To consent or not to consent, that is (not) the (sole) question. "And there is nothing new under the sun". Kohelet (also known as Ecclesiastes), 1:9. Bible

Ethical challenges involved in obtaining consent for research from patients hospitalized in the intensive care unit

Clinical research remains a vital contributor to medical knowledge, and is an established and integral part of the practice of medicine worldwide. Respect for patient autonomy and ethical principles dictate that informed consent must be obtained from subjects before they can be enrolled into clinical research, yet these conditions may be difficult to apply in real practice in the intensive care unit (ICU). A number of factors serve to complexify the consent process in critically ill patients, notably decisional incapacity of the patient due to illness or sedation. Obtaining consent for research from a designated proxy or family member, commonly termed a "surrogate decision maker" (SDM) may be difficult, since SDMs dealing with the emotional, psychological and logistic impact of a sudden hospitalisation of their loved-one are not always receptive to the idea of research or emotionally equipped to reflect rationally on the opportunities being proposed to them. In addition, time constraints and workload pressures on the attending physician may render consent opportunities unfeasible, and the resulting loss of eligible patients could represent a bias in clinical trials, or limit the generalizability of their results. Alternative procedures such as deferred or waived consent have been used in the past and may be suitable alternatives in certain conditions, provided appropriate approval from institutional review boards (IRBs) can be obtained, in accordance with existing legislation. Some of the main questions inherent to the conduct of clinical research in critically ill patients are discussed in this review.

Did studies on HFOV fail to improve ARDS survival because they did not decrease VILI? On the potential validity of a physiological concept enounced several decades ago

High frequency oscillatory ventilation (HFOV) has been the subject of extensive physiological research for 30 years and even more so of an intense debate on its potential usefulness in the treatment of acute respiratory distress syndrome (ARDS). This technique has been enthusiastically promoted by some teams until two high-quality randomized clinical trials in adults with ARDS showed that HFOV did not decrease and might have even increased mortality. As a consequence of these results, physiological concepts such as atelectrauma and biotrauma on which ARDS management with HFOV were based should be reexamined. In contrast, the concept of volutrauma, i.e., end-inspiratory overdistension, as the cause for ventilator-induced lung injury might help explain excess mortality during mechanical ventilation of ARDS when inspiratory volumes are too high. This is what might have happened during one of the recent studies on HFOV. Failure of this complex technique must be put in perspective with the dramatic improvement of ARDS prognosis with very simple interventions such as tidal volume reduction, early pharmacological paralysis, and prone positioning which all limited end-inspiratory volume.

Research in critically ill patients: standards of informed consent

Patients in critical care lose their capability to make a judgement, and constitute a 'vulnerable population' needing special and reinforced protection. Even if the standard of informed consent is an essential way of demonstrating respect for the patient's autonomy, the usual informed-consent procedure is not as applicable as required or sufficient to warrant this ethical principle in critical care.

Informed consent for therapy and research in continuous renal replacement therapy: an international survey

OBJECTIVE

To study the approach of health care workers (HCW) to informed consent for therapy and research in the field of continuous renal replacement therapy (CRRT).

DESIGN

Administration of questionnaire.

SETTING

Two International Courses on Critical Care Nephrology (CCN) held in Vicenza and Melbourne.

PARTICIPANTS

Eight hundred and twenty one course participants.

RESULTS

We obtained 349 analysable questionnaires (42.5% of participants). Only 22.5% of responders always obtain informed consent for CRRT; 70.3% just inform patients/relatives without seeking consent, 7.1% never obtain informed consent. In ICU patients, informed consent is considered 'good, correct and feasible' for therapy and for research by only 13% and 27% of responders, respectively. Consent for clinical research obtained from the next of kin or legal guardian is considered good, correct and feasible' by 56.3% of respondents, while 39.1% believe that next of kin or legal guardians can not really make informed decisions. Finally, nearly half of responders think that present rules hamper research in ICU. For many questions, significant variability of responses was found according to profession, specialty and origin of responders.

CONCLUSIONS

In the field of CRRT, stated practice, beliefs and currently accepted ethical standards vary greatly according to profession, specialty and origin. A significant disagreement between what is widely promoted to be the 'correct' approach and what is currently done is evident.

Beyond randomized, controlled trials

PURPOSE OF REVIEW

Most critical care physicians believe that randomized, controlled trials provide the best available evidence. This review contends that the importance of randomized, controlled trials was overemphasized and that they do not add more to knowledge and practice than physiologic and observational studies. In addition, protection of both patients and proxies may be less adequately ensured during randomized, controlled trials than during observational studies.

RECENT FINDINGS

An analysis of the recent literature on critical care shows that conclusions from randomized, controlled trials are either disputable or do not affect existing practice. In addition, several papers reveal potential conflicts between randomized, controlled trials and ethical principles.

SUMMARY

We may see in the future the twilight of randomized, controlled trials in critically ill patients because scientific, ethical, and sociologic substrata will be progressively lacking as will be funding.