Informed consent

The Role of Informed Consent in Clinical and Research Settings

Informed consent plays an integral role in governing the patient-physician relationship with origins traced back to ancient Greek philosophy. The main pillars of informed consent are autonomy, integrity, respect, and care. In the last century, these notions have been codified into legislation to promote healthy patient-physician relationships. Understanding the process of informed consent is critical for patients, researchers, and medical practitioners. In this article, the authors provide a brief historical narrative of informed consent, elaborate on the process of obtaining an ethically and legally valid informed consent, and present some of the future challenges in the field.

We All Need a Little TLC: An Argument for an Increased Role of Child Life Services in Patient Care and Medical Education

Child life services (CLS) was created through a synthesis of developmental psychology, a recognition of the inherent difficulties of a hospital environment, and a desire to improve the patient experience of children. Many of the principles of CLS can be applied to other patients as well. In this article, the history of CLS is briefly surveyed, followed by a review of the successes of CLS in the hospital. An argument for an increased role for CLS in medical education and the development of a Program for Adult Life Services is then proposed.

On the endoscopic methods used in pediatrics with questionable indications

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Partial isolation from international scientific community can result in application of invasive methods without sufficient indications.

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Performing invasive procedures, the risk-to-benefit ratio should be kept as low as possible.

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Practical recommendations must be based on reliable and reproducible research.

Assent for children's participation in research: why it matters and making it meaningful

BACKGROUND

There are gaps in the existing evidence base about assent, with conflicting and unhelpful views prevalent. We contend that appropriate assent is a valuable process that has important consequences for children's/young people's participation in research. Furthermore, there is a need for a model to support researchers in making decisions about who to assent and how to do this is a meaningful way.

METHODS

We undertook a scoping review of the literature to assess the body of opinion on assent in research with children/young people. An anonymous online survey was conducted to gather views from the wider community undertaking research with children/young people. We also sought to gather examples of current and effective practice that could be shared beyond the level of a single institution and our own experience. Survey participants included 48 health professionals with varied levels of experience, all actively involved in research with children.

RESULTS

Published work, the findings from the online survey and our knowledge as experienced researchers in the field have confirmed four domains that should be considered in order for assent to be meaningful and individualized: child-related factors, family dynamics, study design and complexity and researcher and organizational factors. Mapping these domains onto the three paradigm cases for decision-making around children and young people's assent/consent as recommended by the Nuffield Council on Bioethics has resulted in a model that will aid researchers in understanding the relationship between assent and consent and help them make decisions about when assent is appropriate.

CONCLUSIONS

The debate about assent needs to move away from terminology, definition and legal issues. It should focus instead on practical ways of supporting researchers to work in partnership with children, thus ensuring a more informed, voluntary and more robust and longer lasting commitment to research.

The ethics of obtaining consent in labour for research

BACKGROUND

  It is widely acknowledged that the pregnant population is a vulnerable and potentially disadvantaged one with regard to research. We sought to evaluate compliance with this concept by examining current Australian practices of obtaining consent for research during labour through the published literature and from Australian Human Research Ethics Committees (HRECs) as well as reviewing the relevant literature.

METHODS

  We surveyed Australian HRECs requesting information about their opinions and/or practices surrounding the ethics of research consent during labour or birth. In addition, a literature search was performed to find randomised controlled trials (RCTs) involving interventions during labour in Australia in the last five years.

RESULTS

  Of the HREC respondents, 75% believed it to be ethical to obtain consent for research in labour, 87% would require additional expert assistance to approve, 57% felt the partner should be involved and all proposed research scenarios were thought to require protocol changes. Recent local RCTs reflected a variety of consent strategies, each having their limitations.

CONCLUSIONS

  An under-used but potentially useful strategy may be staged recruitment and consent. Despite the evidence supporting labour as a time requiring increased acuity for informed consent, there is little to suggest that this knowledge is being applied to current Australian HREC and RCT practices. We suggest that further practical guidelines be devised to aid researchers and human ethics committees.

Feasibility of web-based decision aids in neurological patients

Decision aids (DAs) may be helpful in improving patients' participation in medical decision-making. We investigated the potential for web-based DAs in a rehabilitation population. Two self-administered DAs focused on the treatment of acquired ankle-foot impairment in stroke and the treatment of arm-hand function in cervical spinal cord injury (SCI). Data collection comprised a telephone interview and a self-reported paper questionnaire. Of the patients who agreed to participate, 39 stroke patients (44%) and 38 patients with SCI (78%) returned a questionnaire. More than 75% of patients expressed a need for more information about the treatment of disease-related impairment. The DAs were highly appreciated by both patient groups. Nearly all patients expressed a positive attitude towards the use of the web-based DAs in general practice. The DAs had a positive effect on the knowledge about the treatment alternatives in the stroke patients (P = 0.001), although not in the patients with SCI. The DAs reduced patients' conflict about treatment (P < 0.05). The effect of the DAs on patients' desired role in decision-making was limited. Web-based aids are feasible in the rehabilitation population with access to a computer and can improve the knowledge gaps in patients.

An integrative model of shared decision making in medical encounters

OBJECTIVE

Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions.

METHODS

In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles.

RESULTS

Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work.

CONCLUSION

Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM.

PRACTICE IMPLICATIONS

The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.

Neonatal research and the validity of informed consent obtained in the perinatal period

BACKGROUND

Consent for participation in clinical research is considered valid if it is informed, understood, and voluntary. In the case of minors, parents give permission for their child to participate in research studies after being presented with all information needed to make an informed decision. Although informed consent is a vital component of clinical research, there is little information evaluating its validity in neonatal intensive-care populations. The objective of this project was to determine the validity of informed consent obtained from parents of infants enrolled in the multicenter randomized research study, neurologic outcomes and pre-emptive analgesia in the neonate (NEOPAIN).

DESIGN/METHODS

Parents of infants who survived to discharge and had signed consent for their newborn to participate in the NEOPAIN study at the University of Kentucky were asked 20 open-ended questions to determine their level of understanding about the NEOPAIN study. The NEOPAIN consent form, which had been approved by the University of Kentucky Medical Institutional Review Board (IRB), was used to formulate these questions. Questions addressed the timing of consent, parental understanding of the purpose, benefits, and risks of the study, the voluntary nature of the project, and their willingness to enroll in future studies if the opportunity presented. Answers were scored on a Likert scale, with 1 for no understanding and 5 for complete understanding.

RESULTS

Five of 64 parents (7.8%) had no recollection of the NEOPAIN study or of signing consent. Of those who remembered the study, only 67.8% understood the purpose of the study, with a higher proportion of the mothers than fathers knowing the purpose of the study (73.3% vs 57.1%), (p=0.029). Of those who understood the purpose of the study 95% were able to verbalize the benefits, but only 5% understood any potential risks. No parents reported feeling pressured or coerced to sign consent for the project and all parents reported they would enroll their child in additional studies if asked.

CONCLUSIONS

Valid consent in the antenatal/perinatal population is difficult, if not impossible, to obtain. To maximize validity of consent in the antenatal/perinatal population every effort should be made to include mothers in the consent process. Additional attention during the consent process should be given to possible risks of the study.