Waiver of informed consent in prehospital emergency health research in Australia

Top 5 barriers in cardiac arrest research as perceived by international early career researchers - A consensus study

Aim of the study

Cardiac arrest research has not received as much scientific attention as research on other topics. Here, we aimed to identify cardiac arrest research barriers from the perspective of an international group of early career researchers.

Methods

Attendees of the 2022 international masterclass on cardiac arrest registry research accompanied the Global Out-of-Hospital Cardiac Arrest Registry collaborative meeting in Utstein, Norway, and used an adapted hybrid nominal group technique to obtain a diverse and comprehensive perspective. Barriers were identified using a web-based questionnaire and discussed and ranked during an in-person follow-up meeting. After each response was discussed and clarified, barriers were categorized and ranked over two rounds. Each participant scored these from 1 (least significant) to 5 (most significant).

Results

Nine participants generated 36 responses, forming seven overall categories of cardiac arrest research barriers. "Allocated research time" was ranked first in both rounds. "Scientific environment", including appropriate mentorship and support systems, ranked second in the final ranking. "Resources", including funding and infrastructure, ranked third. "Access to and availability of cardiac arrest research data" was the fourth-ranked barrier. This included data from the cardiac arrest registries, medical devices, and clinical studies. Finally, "uniqueness" was the fifth-ranked barrier. This included ethical issues, patient recruitment challenges, and unique characteristics of cardiac arrest.

Conclusion

By identifying cardiac arrest research barriers and suggesting solutions, this study may act as a tool for stakeholders to focus on helping early career researchers overcome these barriers, thus paving the road for future research.

When is it impractical to ask informed consent? A systematic review

BACKGROUND

Informed consent is one of the cornerstones of biomedical research with human subjects. Research ethics committees may allow for a modification or a waiver of consent when the research has social value, involves minimal risk, and if consent is impractical to obtain. While the conditions of social value and minimal risk have received ample attention in research ethics literature, the impractical condition remains unclear. There seem to be different interpretations of the meaning of impractical within academic literature. To address this lack of clarity, we performed a systematic review on the interpretation of impractical.

METHODS

First, we examined international research ethics guidelines on their usage and interpretation of impractical. Next, we used international ethical guidelines to identify synonyms of the term "impractical." Accordingly, PubMed, Embase, and Web of Science were searched for articles that included "informed consent" and "impractical" or one of its synonyms.

RESULTS

We found that there were only a few international ethics guidelines that described what could be considered impractical. Out of 2329 identified academic articles, 42 were included. Impractical was used to describe four different conditions: (1) obtaining informed consent becomes too demanding for researchers, (2) obtaining informed consent leads to invalid study outcomes, (3) obtaining informed consent harms the participant, and (4) obtaining informed consent is meaningless for the participant.

CONCLUSION

There are conditions that render conventional informed consent truly impractical, such as untraceable participants or harm for participants. At the same time, researchers have a moral responsibility to design an infrastructure in which consent can be obtained, even if they face hardship in obtaining consent. In addition, researchers should seek to minimize harm inflicted upon participants when harm may occur as a result of the consent procedure. Invalidity of research due to consent issues should not be regarded as impractical but as a condition that limits the social value of research. Further research is essential for when a waiver of informed consent based on impractical is also reasonable.

Ethical considerations in prehospital ambulance based research: qualitative interview study of expert informants

Background

Prehospital ambulance based research has unique ethical considerations due to urgency, time limitations and the locations involved. We sought to explore these issues through interviews with experts in this research field.

Methods

We undertook semi-structured interviews with expert informants, primarily based in the UK, seeking their views and experiences of ethics in ambulance based clinical research. Participants were questioned regarding their experiences of ambulance based research, their opinions on current regulations and guidelines, and views about their general ethical considerations. Participants were chosen because they were actively involved in, or in their expert capacity (e.g. law) expressed an interest in, ambulance based research.

Results

Fourteen participants were interviewed including principal investigators, researchers, ethicists and medical lawyers. Five major themes were identified: Capacity, Consent, Clinical Considerations, Consultation and Regulation. Questions regarding consent and capacity were foremost in the discussions as all participants highlighted these as areas for concern. The challenges and use of multiple consent models reflected the complexity of research in this environment. The clinical theme referred to the role of paramedics in research and how research involving ambulance services is increasingly informing improvements to patient care and outcomes and reducing the burden on hospital services. Most felt that, although current regulations were fit for purpose, more specific guidance on implementing these in the ambulance setting would be beneficial. This related closely to the theme of consultation, which examined the key role of ethics committees and other regulatory bodies, as well as public engagement.

Conclusions

By interviewing experts in research or ethics in this setting we were able to identify key concerns and highlight areas for future development such as improved guidance.

Views of paramedics on their role in an out-of-hospital ambulance-based trial in ultra-acute stroke: qualitative data from the Rapid Intervention With Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT)

STUDY OBJECTIVE

Optimal practices for recruiting, consenting, and randomizing patients, and delivering treatment in out-of-hospital ultra-acute stroke trials, remain unclear. We aim to identify key barriers and facilitators relevant to the design and conduct of ambulance-based stroke trials and to formulate preliminary recommendations for the design of future trials.

METHODS

Using semistructured interviews, we investigated the experiences and challenges faced by paramedics who took part in a randomized controlled trial in suspected ultra-acute stroke, the Rapid Intervention With Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT), in which recruitment, consent, randomization, assessment, and treatment were delivered by paramedics before hospitalization.

RESULTS

We purposively selected a diversity sample of 14 of the 78 paramedics who participated in RIGHT. We identified 13 themes (7 facilitators and 6 barriers to out-of-hospital stroke research). A simple stroke diagnostic tool, use of proxy consent on behalf of patients, and straightforward trial processes were identified as the main facilitators. Recruitment became easier with each new randomization attempt. Key barriers reported were informed consent in the emergency setting, lack of institutional support for research, learning curve and rarity (each paramedic treats only a few eligible patients), and difficulty in attending training sessions. Interviewed paramedics were motivated to participate in research.

CONCLUSION

Ultra-acute stroke research in the out-of-hospital environment is feasible, but important barriers need to be addressed. Proxy consent by paramedics addresses some of the difficulties with the consent process in the out-of-hospital setting.