Groups potentially at risk for making poorly informed decisions about entry into clinical trials for childhood cancer

Illness severity and parental permission for clinical research in a pediatric ICU population

OBJECTIVE

Research in child subjects requires parental permission. We examined whether parental authorization of involvement in a clinical study is influenced by the child's severity of illness at the time of the consent decision.

DESIGN AND SETTING

Observational study in a multidisciplinary tertiary pediatric and neonatal intensive care.

PATIENTS AND PARTICIPANTS

Parents of 421 children (age range from preterm to 18 years) were asked to consent for participation in a study focusing on measuring their child's nutritional status within 24 h after admission to the ICU. Over 20% of the parents (n=88) refused consent, most of them because they expected the study to be too burdensome for their child.

MEASUREMENTS AND RESULTS

Patient and disease characteristics were comparable in the children for whom consent had or had not been obtained. A higher illness severity score did not decrease the probability of obtaining informed consent, but parents of children with a history of disease were 3.2 times less likely to consent.

CONCLUSIONS

Parents of children with higher illness severity scores are not more likely to decline permission to include their child in clinical observational research on the ICU. History of disease and subjectively perceived burden to the child are important factors that must be considered.

Parental Treatment Decision Making in Pediatric Oncology

OBJECTIVE

To review progress and future plans for a research program about parents' making treatment decisions for their children with cancer.

DATA SOURCES

Theoretical papers, review articles, and research reports.

CONCLUSION

Three important questions need to be addressed to achieve the goal of supporting parents in treatment decision making: 1) Whatfactors predict a parent's preferred role iln decision making? 2) What are the critical outcomes from parental decision making that nurses could help to improve? 3) Is it role choice, actual role assumed, or congruence between preferred and actual role in decision making that predicts decision outcomes for the parents?

IMPLICATIONS FOR NURSING PRACTICE

Research-based responses to the remaining questions about parent treatment decision making will help nurses develop and test interventions designed to support parents in their decision making experiences.

Informed consent in pediatric clinical trials

PURPOSE OF REVIEW

Clinical research in children is increasing. Concerns have been raised about both the inclusion and the exclusion of children in such research. Corresponding to these concerns, issues in informed consent for pediatric trials have become more pressing. This review discusses informed consent in pediatric trials and characterizes the latest literature.

RECENT FINDINGS

Research into the consent process has shown that central concepts in pediatric research such as randomization and the distinctions between phases of clinical trials are not uniformly understood by parents or older pediatric patients. Newer approaches that are being developed to help remedy these deficits include the use of staged informed consent, the incorporation of interactive computer technologies to convey complex ideas, and variations in approaches to assent of the child based on multifactorial assessments of competence. Other variables in the consent process that are being studied for their impact on the process include individual life experiences and cultural background. Gaps in federal regulation and oversight of "informed consent" are emerging as new cases test established assumptions.

SUMMARY

Lessons learned from recent studies regarding oversight of the consent process in pediatric clinical trials, the complex nature of assent, the impact of cultural variables, and more effective means of communicating what is involved in a clinical trial will shape future studies in consent and help to improve the process.

Comparison of the informed consent process for randomized clinical trials in pediatric and adult oncology

PURPOSE

To compare the informed consent processes for phase III pediatric and adult oncology clinical trials in view of the critical importance of human subjects protection in both pediatric and adult cancer care. Findings are discussed in terms of the opportunities for improving pediatric and adult oncology informed consent.

PATIENTS AND METHODS

A total of 219 subjects are reported on. Adult oncology patients made up 36.1% (n = 79) of the sample. Pediatric surrogates made up the remaining 63.9% (n = 140). Subjects in both studies were observed and audiotaped in conversation with their oncologists, and interviewed afterwards. Comparisons between the adult and pediatric subjects were done using chi(2) statistics and t tests.

RESULTS

Differences between the pediatric and adult informed consent processes were found. Adult oncology decision makers were, on average, more fully informed and more actively engaged by their oncologists. Pediatric decision makers were, however, given more information about survival/cure, randomization, and voluntariness. Comprehension difficulties were more frequent among pediatric decision makers. Suggestions for improvement are made in view of the differences between adult and pediatric oncology research environments.

CONCLUSION

Ongoing efforts to improve the ethical framework of clinical cancer research need to take into account the key differences between pediatric and adult oncology informed consent. More research needs to be done to explore the differences between adult and pediatric informed consent processes in oncology.

Good communication in pediatric cancer care: a culturally-informed research agenda

Communication affects people's factual understanding of the situations they are in. This in turn affects consent to be treated and adherence. Although a growing body of literature concerns cancer communication, it generally concerns adult patients; pediatric-specific knowledge is limited. Furthermore, most research focuses shortsightedly on physicians rather than providers who have more patient contact, favors studying the single visit instead of encompassing the cycle of cancer care, does not take the child into account, and ignores the importance of provider-provider communication. Moreover, cultural issues are only narrowly conceived. In exploring culture's role in pediatric cancer care communication, this article demonstrates that culture cannot be defined as just ethnicity or race. Professions also have cultures and resultant differences in communication patterns that can lead to communication failures. It also shows that there is a crucial need for more applied research as well as more qualitative research that can enrich our understanding of the complicated context-related factors facilitating or barring successful pediatric cancer communication.

Exploring issues of parental consent to research: a case-study approach

In this article, a novice nurse researcher relates her personal experience of encountering a challenging situation while taking consent from the parents of a critically ill child. This critical incident raises issues for the researcher of ensuring validity of the consent process and ensuring recruitment of an unbiased sample when issues of language and culture could impede communication. The process of reflection allowed the novice researcher to gain greater insight into her responsibilities as a research nurse in relation to recruiting patients and to reflect on how she would integrate this into her future practice, thus enhancing her confidence in her role.

Correlates of Parental Participation During Informed Consent for Randomized Clinical Trials in the Treatment of Childhood Leukemia

This study described parent participation in the informed consent conference for randomized clinical trials (RCTs) in childhood leukemia and documented the relationship of physician communication to parent participation. Parents of 140 children with newly diagnosed leukemia who were eligible for RCTs were studied at six sites using comprehensive methods involving direct observation and transcripts of parent-physician communication based on audiotapes. Parent participation during the informed consent conference reflected a wide range of content categories. Consistent with hypotheses, Physician Rapport and Partnership Building related to parent participation in the informed consent conference but Information Giving did not. Higher parent socioeconomic status also was related to greater parent participation for two of the three measures of parent participation. Findings suggest that physician behaviors that provide support and facilitate communication may enhance parental participation in the informed consent conference for RCTs in childhood leukemia.