Informed consent for bedside procedures in the pediatric intensive care unit: a preliminary report

OBJECTIVES

No uniform guidelines exist regarding informed consent for bedside procedures in the intensive care unit (ICU), and practice varies widely between institutions. Neither guidelines nor data exist to help pediatric ICU (PICU) directors craft procedural consent policies. We conducted an exploratory study to explore the impact on patients, parents, and healthcare providers of a requirement for informed consent for bedside procedures in the PICU and to describe parental and provider beliefs regarding procedural consent.

DESIGN

Prospective, observational and survey-based exploratory study.

SETTING

Single-center, tertiary care, university-affiliated PICU.

PATIENTS

Children admitted to the PICU and undergoing an invasive bedside procedure.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During two 14-day periods, all bedside procedures conducted in the PICU were identified. Consent forms were reviewed, and parents and the healthcare providers who participated in the consent discussion were invited to complete a brief verbal questionnaire regarding the consent process. Quantitative data are presented using descriptive statistics and qualitative data were analyzed using thematic coding. During the study period, 50 bedside procedures were performed. Informed consent was not obtained for two emergent procedures. Only the first procedure on a child was included in the study, leaving 41 informed consent discussions for analysis. Consent was obtained in person in 33 cases (80%) and over the phone for the remainder. The median reported duration of the informed consent discussion was 5 mins. Ninety-six percent of parents correctly recalled what procedure had been performed, and 92% correctly recalled at least one reason for the procedure, but only 58% recalled at least one risk of the procedure. Parents viewed themselves as the primary decision makers, and many parents believed that their refusal of consent would be honored even if it would potentially harm the child. However, no parent refused or even significantly resisted giving consent for a procedure recommended by their child's healthcare provider.

CONCLUSION

Parental consent for invasive bedside procedures in the PICU can be obtained reliably and without posing an undue time burden on healthcare providers. Most parents perceive a real decision making opportunity surrounding invasive procedures, but agree readily to the recommendations of their healthcare providers.

Information preferences of high literacy pregnant women regarding informed consent models for genetic carrier screening

OBJECTIVE

With the increasing carrier screening options being offered to pregnant women, it is critical to consider what information women want in an informed consent process, and how they make decisions regarding screening.

METHODS

We surveyed 201 pregnant women.

RESULTS

Subjects prefer "to have as much information as possible" (84%), and valued their physician's recommendations (82%) regarding screening. After reviewing two hypothetical scenarios, 71% of participants preferred more information about genetic carrier screening; however, some participants expressed concern that too much information can also lead to anxiety. When specifically asked about components of a potential informed consent process, the highest preferences were to include: the chance of having a child with the disorder (97%), the options for carriers (93%), the value and purpose of testing (91%), and the prognosis if a child has the disease (94%); preference for "symptoms" information differed based on scenario preference (p<0.001).

CONCLUSION

This study is the first to document variation in patients' views regarding the information desired as part of the informed consent process.

PRACTICE IMPLICATIONS

Providers should consider ways to ascertain their patients' preferred informational style, and how to provide information in the amount and style that patients find useful in making decisions.

Informed Versus Uninformed Consent for Prostate Surgery: The Value of Electronic Consents

PURPOSE

We evaluated the documentation of informed consent for 2 common prostate operations using current, conventional, paper based consent forms. Based on the results of the review the conventional paper based consent system was replaced with a new, standardized electronic consent system.

MATERIALS AND METHODS

We retrospectively reviewed the consent forms obtained for transurethral resection of the prostate and radical prostatectomy procedures during the 6-year period 1995 to 2000 at Atlanta Veterans Affairs Medical Center. Analysis focused on the basic elements of informed consent, including a description of the proposed treatment, and the purpose, benefits, risks and alternatives. Based on these findings we standardized the procedure specific information contained in consent forms and stored it electronically in a central network accessible to all urology providers throughout the medical center.

RESULTS

Of the 222 total procedures 204 consent forms were available for review. Senior residents, junior residents and physician assistants obtained consent for 42.2%, 30.9% and 25.5% of procedures, respectively. Information on the purpose and benefits of treatment was missing in 4.4% of cases and deficient in 22.6%. General or procedure specific risks were documented inconsistently in 0% to 96% of cases. Alternative treatment options were missing in 49% of the consent forms and they were significantly deficient in the remaining 51%. Prognosis and surgical risks were documented variably for each procedure. For example, in the radical prostatectomy group 79 patients (88.8%) had appropriate documentation regarding the potential for significant blood loss and yet only 23 (25.8%) had documented consent for blood transfusion. Following the implementation of a new standardized electronic consent program 96.1% of the patients surveyed preferred the new system.

CONCLUSIONS

Conventional nonstandardized consent forms have significant deficiencies and errors. The new system of electronic informed consent is standardized, legible and understandable, and it assists providers in fully informing patients about the treatment, risks, benefits and alternative therapies, thereby supporting ethical and legal standards, and improving the quality of care. In our opinion standardized electronic informed consent should be the new standard of care.

MODULE TWO: INFORMED CONSENT

The objective of this module is to familiarise you with the concept of informed consent, its ethical basis, its elements, and typical problems that are encountered even by the most well intentioned researchers when trying to achieve genuine informed consent.