent was a principal concern to a minority (4%) only. Should research efforts generate information on future health risks, a majority (55%) would want to be told only if treatment was available.

CONCLUSION

Though genetic research in bioethical debate is often viewed as a potential threat to the integrity of the donor, the confidentiality of medical records still seems to concern donors more. Research ethical committees have support in the majority of the population for some surrogate decisions. The current emphasis on the question of informed consent in policy making for biobank-based research does not seem to be reflected unambiguously in the concerns of the general public.

Do men know that they have had a prostate-specific antigen test? Accuracy of self-reports of testing at 2 sites

This study determined the accuracy of self-reports of prostate-specific antigen (PSA) testing. Men (N = 402) attending 2 outpatient clinics were asked: "Did you have a PSA test today?" and their medical records were checked. Concordance, sensitivity, and false-negative values were 65%, 67%, and 33%, respectively, at 1 clinic site and 88%, 64%, and 36% at the other. The accuracy of self-reports of PSA testing should be interpreted with caution.

The patient who refuses nursing care

OBJECTIVES

The aim of this paper is to examine the way in which nurses manage patients who refuse nursing care procedures.

DESIGN

This paper reports on a qualitative study which was undertaken to explore the way in which nurses obtain consent prior to nursing care procedures. Focus groups were carried out to obtain background data concerning how consent is obtained. Critical incidents were collected through in depth interviews as a means of focusing on specific incidents in clinical practice.

SETTING

Two teaching hospitals in England.

PARTICIPANTS

Purposive sample of qualified nurses.

RESULTS

When a patient refuses nursing care, nurses respond by giving information until the patient finally accedes to the procedure. Nurses will go to great lengths to achieve patients' agreement to the procedure, but the extent to which the agreement remains voluntary cannot be ascertained by the data collected in this study. If the patient does not eventually agree to a procedure, there is evidence that nurses will administer the care in the absence of consent.

CONCLUSIONS

Nurses are concerned to obtain the patient's consent prior to the administration of nursing care but if this cannot be achieved do not regard obtaining consent as an absolute requirement. Consent is preferred, but not considered essential. Nurses have some understanding of the principles of informed consent but do not apply them to everyday clinical nursing practice.

Consent for tonsillectomy

Rulings in recent negligence cases reveal a shift towards what the 'reasonable patient' would expect in deciding the risks doctors must disclose to patients. This survey aimed to investigate whether the 'reasonable patient' and 'responsible body of medical opinion' agree about which risks should be discussed regarding tonsillectomy. Using questionnaires, surgeons were asked which of the 10 complications they routinely discussed and patients were asked how seriously they regarded these complications. The results were compared with the Test of Proportions. Most surgeons routinely mentioned otalgia, odynophagia, throat infection and re-operation. Most patients regarded potentially fatal bleeding, pneumonia and blood transfusion as very serious but only the minority of surgeons mentioned these (P < 0.001). When obtaining consent for tonsillectomy, surgeons do not routinely mention all the risks that the 'reasonable patient' would expect. The 'reasonable patient' would expect that re-operation, transfusion, pneumonia and fatal blood loss are discussed.

[Consenting to ambiguities: a documental analysis of informed consent forms used in assisted human reproduction clinics]

With the field of assisted human reproduction as a case study, this article presents the results of a study on informed consent forms, linking the understanding of the use of social languages - especially the language of risk - and its implications on the relationship between health professionals and clients. Informed by a social psychology perspective and aligned with the qualitative tradition in research, the study was oriented by a theoretical approach to discursive practice, whereby the language of risk is understood as a way of speaking of future control of risks. The analysis centered on the text of 27 informed consent forms provided by eight Brazilian clinics. Besides understanding the linguistic specificities, the analysis attempted to answer the question, "What is being consented to?" The results showed the ambiguity of a document which presupposes the use of the metaphor of taking versus not taking risks. That is, the document may be used in a democratic, bureaucratic, or even authoritarian way, while the communication of risks and benefits subsidizes both the decision-making and the dilution of responsibility throughout the relational network.

Therapeutic misconception and the appreciation of risks in clinical trials

Studies repeatedly have shown that clinical research subjects have trouble appreciating the implications for their clinical care of participating in a clinical trial. When this failure is based on a lack of appreciation of the impact on individualized clinical care of elements of the research design, it has been called the "therapeutic misconception". Failure to distinguish the consequences of research participation from receiving ordinary treatment may seriously undermine the informed consent of research subjects. This article reports results concerning appreciation of the risks of trial participation from intensive interviews with 155 subjects from 40 different clinical trials at two different medical centers in the USA. Working from transcripts of the interviews, every statement of a risk or disadvantage of trial participation was identified and coded into one of 5 different categories. Totally, 23.9% of subjects reported no risks or disadvantages in spite of being explicitly asked about them. Another 2.6% reported only incidental disadvantages such as having to drive a long way to get to the experimental site. In all 14.2% reported only disadvantages associated with the standard treatment (usually side effects). Another 45.8% told the interviewer about disadvantages and risks associated with the experimental intervention (usually side effects). Only 13.5% could report any risks or disadvantages resulting from the research design itself, such as randomization, placebos, double-blind designs and restrictive protocols. The results of this research suggest that subjects often sign consents to participate in clinical trials with only the most modest appreciation of the risks and disadvantages of participation.

The leap to trust: perspective of cholecystectomy patients on informed decision making and consent1 1No competing interests declared

BACKGROUND

Although experts in ethics and law prescribe autonomous decision making as an essential component of informed consent to operative treatment, patients with esophageal cancer told us in a previous study that they preferred to entrust decision making to their caregivers in the context of life-threatening illness. The purpose of this study was to describe the patients' perspective on the process of informed decision making and consent to operative treatment in the context of a less frightening illness and intervention.

STUDY DESIGN

Face-to-face interviews with 33 patients recovering from elective cholecystectomy for cholelithiasis were conducted at Toronto General Hospital in Ontario, Canada. The views of patients were analyzed using a qualitative approach.

RESULTS

Patients described a spectrum of initial attitudes toward operative treatment ranging from profound distrust to unquestioning faith. Important factors influencing the decision to accept cholecystectomy included increasingly intolerable symptoms and fear of complications of the disease. Patients managed their doubts and fear by various means, without fully resolving them.

CONCLUSIONS

In the context of symptomatic chronic cholelithiasis, pathways to consent for operative treatment originated at diverse, culturally determined starting points. Patients work their way through the decision process along many paths. Some rely on gathering information, but eventually all set aside unresolved residual doubts and fears, enabling a leap to trust and a decision to act.

Capacity to consent to treatment: empirical comparison of three instruments in older adults with and without dementia

PURPOSE

The purpose of this study was to compare adults with and without dementia on capacities to consent to treatment as assessed by three instruments.

DESIGN AND METHODS

Eighty-eight older adults with mild to moderate dementia were compared with 88 matched controls on four indices of legal competency to consent to medical treatment as assessed with three capacity instruments.

RESULTS

Mean performance of adults with dementia on a legal standard of understanding treatment information was impaired relative to controls on all instruments, and it was also impaired for an appreciation standard on one instrument and a reasoning standard on two instruments. However, in categorical ratings, most adults with dementia were within the normal range on all decisional capacities. Legal standards were operationalized differently across the three instruments for the capacities of appreciation and reasoning.

IMPLICATIONS

Most adults with mild dementia can participate in medical decision making as defined by legal standards, although memory impairments may limit demonstration of understanding of diagnostic and treatment information. In dementia, assessments of reasoning about treatment options should focus on whether a person can describe salient reasons for a specific choice, whereas assessments of appreciation of the meaning of diagnostic and treatment information should focus on whether a person can describe the implications of various choices for future states. More research is needed to establish the reliability and validity of assessment tools and of capacity constructs.

The influence of risk and monetary payment on the research participation decision making process

OBJECTIVES

To determine the effects of risk and payment on subjects' willingness to participate, and to examine how payment influences subjects' potential behaviours and risk evaluations.

METHODS

A 3 (level of risk) x 3 (level of monetary payment), between subjects, completely randomised factorial design was used. Students enrolled at one of five US pharmacy schools read a recruitment notice and informed consent form for a hypothetical study, and completed a questionnaire. Risk level was manipulated using recruitment notices and informed consent documents from hypothetical biomedical research projects. Payment levels were determined using the payment models evaluated by Dickert and Grady as a guide. Five dependent variables were assessed in the questionnaire: willingness to participate, willingness to participate with no payment, propensity to neglect to tell about restricted activities, propensity to neglect to tell about negative effects, and risk rating.

RESULTS

Monetary payment had positive effects on respondents' willingness to participate in research, regardless of the level of risk. However, higher monetary payments did not appear to blind respondents to the risks of a study. Payment had some influence on respondents' potential behaviours regarding concealing information about restricted activities. However, payment did not appear to have a significant effect on respondents' propensity to neglect to tell researchers about negative effects.

CONCLUSIONS

Monetary payments appear to do what they are intended to do: make subjects more willing to participate in research. Concerns about payments blinding subjects to risks could not be substantiated in the present study. However, the findings do raise other concerns--notably the potential for payments to diminish the integrity of a study's findings. Future research is critical to make sound decisions about the payment of research subjects.

Informed consent and the JHO in Scotland

AIM

To define the views of junior house-officers (JHOs) concerning consent for general surgical conditions.

METHODS

Questionnaire-based descriptive study on two cohorts of JHOs, separated by 3 years of major national and local directives.

RESULTS

From the JHO perspective: (i) there has been a shift away from the JHO being the main signatory, (ii) many JHOs (58% in 2000; 47% in 2003) feel unsupported with respect to obtaining consent, (iii) knowledge concerning any consultant/unit's complication rates was poor (<30%), (iv) knowledge concerning complication rates for several paradigm procedures was also poor, though it improved from 2000 to 2003, (v) there is no formal training in consent.

CONCLUSIONS

Despite the JHO group of 2003 outperforming that of 2000, there is major scope for improvement from patient, legal, educational and risk-management perspectives.

Chirurgie et transfusion chez les patients témoins de Jéhovah. Mise au point médico-légale

The religious convictions of the witnesses of Jehovah leads them to refuse transfusion of blood, of its major components and of blood sparing procedures breaking the physical contact between the patient and his blood. We recall the rules of good practice in case of elective surgery concerning exhaustive information of the patient within multidisciplinary team associating anesthetist and surgeon advised by the forensic pathologist. This consultation must, to our point of view, be concluded by a report which summarizes what is accepted or not by the patient. This report will be initialed by the patient. This consultation can never lead the physician to swear to never use a transfusion whatever the circumstances. In case of emergency if and only some conditions are met (everything was made to convince the patient, vital emergency, no therapeutic choice, therapeutic care adapted to the patient heath status), the physician can be brought to overpass the patient's will to not receive blood transfusion. Current jurisprudence has, to date, never recognized as faulty the physicians having practiced such transfusions whenever they took place within a precise framework.

The psychological dimension of informed consent: dissonance processes in genetic testing

This paper discusses the issue of the psychological dimension of informed consent. In this paper, the author proposes that informed consent is a continuous variable rather than a dichotomous one. When clients better understand their motives and actual, rather than just perceived degree of choice in pursuing a particular option in a medical setting, their level of informed consent is greater. Findings from existing literature in the field of genetic testing are examined in terms of dissonance theory. These findings suggest that testing candidates sometimes overestimate their coping skills and minimize the threat to psychological integrity that a particular genetic result may pose. Counseling directed towards realistic appraisal of degree of choice in pursuing testing is examined as an aspect of supporting informed consent and possibly reducing the potential for adverse psychological outcome in the longer term.

Patients' consent preferences regarding the use of their health information for research purposes: a qualitative study

OBJECTIVE

To explore the consent preferences of patients whose health data are currently being used for research purposes.

METHODS

Semi-structured interviews were conducted with 17 patients whose primary physicians were taking part in a study that utilized de-identified individual-level health information from their electronic medical record. All physicians practised in southwestern Ontario. All interviews were taped, transcribed verbatim and analysed using a constant comparative method. All transcripts and debriefing notes were read and reread to elicit general themes.

RESULTS

Three main themes emerged from the data: patients recognized the need to balance their consent preferences with time pressures in the clinical encounter when deciding the nature of consent for a study; patients generally regarded the seeking of consent as being an issue of respect for them as individuals; and patients were also weighing their perceived benefits and concerns related to the research. For these patients, seeking their consent was an important step in research participation. For some patients, the sponsor and the research topic were factors that would influence their decision to provide consent.

CONCLUSION

Patients want their consent to be sought when their data are used for research purposes. This will involve explicitly informing patients that a study is taking place, providing written consent and offering regular updates about the study.

The effect of format modifications and reading comprehension on recall of informed consent information by low-income parents: a comparison of print, video, and computer-based presentations

A randomized trial comparing the amount of knowledge orally recalled from four different presentations of the same consent information was conducted in a non-clinic sample of 233 low-income parents who displayed a range of reading comprehension skill. The study simulated recruitment of children into one of two actual studies underway at another location: one involved high risk to participants, the other did not. Use of a non-clinic sample controlled for prior knowledge of the conditions, and avoiding discussion of the information further assured that differences in recalled information could be attributed more confidently to the format itself. The formats included the original written forms, enhanced print (simpler language, topic headings, pictures), narrated videotapes, and self-paced PowerPoint presentations via laptop computer with bulleted print information, pictures, and narration. No format-related differences in recalled information were found in the full sample but for the 124 individuals with reading comprehension scores at or below the 8th grade level, the enhanced print version tended to be more effective than either the original form or the video. Across all formats, more information was recalled about the low-risk study. The findings emphasize the necessity for clinicians and researchers to verify understanding of consent information, especially when there is risk of reduced literacy skill. Reliance on video to convey information in preference to well-done print media appeared questionable.

Staged informed consent for a randomized clinical trial in childhood leukemia: impact on the consent process

BACKGROUND

Children Cancer Group (CCG) 1991 is the first childhood acute lymphoblastic leukemia trial within CCG that allowed the utilization of a staged approach to the consent process.

METHODS

One hundred and forty subjects participated in the Project on Informed Consent which compared the primary outcome measures in the consent process of patients enrolled in CCG-1991 with those enrolled in other CCG leukemia studies.

RESULTS

The parents' trust scores were higher for the CCG-1991 compared with other protocols. Eighty percent of parents enrolled in CCG-1991 understood the distinction between the randomized clinical trial and the standard treatment arm, compared with 62.5% in the other studies, P = 0.05. Multiple other outcome measures suggested a positive impact from staged informed consent.

CONCLUSIONS

Our results suggest that a consent process with a staged approach can help investigators obtain a more truly informed consent. Future research is needed to confirm the benefits of the staged approach to the informed consent process.

Informed consent for invasive procedures in a community hospital medical intensive care unit

OBJECTIVE

To describe the informed consent practices in the medical intensive care unit (MICU) of a university-affiliated, community teaching hospital.

DESIGN

Prospective, observational study.

SUBJECTS

177 critically ill patients.

MEASUREMENTS

Study personnel identified all critically ill patients who had an invasive medical procedure during the study period (120 days). It was first determined whether written informed consent was obtained for the procedure. If it was, standardized questionnaires were used to determine whether consent-givers recalled the indications, complications, and alternatives of invasive medical procedures. Documentation of consent and of the performance of invasive procedures in the medical records was also examined. An educational in-service was created to help improve the informed consent process. After a 45-day lead-in (control) period, the in-service was administered and IC was again studied for 75 days.

RESULTS

A total of 181 procedures were performed on 112 patients over 120 days in the MICU. The rates of written consent for invasive procedures averaged 89%; rates of consent were not affected by the educational in-service. Following administration of the in-service, consent-givers recalled a greater number of complications (2.5 to 4.1, P=0.01) and documentation of consent improved.

CONCLUSIONS

These results suggest that informed consent can be obtained procedure-by-procedure, as needed, at a high frequency, and with reasonable consenter comprehension.

The challenges of informed consent for rapid HIV testing in labor

BACKGROUND

Although increasing attention has been focused on the adequacy of the informed consent process for participation in research studies, there has been little systematic evaluation of the process, particularly when consent is obtained in the labor and delivery setting. The Mother Infant Rapid Intervention at Delivery (MIRIAD) study is an ongoing multisite study initiated by the Centers for Disease Control and Prevention (CDC) designed to evaluate the feasibility of offering 24-hour counseling and voluntary rapid HIV testing and antriretroviral therapy when indicated to women with unknown HIV status who are in labor.

METHODS

To address concerns about obtaining informed consent from women in labor, we have completed focus groups, conducted a pilot of the informed consent process among women in labor, developed flip-charts to enhance comprehension, and plan an ongoing evaluation of the informed consent process throughout the course of the MIRIAD study.

RESULTS

In the pilot study, approximately 70% of women were able to state in their own words the purpose and benefits of the research study. Substantially fewer women (25%) were able to state one or more risks of the study.

CONCLUSIONS

We hope that the MIRIAD study will make a valuable contribution by defining best approaches for informed consent and will provide guidance when it is necessary to obtain consent from laboring women for crucial interventions.

Ethics seminars: vulnerable populations in emergency medicine research

Regulatory bodies and institutional review boards are increasingly considering human subjects who are vulnerable to research not because of their intrinsic characteristics, but because of the particular situations or circumstances that they bring with them as potential research participants. Several subsets of emergency department patients may be considered vulnerable in the research setting. This may include patients who are vulnerable because of a medical condition, a baseline limitation of intellectual function, a social setting, psychosocial stressors, or other factors. These issues should be carefully considered when including such patients in research protocols. Special efforts should be made to ensure voluntary participation and understanding of the purposes and risks of participation.

Requesting organ donation: the case of self-efficacy--effects of the European Donor Hospital Education Programme (EDHEP)

One of the major reasons for the shortage of donor organs is the high number of refusals by relatives. Studies have shown that the quality of communication with bereaved relatives influences whether to object or agree to organ and/or tissue donation. Breaking news of brain stem death, approaching relatives for permission to donate organs while also appropriately managing emotional reactions of relatives are complex tasks, which require knowledge of the domains as well as adequate skills to communicate information and understanding. In this study the effect of the European Donor Hospital Education Programme (EDHEP) on the self-efficacy of Intensive Care staff is evaluated. Self-efficacy scores significantly improved after attending EDHEP; an effect that was maintained at six month follow-up. EDHEP participants with high baseline scores on self-efficacy, maintained the increase at follow-up. EDHEP participants with low baseline scores on self-efficacy showed the greatest increase at the post-test. Increases in self-efficacy were significantly related to decreases in the perceived difficulty of requesting. Experience had a significant effect on both self-efficacy beliefs and perceived difficulty of requesting donation. As self-efficacy beliefs are perceived as better predictors for future behaviour than prior attainments, the results call for further research in this domain. The data indicate that training programmes should be tailored not only to working circumstances of participants, but should also take levels of experience and self-efficacy into account. Further study is necessary and the best way to proceed is to relate the outcomes of this study to behavioural outcomes.

Children and adolescents' capacity to provide informed consent for participation in research

Researchers who work with children and adolescents are confronted with a special set of ethical issues regarding informed consent. Federal guidelines generally stipulate that minors cannot provide informed consent for participation in research. Instead parental or guardian permission must be obtained for a minor to participate in research. However the literature in developmental psychology has shown that adolescents are able to make meaningful decisions and advocates for youth have argued that researchers must respect the autonomy rights of children and adolescents. The present review examines the developmental literature on children and adolescents' capacities to make informed, voluntary, and rational decisions to participate in research. The purposes and benefits of assent are identified. Recommendations are offered on how to enhance and respect minors' developing autonomy while protecting them from risks of research.

Informed consent--or the physician's anxiety delegated to the patient

Medical information, the precondition of informed consent, the author argues, is passed on to the patient not only on the concrete cognitive level; deeper unconscious and emotional levels pertaining to transferential and countertransferential aspects of the patient-physician relationship may have an important impact on the healing process. Two short examples illustrate how the physician's own anxieties may interfere with his informing of the patient. The article concludes with a plea for including psychotherapeutic teaching in medical training.

[Informed consent for angiography and endovascular treatment]

The aim of this paper was to evaluate the methods of passing information concerning angiography and endovascular treatment from doctors to patients. Patients undergoing modern procedures are especially prone to anxiety or even panic caused by the lack of sufficient information about the planned procedure. There are many reasons for such phenomena. One of them is extremely fast improvement of new, sophisticated technology and lack of humane attitude to patients. Authors examined 60 patients before and after angiography and endovascular treatment. Most of them (92%) knew nothing about the procedures. 30% of the patients gained information from other patients. After angiography and endovascular treatment most of patients assessed the procedures as less dangerous than expected. Our questionnaire is attached to this paper.

Confounding extremities: surgery at the medico-ethical limits of self-modification

Controversy swept the U.K. in January of 2000 over public disclosure of the fact that a Scottish surgeon named Robert Smith had amputated the limbs of two able-bodied individuals who reportedly suffered from a condition known as apotemnophilia. The patients, both of whom had sought and consented to the surgery, claimed they had desperately desired for years to live as amputees and had been unable, despite considerable efforts, to reconcile themselves psychologically to living with the bodies with which they were born. Both surgeries were successful, and both patients, who had undergone psychiatric evaluation prior to the amputations, subsequently reported having no regrets. In the wake of a wave of sensationalistic stories in the media, the hospital at which the surgeries had been performed, the Falkirk and District Royal Infirmary, banned any future surgeries of the kind. Outraged local politicians promptly announced their intention to pass laws banning the procedure outright. One member of Scottish Parliament declared the surgery obscene and asserted that the whole thing is repugnant and legislation needs to be brought in now to outlaw this.

The not unreasonable standard for assessment of surrogates and surrogate decisions

Standard views on surrogate decision making present alternative ideal models of what ideal surrogates should consider in rendering a decision. They do not, however, explain the physician's responsibility to a patient who lacks decisional capacity or how a physician should regard surrogates and surrogate decisions. The authors argue that it is critical to recognize the moral difference between a patient's decisions and a surrogate's and the professional responsibilities implied by that distinction. In every case involving a patient who lacks decisional capacity, physicians and the treatment team have to make judgments about the appropriateness of both the surrogate and the surrogate's decision. They have to assess the surrogate's decisional capacity and attitude toward the patient as well as the reasons that support the surrogate's decision. This paper provides a model for acceptable surrogate decisions and a standard for blocking inappropriate surrogates. Only decisions based on widely shared reasons are allowable for surrogate refusal of highly beneficial treatment.