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Seeger R, Udoh U, Dewar B, Nicholls S, Fedyk M, Fahed R, Perry J, Hill MD, Menon B, Swartz RH, Poppe AY, Gocan S, Brehaut J, Dainty K, Shepherd V, Dowlatshahi D, Shamy M. Advance Consent in Acute Stroke Trials: Survey of Canadian Research Ethics Board Chairs. Can J Neurol Sci 2024; 51:285-288. [PMID: 37485900 DOI: 10.1017/cjn.2023.247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Advance consent could allow individuals at high risk of stroke to provide consent before they might become eligible for enrollment in acute stroke trials. This survey explores the acceptability of this novel technique to Canadian Research Ethics Board (REB) chairs that review acute stroke trials. Responses from 15 REB chairs showed that majority of respondents expressed comfort approving studies that adopt advance consent. There was no clear preference for advance consent over deferral of consent, although respondents expressed significant concern with broad rather than trial-specific advance consent. These findings shed light on the acceptability of advance consent to Canadian ethics regulators.
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Affiliation(s)
- Rena Seeger
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ubong Udoh
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Stuart Nicholls
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mark Fedyk
- School of Medicine, University of California, Davis, Davis, CA, USA
| | - Robert Fahed
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jeff Perry
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary and Calgary Stroke Program, Calgary, AB, Canada
| | - Bijoy Menon
- Department of Clinical Neurosciences, University of Calgary and Calgary Stroke Program, Calgary, AB, Canada
| | - Richard H Swartz
- Department of Medicine, University of Toronto & Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexandre Y Poppe
- Department of Neurosciences, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Sophia Gocan
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jamie Brehaut
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Katie Dainty
- Department of Research and Innovation, North York General Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | - Dar Dowlatshahi
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Michel Shamy
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
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Lois A, Kohler JE, Monsell SE, Pullar KM, Victory J, Odom SR, Fischkoff K, Kaji AH, Evans HL, Sohn V, Kao LS, Dodwad SJ, Ehlers AP, Alam HB, Park PK, Krishnadasan A, Talan DA, Siparsky N, Price TP, Ayoung-Chee P, Chiang W, Salzberg M, Jones A, Kutcher ME, Liang MK, Thompson CM, Self WH, Bizzell B, Comstock BA, Lavallee DC, Flum DR, Fannon E, Kessler LG, Heagerty PJ, Lawrence SO, Pham TN, Davidson GH. A Video-Based Consent Tool: Development and Effect of Risk-Benefit Framing on Intention to Randomize. J Surg Res 2023; 283:357-367. [PMID: 36427446 DOI: 10.1016/j.jss.2022.10.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/14/2022] [Accepted: 10/16/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Nearly 75% of clinical trials fail to enroll enough participants, and cohorts often fail to reflect the clinical and demographic diversity of at-risk populations. Effective recruitment strategies are critically important for successful clinical trials. Framing treatment risks are known to affect medical decision-making for both physicians and patients but has not been rigorously studied in surgical trials. We sought to examine the impact of a high-quality video-based consent tool and the effect of risk-benefit framing on patient willingness to participate in a surgical clinical trial. METHODS A standardized video consent was shown to all potential participants in the Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial, a randomized controlled trial comparing antibiotics and surgery for acute appendicitis. We report (1) differences in recruitment between two versions of a video-based tool that differed in production quality and (2) the impact of risk-benefit framing on participant randomization rates. The reasons for declining randomization were also assessed. RESULTS Of 4697 eligible patients approached to participate in the CODA trial, 1535 (33% [95% confidence interval (CI): 31%-34%]) agreed to randomization; this did not change from video version 1 to version 2. There was no difference in participation between positively framed videos (32% [95% CI: 30%-34%]) versus negatively framed videos (33.0% [95% CI: 30.8-35.2]). The most common reason for declining participation was treatment preference (72% for surgery and 18% for antibiotics). CONCLUSIONS Neither the change from video 1 to video 2 nor the positive versus negative framing affected participant willingness to randomize. The stakeholder-informed video-based consenting tool used in CODA was an effective strategy for the recruitment of a heterogeneous patient population within the proposed study period.
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Niznick N, Lun R, Dewar B, Perry J, Dowlatshahi D, Shamy M. Advance consent for participation in randomised controlled trials for emergency conditions: a scoping review. BMJ Open 2023; 13:e066742. [PMID: 36750278 PMCID: PMC9906254 DOI: 10.1136/bmjopen-2022-066742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
OBJECTIVE Advance consent is a recognised method of obtaining informed consent for participation in research, whereby a potential participant provides consent for future involvement in a study contingent on qualifying for the study's inclusion criteria on a later date. The goal of this study is to map the existing literature on the use of advance consent for enrolment in randomised controlled trials (RCTs) for emergency conditions. DESIGN Scoping review designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews guidelines. DATA SOURCES We searched electronic databases including MEDLINE, Embase, Web of Science and the Cochrane Register of Clinical Trials from inception to 10 February 2020. ELIGIBILITY CRITERIA Eligible studies included articles that discussed or employed the use of advance consent for enrolment in RCTs related to emergency conditions. There were no restrictions on the type of eligible study. Data were extracted directly from included papers using a standardised data charting form. We produced a narrative review including article type and authors' dispositions towards advance consent. RESULTS Our search yielded 1039 titles with duplicates removed. Six articles met inclusion criteria. Three articles discussed the theoretical use of research advance directives in emergency conditions; one article evaluated stakeholders' perceptions of advance consent; and one article described a method for patients to document their preferences for participation in future research. Only one study employed advance consent to enrol participants into a clinical trial for an emergency condition. CONCLUSION Our review demonstrates that there has been minimal exploration of advance consent for enrolment in RCTs for emergency conditions. Future studies could aim to assess the acceptability of advance consent to participants, along with the feasibility of enrolling research participants using this method of consent. PROTOCOL The protocol for this scoping review was published a priori.
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Affiliation(s)
- Naomi Niznick
- Division of Neurology, Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ronda Lun
- Division of Neurology, Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jeffrey Perry
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology, Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michel Shamy
- Division of Neurology, Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Wibring K, Lingman M, Herlitz J, Pettersson H, Lerjebo A, Bång A. Clinical presentation in EMS patients with acute chest pain in relation to sex, age and medical history: prospective cohort study. BMJ Open 2022; 12:e054622. [PMID: 35940838 PMCID: PMC9364405 DOI: 10.1136/bmjopen-2021-054622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To assess symptom presentation related to age, sex and previous medical history in patients with chest pain. DESIGN Prospective observational cohort study. SETTING Two-centre study in a Swedish county emergency medical service (EMS) organisation. PARTICIPANTS Unselected inclusion of 2917 patients with chest pain cared for by the EMS during 2018. DATA ANALYSIS Multivariate analysis on the association between symptom characteristics, patients' sex, age, previous acute coronary syndrome (ACS) or diabetes and the final outcome of acute myocardial infarction (AMI). RESULTS Symptomology in patients assessed by the EMS due to acute chest pain varied with sex and age and also with previous ACS or diabetes. Women suffered more often from nausea (OR 1.6) and pain in throat (OR 2.1) or back (OR 2.1). Their pain was more often affected by palpation (1.7) or movement (OR 1.4). Older patients more often described pain onset while sleeping (OR 1.5) and that the onset of symptoms was slow, over hours rather than minutes (OR 1.4). They were less likely to report pain in other parts of their body than their chest (OR 1.4). They were to a lesser extent clammy (OR 0.6) or nauseous (OR 0.6). These differences were present regardless of whether the symptoms were caused by AMI or not. CONCLUSIONS A number of aspects of the symptom of chest pain appear to differ in unselected prehospital patients with chest pain in relation to age, sex and medical history, regardless of whether the chest pain was caused by a myocardial infarction or not. This complicates the possibility in prehospital care of using symptoms to predict the underlying aetiology of acute chest pain.
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Affiliation(s)
- Kristoffer Wibring
- Institute of Health and Care Sciences, University of Gothenburg, Goteborg, Sweden
- Department of Ambulance and Prehospital Care, Halland County, Halmstad, Sweden
| | - Markus Lingman
- Department of Molecular, University of Gothenburg, Goteborg, Sweden
- Halland hospital group, Halland County, Halmstad, Sweden
| | - Johan Herlitz
- Research centre PreHospen, University of Borås, Boras, Sweden
| | - Helena Pettersson
- Department of Ambulance and Prehospital Care, Halland County, Halmstad, Sweden
| | - Anette Lerjebo
- Department of Ambulance and Prehospital Care, Halland County, Halmstad, Sweden
| | - Angela Bång
- Institute of Health and Care Sciences, University of Gothenburg, Goteborg, Sweden
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Bellomo T, Fokas J, Tsao N, Anderson C, Becker C, Gioscia-Ryan R, Meurer W. Ethical Considerations during the Informed Consent Process for Acute Ischemic Stroke in International Clinical Trials. Ethics Hum Res 2022; 44:14-25. [PMID: 35802793 DOI: 10.1002/eahr.500133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
We sought to investigate the experiences of researchers in existing active-control trials in acute ischemic stroke comparing investigational therapy to tissue plasminogen activator (tPA) in order to identify the approaches and challenges in obtaining informed consent. Out of 401 articles evaluated, 14 trials met inclusion criteria. Trial representatives were contacted to complete a survey concerning the consent process. None of the 14 trials published materials related to the informed consent process. Trials with 75% to 100% of patients directly consented had shorter door-to-treatment (DTT) times than trials that directly consented less than 50% of patients. Trials that had translators available (for recruiting participants who were not native speakers in the local language) and translated consent documents had longer DTT times. The study findings suggest that differences in the standards of informed consent internationally may allow more patients with moderate strokes to provide direct consent without delaying DTT time. Future trials should emphasize transparency to the public and scientific community in the informed consent process.
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Affiliation(s)
- Tiffany Bellomo
- Vascular surgery resident at the Massachusetts General Hospital
| | - Jennifer Fokas
- Neurology resident at McGaw Medical Center of Northwestern University
| | - Noah Tsao
- Medical student at the University of Rochester
| | | | | | | | - William Meurer
- Associate professor of emergency medicine at the University of Michigan
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Young MJ, Bodien YG, Edlow BL. Ethical Considerations in Clinical Trials for Disorders of Consciousness. Brain Sci 2022; 12:211. [PMID: 35203974 PMCID: PMC8870384 DOI: 10.3390/brainsci12020211] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 11/30/2022] Open
Abstract
As the clinical trial landscape for patients with disorders of consciousness (DoC) expands, consideration of associated ethical challenges and opportunities is of ever-increasing importance. Responsible conduct of research in the vulnerable population of persons with DoC, including those with coma, vegetative state/unresponsive wakefulness syndrome (VS/UWS), minimally conscious state (MCS), covert cortical processing (CCP), and cognitive motor dissociation (CMD), demands proactive deliberation of unique ethical issues that may arise and the adoption of robust protections to safeguard patients, surrogates, and other key stakeholders. Here we identify and critically evaluate four central categories of ethical considerations in clinical trials involving participants with DoC: (1) autonomy, respect for persons and informed consent of individuals with liminal consciousness; (2) balancing unknown benefits and risks, especially considering the epistemological gap between behavior and consciousness that complicates ordinary ascription of subjective states; (3) disclosure to surrogates and clinical teams of investigational results pertaining to consciousness; and (4) justice considerations, including equitable access to clinical trial enrollment across communities and geographies. We outline guiding principles and research opportunities for clinicians, neuroethicists, and researchers engaged in DoC clinical trials to advance ethical study design and deployment in this complex yet crucial area of investigation.
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Affiliation(s)
- Michael J. Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA; (Y.G.B.); (B.L.E.)
| | - Yelena G. Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA; (Y.G.B.); (B.L.E.)
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02114, USA
| | - Brian L. Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA; (Y.G.B.); (B.L.E.)
- Athinoula A. Martinos Center for Biomedical Imaging, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA 02114, USA
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Stassen W, Rambharose S, Wallis L, Moodley K. The acceptability of delayed consent for prehospital emergency care research in the Western Cape province of South Africa. PLoS One 2022; 17:e0262020. [PMID: 35061748 PMCID: PMC8782530 DOI: 10.1371/journal.pone.0262020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 12/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Informed consent is an essential prerequisite for enrolling patients into a study. Obtaining informed consent in an emergency is complex and often impossible. Delayed consent has been suggested for emergency care research. This study aims to determine the acceptability of prehospital emergency care research with delayed consent in the Western Cape community of South Africa. METHODS This study was an online survey of a stratified, representative sample of community members in the Western Cape province of South Africa. We calculated a powered sample size to be 385, and a stratified sampling method was employed. The survey was based on similar studies and piloted. Data were analysed descriptively. RESULTS A total of 807 surveys were returned. Most respondents felt that enrolment into prehospital research would be acceptable if it offered direct benefit to them (n = 455; 68%) or if their condition was life-threatening and the research would identify improved treatment for future patients with a similar condition (n = 474; 70%). Similar results were appreciable when asked about the participation of their family member (n = 445; 66%) or their child (n = 422; 62%) regarding direct prospects of benefit. Overwhelmingly, respondents indicated that they would prefer to be informed of their own (n = 590; 85%), their family member's (n = 593; 84%) or their child's (n = 587; 86%) participation in a study immediately or as soon as possible. Only 35% (n = 283) agreed to retention data of deceased patients without the next of kin's consent. CONCLUSION We report majority agreement of respondents for emergency care research with delayed consent if the interventions offered direct benefit to the research participant, if the participant's condition was life-threatening and the work held the prospect of benefit for future patients, and if the protocol for delayed consent was approved by a human research ethics committee. These results should be explored using qualitative methods.
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Affiliation(s)
- Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Sanjeev Rambharose
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Lee Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Keymanthri Moodley
- Department of Medicine, Centre for Medical Ethics and Law, Stellenbosch University, Stellenbosch, South Africa
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Al-Shatnawi SF, Alzoubi KH, Khasawneh RA, Khabour OF, Almomani BA. Exception from informed consent for biomedical research in emergency settings: A study from Jordan. Heliyon 2021; 7:e08487. [PMID: 34917796 PMCID: PMC8645444 DOI: 10.1016/j.heliyon.2021.e08487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/09/2021] [Accepted: 11/23/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Research conduction in emergency settings is of paramount importance to promote knowledge and experiences related to treating acutely ill patients. However, the complexity of situations creates a considerable ethical challenge facing researchers who basically deal with emergent cases. This study aimed to determine attitudes of healthcare providers (HCPs) towards exception from informed consent (EFIC) and enrollment willingness in emergency research in Jordan. METHODS A quantitative research with face-to-face questionnaire was conducted by an interviewer during 6-month period in 2019. Survey measures included items related to EFIC policy and overall willingness of HCPs to participate or support their family members' participation in emergency research. RESULTS A total of 151 HCPs in the emergency departments (EDs) in Jordan was recruited. Positive attitude toward emergency research dominated among participants; about 21.9% of participants reported previous experience in the conduction of emergency research and 12.3% had related publications. Regarding EFIC policy, there was a general consensus of disagreement to most of the examined items. There was a trend for little support of EFIC policy when questioned about the enrollment of family members or public in emergency research, however, the application of EFIC was accepted for self-enrollment of respondents in emergency research. No significant differences (P = 0.37), among participants from different disciplines, were reported regarding the attitudes towards EFIC items or willingness to enroll in emergency research. CONCLUSIONS Generally, HCPs reported an overall positive support to emergency research despite a consensus of disagreement related to EFIC terms. Therefore, it is recommended to pursue future studies to compare well-informed subjects; recruited from well-developed institutions in regard to emergency research potentials; with the present basic attitudinal surveillance in order to dissipate the effect of such confounder and to get better insight of the actual attitudes related to emergency research and EFIC. In addition, efficient multidisciplinary communication channels between researchers and policy makers can lather the way to collaborative research with simultaneous innovative delivery of quality emergency care.
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Affiliation(s)
- Samah F. Al-Shatnawi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan,Corresponding author.
| | - Karem H. Alzoubi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Rawand A. Khasawneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Omar F. Khabour
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Basima A. Almomani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
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Kaye DK. Motivation to participate and experiences of the informed consent process for randomized clinical trials in emergency obstetric care in Uganda. BMC Med Ethics 2021; 22:104. [PMID: 34320963 PMCID: PMC8317416 DOI: 10.1186/s12910-021-00672-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 07/22/2021] [Indexed: 11/29/2022] Open
Abstract
Background Informed consent, whose goal is to assure that participants enter research voluntarily after disclosure of potential risks and benefits, may be impossible or impractical in emergency research. In low resource settings, there is limited information on the experiences of the informed consent process for randomized clinical trials in the emergency care context. The objective of this study was to explore the experiences of the informed consent process and factors that motivated participation in two obstetrics and newborn care randomized clinical trials (RCTs). Methods This was a qualitative study conducted among former participants of RCTs in the emergency obstetric care context, conducted at Kawempe National Referral Hospital, Uganda. It employed 30 in-depth interviews conducted from June 1, 2019 to August 30, 2019. Issues explored included attitudes about research, the purpose of the research in which they participated, motivations to take part in the study, factors that influenced enrolment decisions, and experiences of the informed consent process. Results Respondents felt that research was necessary to investigate the cause, prevention or complications of illness. The decisions to participate were influenced by hope for material or therapeutic benefit, trust in the healthcare system and influence of friends and family members. Many were satisfied with the informed consent process, though they did not understand some aspects of the research. Conclusion Respondents valued participation in RCTs in emergency obstetric and newborn care. Hope for benefit, altruism, desire to further scientific knowledge and trust in the investigators featured prominently in the motivation to participate. Both intrinsic and extrinsic factors were motivators for RCT participation.
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Affiliation(s)
- Dan Kabonge Kaye
- College of Health Sciences, Department of Obstetrics and Gynecology, Makerere University, P.O. Box 7072, Kampala, Uganda. .,Johns Hopkins University, Berman Institute of Bioethics, Deering Hall, 1809 Ashland Avenue, Baltimore, MD, 21205, USA.
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Langlois A, Armstrong S, Siriwardena AN. Do National and International Ethics Documents Accord With the Consent Substitute Model for Emergency Research? Acad Emerg Med 2021; 28:569-577. [PMID: 33247985 DOI: 10.1111/acem.14179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/09/2020] [Accepted: 11/21/2020] [Indexed: 12/01/2022]
Abstract
In 2010 Largent, Wendler, and Emanuel proposed the "consent substitute model" for emergency research with incapacitated participants. The model provides a means to enroll participants in emergency research without consent, if five conditions are met: 1) the research addresses the patients' urgent medical needs, 2) the risk-benefit ratio is favorable, 3) there are no known conflicts with patients' values or interests, 4) cumulative net risk is minimal, and 5) consent is given as soon as possible. We review national and international ethics laws, regulations, and guidelines to determine 1) whether they accord with the consent substitute model's five conditions and 2) the level of congruence across these documents. We find that only one document meets all five conditions and that there is significant disparity among the documents, particularly between national and international ones. These differences may have stymied international collaboration in emergency research. We recommend that the two international documents used most, the International Council for Harmonization's Guideline for Good Clinical Practice and the World Medical Association's Declaration of Helsinki, are revised to include more specific provisions on emergency medical research.
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Affiliation(s)
- Adèle Langlois
- From the School of Social and Political Sciences University of Lincoln LincolnUK
| | - Stephanie Armstrong
- and the Community and Health Research Unit College of Social Science University of Lincoln Lincoln UK
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Wibring K, Lingman M, Herlitz J, Amin S, Bång A. Prehospital stratification in acute chest pain patient into high risk and low risk by emergency medical service: a prospective cohort study. BMJ Open 2021; 11:e044938. [PMID: 33858871 PMCID: PMC8055143 DOI: 10.1136/bmjopen-2020-044938] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To describe contemporary characteristics and diagnoses in prehospital patients with chest pain and to identify factors suitable for the early recognition of high-risk and low-risk conditions. DESIGN Prospective observational cohort study. SETTING Two centre study in a Swedish county emergency medical services (EMS) organisation. PARTICIPANTS Unselected inclusion of 2917 patients with chest pain contacting the EMS due to chest pain during 2018. PRIMARY OUTCOME MEASURES Low-risk or high-risk condition, that is, occurrence of time-sensitive diagnosis on hospital discharge. RESULTS Of included EMS missions, 68% concerned patients with a low-risk condition without medical need of acute hospital treatment in hindsight. Sixteen per cent concerned patients with a high-risk condition in need of rapid transport to hospital care. Numerous variables with significant association with low-risk or high-risk conditions were found. In total high-risk and low-risk prediction models shared six predictive variables of which ST-depression on ECG and age were most important. Previously known risk factors such as history of acute coronary syndrome, diabetes and hypertension had no predictive value in the multivariate analyses. Some aspects of the symptoms such as pain intensity, pain in the right arm and paleness did on the other hand appear to be helpful. The area under the curve (AUC) for prediction of low-risk candidates was 0.786 and for high-risk candidates 0.796. The addition of troponin in a subset increased the AUC to >0.8 for both. CONCLUSIONS A majority of patients with chest pain cared for by the EMS suffer from a low-risk condition and have no prognostic reason for acute hospital care given their diagnosis on hospital discharge. A smaller proportion has a high-risk condition and is in need of prompt specialist care. Building models with good accuracy for prehospital identification of these groups is possible. The use of risk stratification models could make a more personalised care possible with increased patient safety.
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Affiliation(s)
- Kristoffer Wibring
- Institute of Health and Care Sciences, Gothenburg University, Sahlgrenska Academy, Goteborg, Sweden
- Department of Ambulance and Prehospital Care, Halland County, Halmstad, Sweden
| | - Markus Lingman
- Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, Göteborg, Sweden
- Department of Development, Halland Hospital, Halland County, Halmstad, Sweden
| | - Johan Herlitz
- The Prehospital Research Center Western Sweden, University of Borås, Borås, Sweden
| | - Sinan Amin
- Department of Cardiology, Halland Hospital, Halland County, Halmstad, Sweden
| | - Angela Bång
- Institute of Health and Care Sciences, Gothenburg University, Sahlgrenska Academy, Goteborg, Sweden
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Vohra S, Reilly M, Rac VE, Bhaloo Z, Zayak D, Wimmer J, Vincer M, Ferrelli K, Kiss A, Soll R, Dunn M. Differences in demographics and outcomes based on method of consent for a randomised controlled trial on heat loss prevention in the delivery room. Arch Dis Child Fetal Neonatal Ed 2021; 106:118-124. [PMID: 33234598 DOI: 10.1136/archdischild-2020-319045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Informed consent is standard in research. International guidelines allow for research without prior consent in emergent situations, such as neonatal resuscitation. Research without prior consent was incorporated in the Vermont Oxford Network Heat Loss Prevention Trial. We evaluated whether significant differences in outcomes exist based on the consent method. DESIGN Subgroup analysis of infants enrolled in a randomised controlled trial conducted from 2004 to 2010. SETTING A multicentre trial with 38 participating centres. PARTICIPANTS Infants born 24-27 weeks of gestation. 3048 infants assessed, 2231 excluded due to fetal congenital anomalies, failure to obtain consent or gestation less than 24 weeks. 817 randomised, 4 withdrew consent, total of 813 analysed. MAIN OUTCOME MEASURE The difference in mortality between consent groups. RESULTS No significant differences were found in mortality at 36 weeks (80.2%, 77.4%, p=0.492) or 6 months corrected gestational age (80.7%, 79.7%, p=0.765). Infants enrolled after informed consent were more likely to have mothers who had received antenatal steroids (95.2%, 84.0%, p<0.0001). They also had significantly higher Apgar scores at 1 (5.0, 4.4, p=0.019), 5 (7.3, 6.7, p=0.025) and 10 min (7.5, 6.3, p=0.0003). CONCLUSIONS AND RELEVANCE Research without prior consent resulted in the inclusion of infants with different baseline characteristics than those enrolled after informed consent. There were no significant differences in mortality. Significantly higher Apgar scores in the informed consent group suggest that some of the sicker infants would have been excluded from enrolment under informed consent. Research without prior consent should be considered in neonatal resuscitation research.
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Affiliation(s)
- Sunita Vohra
- Pediatrics, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Maureen Reilly
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Valeria E Rac
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Zafira Bhaloo
- Pediatrics, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Denise Zayak
- Newborn-Perinatal Medicine, Vermont Oxford Network, Burlington, Vermont, USA
| | - John Wimmer
- Cone Health, Women's Hospital of Greensboro, Greensboro, North Carolina, USA
| | - Michael Vincer
- Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karla Ferrelli
- Newborn-Perinatal Medicine, Vermont Oxford Network, Burlington, Vermont, USA
| | - Alex Kiss
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Roger Soll
- Newborn-Perinatal Medicine, Vermont Oxford Network, Burlington, Vermont, USA.,Pediatrics, University of Vermont, Burlington, Vermont, USA
| | - Michael Dunn
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Pediatrics, University of Toronto, Toronto, Ontario, Canada
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13
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Niznick N, Lun R, Dewar B, Dowlatshahi D, Shamy M. Advanced consent for participation in acute care randomised control trials: protocol for a scoping review. BMJ Open 2020; 10:e039172. [PMID: 33067291 PMCID: PMC7569993 DOI: 10.1136/bmjopen-2020-039172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Informed consent is essential to clinical research, though obtaining informed consent for participation in research for emergency conditions is challenging. Adapted consent methods include consent from a substitute-decision maker, deferral of consent and waiver of consent. A novel approach is to use advanced consent, where a potential participant provides consent in the present in the event that they become eligible for enrolment into a future study. This scoping review will map and synthesise the literature on the use of advanced consent for participation and enrolment in randomised control trials for emergency conditions. METHODS AND ANALYSIS Guided by Arksey and O'Malley's scoping review methodology framework, we will search electronic databases (Medline, Embase, Web of Science and the Cochrane Register of Clinical Trials), the grey literature sources and reference lists of relevant studies. Eligible studies will include English language articles that discuss, examine or employ the use of advanced consent for enrolment in randomised control trials, specifically related to emergency conditions or emergency treatment. Diverse types of articles will be eligible for inclusion, including peer-reviewed qualitative and quantitative studies such as randomised control trials, observational studies, surveys, systematic reviews, as well as narrative reviews and ethics papers. Studies will be screened by two independent reviewers to determine eligibility for inclusion. Data on bibliographic information, study characteristics and methodology, and reported results, specifically author disposition, will be extracted and described using qualitative analysis. ETHICS AND DISSEMINATION Formal ethics review is not required as primary data will not be collected. The findings of this study will be disseminated through a peer-reviewed publication. The findings of this study will help identify knowledge gaps that may guide areas for future research and may aid in the design of future clinical trials using advanced consent.
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Affiliation(s)
- Naomi Niznick
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ronda Lun
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michel Shamy
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
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14
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McMullan J, Droege C, Strilka R, Hart K, Lindsell C. Intranasal Ketamine as an Adjunct to Fentanyl for the Prehospital Treatment of Acute Traumatic Pain: Design and Rationale of a Randomized Controlled Trial. PREHOSP EMERG CARE 2020; 25:519-529. [PMID: 32772873 DOI: 10.1080/10903127.2020.1808746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Objective: Acute pain management is fundamental in prehospital trauma care. Early pain control may decrease the risk of developing post-traumatic stress disorder (PTSD) and chronic pain. Fentanyl and ketamine are frequently used off-label, but there is a paucity of comparative data to guide decision-making about treatment of prehospital severe, acute pain. This trial will determine whether the addition of single dose of intranasal ketamine to fentanyl is more effective for the treatment of acute traumatic pain than administration of fentanyl alone.Methods: This two-part study consists of prehospital and 90-day follow-up components (NCT02866071). The prehospital trial is a blinded, randomized, controlled trial of adult men (age 18-65 years) rating pain ≥7/10 after an acute traumatic injury of any type. Women will be excluded due to inability to confirm pregnancy status and unknown fetal risk. Paramedics will screen patients receiving standard of care fentanyl and, after obtaining standard informed consent, administer 50 mg intranasal ketamine or matching volume saline as placebo. Upon emergency department (ED) arrival, research associates will serially assess pain, concomitant treatments, and adverse side effects. Enrolled subjects will be approached for consent to participate in the 90-day follow-up study to determine rates of PTSD and chronic pain development. The primary outcome of the prehospital study is reduction in pain on the Verbal Numerical Rating Scale between baseline and 30-minutes after study drug administration. The proportion achieving a reduction of ≥2-points will be compared between study arms using a Chi-square test. Secondary outcomes of the prehospital trial include reduction in reported pain at the time of ED arrival and at 30 minutes intervals for up to three hours of ED care, the incidence of adverse events, and additional opiate requirements prior to ED arrival and within the first three hours of ED care. The outcomes in the follow-up study are satisfaction with life and development of PTSD or chronic pain at 90 days after injury. An intention-to-treat approach will be used.Conclusion: These studies will test the hypotheses that ketamine plus fentanyl, when compared to fentanyl alone, effectively manages pain, decreases opiate requirements, and decreases PTSD at 90 days.
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15
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McMullan J, Droege C, Strilka CR, Lindsell C, Linke MJ. Food and Drug Administration and Institutional Review Board Approval of a Novel Prehospital Informed Consent Process for Emergency Research. PREHOSP EMERG CARE 2020; 25:512-518. [DOI: 10.1080/10903127.2020.1806969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Paratz E, Semsarian C, La Gerche A. Mind the gap: Knowledge deficits in evaluating young sudden cardiac death. Heart Rhythm 2020; 17:2208-2214. [PMID: 32721478 DOI: 10.1016/j.hrthm.2020.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
Sudden cardiac arrest affects around half a million people aged under 50 years old annually, with a 90% mortality rate. Despite high patient numbers and clear clinical need to improve outcomes, many gaps exist in the evidence underpinning patients' management. Domains identifying the greatest barriers to conducting trials are the prehospital and forensic settings, which also provide care to the majority of patients. Addressing gaps in evidence along each point of the cardiac arrest trajectory is a key clinical priority.
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Affiliation(s)
- Elizabeth Paratz
- Clinical Research Domain, Baker Heart & Diabetes Institute, Melbourne, Australia; National Centre for Sports Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Australia.
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Andre La Gerche
- Clinical Research Domain, Baker Heart & Diabetes Institute, Melbourne, Australia; National Centre for Sports Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Australia
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17
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Dickert NW, Bernard AM, Brabson JM, Hunter RJ, McLemore R, Mitchell AR, Palmer S, Reed B, Riedford M, Simpson RT, Speight CD, Steadman T, D Pentz R. Partnering With Patients to Bridge Gaps in Consent for Acute Care Research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:7-17. [PMID: 32364468 DOI: 10.1080/15265161.2020.1745931] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Clinical trials for acute conditions such as myocardial infarction and stroke pose challenges related to informed consent due to time limitations, stress, and severe illness. Consent processes should be sensitive to the context in which trials are conducted and to needs of patients and surrogate decision-makers. This manuscript describes a collaborative effort between ethicists, researchers, patients, and surrogates to develop patient-driven, patient-centered approaches to consent for clinical trials in acute myocardial infarction and stroke.Our group identified important ways in which existing consent processes and forms for clinical trials fail to meet patients' and surrogates' needs in the acute context. We collaborated to create model forms and consent processes that are substantially shorter and, hopefully, better-matched to patients' and surrogates' needs and expectations from the perspective of content, structure, and tone. These changes, however, challenge some common conventions regarding consent.
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18
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Zègre-Hemsey JK. Optimizing Patient Outcomes in Emergency Cardiac Care Through Advances in Technology: Nurse Scientists in Action. J Emerg Nurs 2020; 46:136-138. [PMID: 32164928 DOI: 10.1016/j.jen.2020.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 11/27/2022]
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19
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Scicluna VM, Goldkind SF, Mitchell AR, Pentz RD, Speight CD, Silbergleit R, Dickert NW. Determinants of Patient and Surrogate Experiences With Acute Care Research Consent: A Key Informant Interview Study. J Am Heart Assoc 2019; 8:e012599. [PMID: 31698980 PMCID: PMC6915273 DOI: 10.1161/jaha.119.012599] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Informed consent for acute myocardial infarction and stroke research is challenging. Time for enrollment decisions is limited, patients and family are usually stressed, and being asked to participate in research is often unexpected. Despite these barriers, patients and surrogates have reported a preference for prospective involvement in research decisions and generally positive views of the consent process. It is unknown what drives positive or negative consent experiences. These data are crucial to making consent processes more context appropriate. Methods and Results We conducted a qualitative interview study with 27 patients and surrogates enrolled in acute myocardial infarction and stroke trials in the past 5 years. Purposive sampling from the P-CARE (Patient-Centered Approaches to Research Enrollment) study was based on participant characteristics and responses to initial patient-centered interviews. In-depth interviews used open-ended questions to explore factors influencing consent experiences. Qualitative descriptive analysis was performed utilizing a multilevel coding strategy. Participants identified specific researcher behaviors as important, including expressions of respect, professionalism, and nonpressuring communication. Participants preferred consent conversations focused on risks/benefits and the trial protocol. They had varying views of consent forms and communicated several reasons the form was valuable unrelated to informational content. Participants also valued postenrollment interactions as opportunities to ask questions and learn about the study. Conclusions Barriers to consent in acute myocardial infarction and stroke trials are unavoidable, but participants identified productive ways to demonstrate respect for patients during enrollment conversations. These include key researcher behaviors, concentrating consent discussions on what participants find most important, and structured postenrollment follow-up.
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Affiliation(s)
| | | | | | - Rebecca D Pentz
- Emory University School of Medicine Atlanta GA.,Winship Cancer Institute Atlanta GA
| | | | | | - Neal W Dickert
- Emory University School of Medicine Atlanta GA.,Emory University Rollins School of Public Health Atlanta GA
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20
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Dickert NW. A Pragmatic Trial for Emergency Medical Service Providers' Prehospital Response to Suidality: Consent Is Not Essential, but Limited Patient Engagement May Be Meaningful. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:105-107. [PMID: 31566490 DOI: 10.1080/15265161.2019.1654020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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21
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Millum J, Beecroft B, Hardcastle TC, Hirshon JM, Hyder AA, Newberry JA, Saenz C. Emergency care research ethics in low-income and middle-income countries. BMJ Glob Health 2019; 4:e001260. [PMID: 31406598 PMCID: PMC6666811 DOI: 10.1136/bmjgh-2018-001260] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/04/2019] [Accepted: 01/12/2019] [Indexed: 01/10/2023] Open
Abstract
A large proportion of the total global burden of disease is caused by emergency medical conditions. Emergency care research is essential to improving emergency medicine but this research can raise some distinctive ethical challenges, especially with regard to (1) standard of care and risk–benefit assessment; (2) blurring of the roles of clinician and researcher; (3) enrolment of populations with intersecting vulnerabilities; (4) fair participant selection; (5) quality of consent; and (6) community engagement. Despite the importance of research to improve emergency care in low-income and middle-income countries (LMICs) and the widely acknowledged ethical challenges, very little has been written on the ethics of emergency care research in LMICs. This paper examines the ethical and regulatory challenges to conducting emergency care research with human participants in LMICs. We outline key challenges, present potential solutions or frameworks for addressing these challenges, and identify gaps. Despite the ethical and regulatory challenges, conducting high-quality, ethical emergency care research in LMICs is possible and it is essential for global health.
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Affiliation(s)
- Joseph Millum
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Blythe Beecroft
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Jon Mark Hirshon
- University of Maryland School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Adnan A Hyder
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Jennifer A Newberry
- Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Carla Saenz
- Regional Program on Bioethics, Department of Health Systems and Services, Pan American Health Organization, Washington, DC, United States
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22
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Razzak J, Beecroft B, Brown J, Hargarten S, Anand N. Emergency care research as a global health priority: key scientific opportunities and challenges. BMJ Glob Health 2019; 4:e001486. [PMID: 31406602 PMCID: PMC6666807 DOI: 10.1136/bmjgh-2019-001486] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 02/25/2019] [Indexed: 11/03/2022] Open
Abstract
Quality emergency medical care is critical to reducing the burden of disease in low-income and middle-income countries (LMICs) and protecting the health of populations during disasters and epidemics. However, conducting research in emergency care settings in LMIC settings entails unique methodological and operational challenges. Therefore, new approaches and strategies that address these challenges need to be developed and will require increased attention from scientists, academic institutions and the global health research funding community. Research priorities to address emergency care in LMICs have also not been well defined, resulting in limited research output from LMICs. This manuscript frames the efforts of four multidisciplinary working groups, which were established under the auspices of the Fogarty International Center as part of the Collaborative on Enhancing Emergency Care Research in LMICs and serves as an introduction to this series, which identifies challenges and solutions in the context of emergency care research in LMICs. The objective of this introductory paper is to articulate the need for emergency care research in LMICs and underscore its future promise. We present public health arguments for greater investment in emergency care research, identify barriers to develop and conduct research, and present a list of research priorities for community organizations, academic institutions and funding agencies. We conclude that advances in emergency care research will be critical to achieve national and global health targets, such as the Sustainable Development Goals (SDGs), and to ensure that evidence informs how such research is best conducted.
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Affiliation(s)
- Junaid Razzak
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Blythe Beecroft
- Center for Global Health Studies, John E Fogarty International Center, Bethesda, Maryland, USA
| | - Jeremy Brown
- Office of Emergency Care Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Stephen Hargarten
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nalini Anand
- Center for Global Health Studies, John E Fogarty International Center, Bethesda, Maryland, USA
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23
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Kaye DK, Chongwe G, Sewankambo NK. Ethical tensions in the informed consent process for randomized clinical trials in emergency obstetric and newborn care in low and middle-income countries. BMC Med Ethics 2019; 20:27. [PMID: 31029121 PMCID: PMC6486986 DOI: 10.1186/s12910-019-0363-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 04/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is unanimous agreement regarding the need to ethically conduct research for improving therapy for patients admitted to hospital with acute conditions, including in emergency obstetric care. We present a conceptual analysis of ethical tensions inherent in the informed consent process for randomized clinical trials for emergency obstetric care and suggest ways in which these could be mitigated. DISCUSSION A valid consenting process, leading to an informed consent, is a cornerstone of this aspect necessary for preservation and maintenance of respect for autonomy and dignity. In emergency obstetric care research, obtaining informed consent can be problematic, leading to ethical tension between different moral considerations. Potential participants may be vulnerable due to severity of disease, powerlessness or impaired decisional capacity. Time for the consent process is limited, and some interventions have a narrow therapeutic window. These factors create ethical tension in allowing potentially beneficial research while avoiding potential harms and maintaining respect for dignity, human rights, justice and autonomy of the participants. CONCLUSION Informed consent in emergency obstetric care in low- and middle-income countries poses numerous ethical challenges. Allowing research on vulnerable populations while maintaining respect for participant dignity and autonomy, protecting participants from potential harms and promoting justice underlie the ethical tensions in the research in emergency obstetric and newborn care. Those involved in research conduct or oversight have a duty of fair inclusion, to avoid denying participants the right to participate and to any potential research benefits.
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Affiliation(s)
- Dan K Kaye
- College of Health Sciences, Department of Obstetrics and Gynecology, Makerere University, P.O. Box 7072, Kampala, Uganda.
- Johns Hopkins University, Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, 21205, USA.
| | - Gershom Chongwe
- Johns Hopkins University, Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, 21205, USA
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, P.O. Box 50110, Lusaka, Zambia
| | - Nelson K Sewankambo
- College of Health Sciences, Department of Medicine, Makerere University, P.O. Box 7072, Kampala, Uganda
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24
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Dickert NW, Scicluna VM, Adeoye O, Angiolillo DJ, Blankenship JC, Devireddy CM, Frankel MR, Goldkind SF, Kumar G, Ko YA, Mitchell AR, Nogueria RG, Parker RM, Patel MR, Riedford M, Silbergleit R, Speight CD, Spokoyny I, Weinfurt KP, Pentz RD. Emergency Consent: Patients' and Surrogates' Perspectives on Consent for Clinical Trials in Acute Stroke and Myocardial Infarction. J Am Heart Assoc 2019; 8:e010905. [PMID: 30663498 PMCID: PMC6497349 DOI: 10.1161/jaha.118.010905] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Emergent informed consent for clinical trials in acute myocardial infarction (AMI) and stroke is challenging. The role and value of consent are controversial, and insufficient data exist regarding patients’ and surrogates’ experiences. Methods and Results We conducted structured interviews with patients (or surrogates) enrolled in AMI or acute stroke trials at 6 sites between 2011 and 2016. Primary domains included trial recall, consent experiences, and preferences regarding involvement. Descriptive and test statistics were used to characterize responses and explore relationships between key domains and characteristics. Multivariable logistic regression was used to examine associations between key covariates and consent preferences. There were 176 (84 stroke, 92 AMI) completed interviews. Most stroke respondents (82%) were surrogates; all AMI respondents were patients. Average time from trial enrollment to interview was 1.9 years (stroke) and 2.8 years (AMI); 89% of stroke and 62% of AMI respondents remembered being in the trial, and among these respondents, 80% (stroke) and 44% (AMI) remembered reading some of the consent form. Over 90% reported not feeling pressure to enroll, being treated in a caring way, and being treated with dignity. A minority (16% stroke and 26% AMI) reported they would have preferred not to be asked for consent. Just over half (61% stroke and 53% AMI) recalled a postenrollment conversation about the study. Conclusions Most respondents felt they were treated respectfully and were glad they had been asked for consent. Trial recall was relatively low, and many respondents recalled little postenrollment discussion. Further development of context‐sensitive approaches to consent is important.
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Affiliation(s)
- Neal W Dickert
- 1 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | | | - Opeolu Adeoye
- 5 Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Dominick J Angiolillo
- 6 Division of Cardiology Department of Medicine University of Florida College of Medicine-Jacksonville Jacksonville FL
| | | | - Chandan M Devireddy
- 1 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Michael R Frankel
- 2 Department of Neurology Emory University School of Medicine Atlanta GA
| | - Sara F Goldkind
- 8 Research and Clinical Bioethics Consultant Goldkind Consulting LLC Potomac MD
| | - Gautam Kumar
- 1 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA.,9 Atlanta VA Medical Center Decatur GA
| | - Yi-An Ko
- 10 Department of Biostatistics and Bioinformatics Emory University Rollins School of Public Health Atlanta GA
| | - Andrea R Mitchell
- 1 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Raul G Nogueria
- 2 Department of Neurology Emory University School of Medicine Atlanta GA
| | - Ruth M Parker
- 11 Department of Medicine Emory University School of Medicine Atlanta GA
| | - Manesh R Patel
- 12 Division of Cardiology Department of Medicine Duke University School of Medicine Durham NC
| | - Michele Riedford
- 14 Emory Healthcare Patient and Family Advisory Council Atlanta GA
| | - Robert Silbergleit
- 15 Department of Emergency Medicine University of Michigan Medical School Ann Arbor MI
| | - Candace D Speight
- 1 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Ilana Spokoyny
- 16 Department of Neurology California Pacific Medical Center San Francisco CA
| | - Kevin P Weinfurt
- 13 Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Rebecca D Pentz
- 3 Winship Cancer Institute Emory University School of Medicine Atlanta GA
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25
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Krobisch V, Deutschbein J, Möckel M, Schmiedhofer M, Schneider A, Inhoff T, Keil T, Heintze C, Rose M, Müller-Werdan U, Schenk L. [Empirical health services research in emergency and acute medicine : Preliminary results of concomitant monitoring of patient recruitment and sample quality]. Med Klin Intensivmed Notfmed 2019; 115:125-133. [PMID: 30603954 DOI: 10.1007/s00063-018-0522-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/22/2018] [Accepted: 11/09/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Up until now, research data on the implementation of empirical health services research in emergency departments in Germany are scarce. STUDY AIM A monitoring instrument applied in a multicenter prospective cohort study in emergency departments (EDs) is described and discussed regarding requirements for the control and supervision of data collection. MATERIALS AND METHODS Patients with cardiac diseases, respiratory tract infections, and hip fractures were recruited in eight EDs located in a central district of Berlin. Enrolment figures and nonresponder reasons were analyzed through descriptive statistics. Potential sample bias was examined in terms of response rates as well as the distribution of age and sex in the group of participants and nonresponders. Qualitative content analysis was applied to data from routine supervisory and feedback meetings with study nurses. RESULTS Within the first 8 months of data collection, 61.1% of the aimed 1104 patients were recruited. Most frequently stated nonresponder reasons were the dense work and care processes in EDs (41.9%) and patients' disease burden (24.7%). Moreover, qualitative results revealed problems with identifying potentially eligible participants and difficulties because of missing research infrastructure in study centers. The response rate of 50.7% and approximately equal distribution of age and sex in participants and nonresponders do not indicate sample biases. DISCUSSION The monitoring instrument has proven to be suited for empirical research in EDs and revealed optimization potential. We recommend using qualitative and quantitative data systematically.
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Affiliation(s)
- V Krobisch
- Institut für Medizinische Soziologie und Rehabilitationswissenschaft, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland.
| | - J Deutschbein
- Institut für Medizinische Soziologie und Rehabilitationswissenschaft, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - M Möckel
- Notfall- und Akutmedizin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - M Schmiedhofer
- Notfall- und Akutmedizin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - A Schneider
- Institut für Medizinische Soziologie und Rehabilitationswissenschaft, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - T Inhoff
- Notfall- und Akutmedizin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - T Keil
- Institut für Sozialmedizin, Epidemiologie und Gesundheitsökonomie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - C Heintze
- Institut für Allgemeinmedizin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - M Rose
- Medizinische Klinik mit Schwerpunkt Psychosomatik, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - U Müller-Werdan
- Klinik für Geriatrie und Altersmedizin der Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, und Evangelisches Geriatriezentrum Berlin, Berlin, Deutschland
| | - L Schenk
- Institut für Medizinische Soziologie und Rehabilitationswissenschaft, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
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Dickert NW, Wendler D, Devireddy CM, Goldkind SF, Ko YA, Speight CD, Kim SY. Understanding preferences regarding consent for pragmatic trials in acute care. Clin Trials 2018; 15:567-578. [PMID: 30280582 DOI: 10.1177/1740774518801007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There has been debate about the role of consent in pragmatic trials comparing qualitatively similar interventions. Consent preferences may differ in acute care contexts, given severe illness, time constraints, and other barriers to consent. In addition, studies have not assessed the impact of disclosing financial considerations as a justification for trials. This study was designed to assess preferences of the general public regarding consent for a pragmatic trial in ST-elevation myocardial infarction. METHODS This survey was completed using an online, probability-based panel representative of the US population. It incorporated a randomized, experimental (2 × 2) design assessing (1) preference for written consent versus an alternative (notification after enrollment or brief verbal consent) and (2) impact of including cost as a motivating factor for the trial. The survey used a scenario based on a recent pragmatic trial in ST-elevation myocardial infarction. Primary independent variables were personal preference and recommendation as a member of a review board regarding written consent versus the assigned alternative strategy and personal attitude toward trial enrollment. Descriptive analyses were conducted using post-stratification weights. Regression models were created to examine relationships between demographic variables and consent preference and willingness to enroll. Provision of cost information was incorporated into a regression model to examine its impact on consent preference. RESULTS The study included 2027 participants. Of those participants, 51.1% versus 45.8% stated a personal preference for written consent versus notification after enrollment; however, 60.0% versus 35.5% preferred brief verbal consent to written consent. Even among respondents stating they would be unlikely to enroll in the trial if asked, more respondents (50.6%) preferred brief verbal consent. The preference for verbal consent was generally shared across demographic categories, although lower educational attainment was associated with reduced acceptance (p = 0.001 for trend). Respondents were more likely to support an alternative to written consent when asked their personal preference than when asked their recommendation as a member of a review board. The provision of cost information did not have a meaningful effect on consent preferences, attitudes toward enrollment, or views about the study. CONCLUSION Respondents generally supported prospective involvement in enrollment decisions in the setting of acute myocardial infarction and were particularly supportive of brief verbal consent. This support persisted across demographic categories. The finding that individuals were more likely to support alternatives to written consent when asked for a personal preference rather than as a "committee member" suggests that conservative institutional approaches to consent could hinder implementation of more patient-centered approaches. The role of cost transparency in consent discussions warrants further study.
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Affiliation(s)
- Neal W Dickert
- 1 Division of Cardiology, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA.,2 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - David Wendler
- 3 Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Chandan M Devireddy
- 1 Division of Cardiology, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Yi-An Ko
- 1 Division of Cardiology, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Candace D Speight
- 1 Division of Cardiology, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Scott Yh Kim
- 2 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Dickert NW, Sugarman J. Ethics and Regulatory Barriers to Research in Emergency Settings. Ann Emerg Med 2018; 72:386-388. [DOI: 10.1016/j.annemergmed.2018.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Indexed: 10/28/2022]
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Biros M. Capacity, Vulnerability, and Informed Consent for Research. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2018; 46:72-78. [PMID: 29991882 PMCID: PMC6035898 DOI: 10.1177/1073110518766021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
This article presents an overview for clinician investigators on the concepts of decision-making capacity and vulnerability as related to human subjects research. Tools for capacity assessment and unacknowledged sources of vulnerability are discussed, and the practical gaps in current informed consent requirements related to impaired capacity and potential vulnerability are described. Options are suggested for research discussions when full regulatory consent is not possible and an exception from informed consent does not apply.
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Affiliation(s)
- Michelle Biros
- Ernest and Bernice Endowed Professor of Emergency Medicine and Interim Chief of the Department of Emergency Medicine at the University of Minnesota School of Medicine. She is an elected member of the National Academy of Medicine (formerly the Institute of Medicine). In 1994, she worked with the FDA to help develop the Exception from Informed Consent (EFIC) Requirements for Emergency Research. She currently serves as the Advisor for Vulnerable Populations for the Human Subjects Protection Program at the University of Minnesota
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Dickert NW, Eyal N, Goldkind SF, Grady C, Joffe S, Lo B, Miller FG, Pentz RD, Silbergleit R, Weinfurt KP, Wendler D, Kim SYH. Reframing Consent for Clinical Research: A Function-Based Approach. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:3-11. [PMID: 29148951 DOI: 10.1080/15265161.2017.1388448] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Although informed consent is important in clinical research, questions persist regarding when it is necessary, what it requires, and how it should be obtained. The standard view in research ethics is that the function of informed consent is to respect individual autonomy. However, consent processes are multidimensional and serve other ethical functions as well. These functions deserve particular attention when barriers to consent exist. We argue that consent serves seven ethically important and conceptually distinct functions. The first four functions pertain principally to individual participants: (1) providing transparency; (2) allowing control and authorization; (3) promoting concordance with participants' values; and (4) protecting and promoting welfare interests. Three other functions are systemic or policy focused: (5) promoting trust; (6) satisfying regulatory requirements; and (7) promoting integrity in research. Reframing consent around these functions can guide approaches to consent that are context sensitive and that maximize achievable goals.
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Affiliation(s)
| | - Nir Eyal
- b Harvard University T H Chan School of Public Health
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Dickert NW, Hendershot KA, Speight CD, Fehr AE. Patients' views of consent in clinical trials for acute myocardial infarction: impact of trial design. JOURNAL OF MEDICAL ETHICS 2017; 43:524-529. [PMID: 28039285 DOI: 10.1136/medethics-2016-103866] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/21/2016] [Accepted: 12/07/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Seeking prospective informed consent is difficult in clinical trials for emergent conditions such as acute myocardial infarction (AMI). Prior data suggest that enrolment decisions of patients are often poorly informed in AMI trials but that patients prefer to be asked permission before enrolment. It is unknown whether this is true across trial designs or in comparative effectiveness research (CER) with approved treatments. METHODS Structured interviews were conducted with 30 patients with AMI. Participants considered three scenarios: (1) a CER trial of approved antiplatelet drugs; (2) a placebo-controlled trial of a novel drug to reduce myocardial injury and (3) a CER trial of an intra-aortic balloon pump versus medication. Participants were asked their desired involvement in enrolment decisions and willingness to participate. Descriptive analysis was performed of Likert scale data, and qualitative descriptive analysis was performed of textual data. RESULTS Across scenarios, most participants (73%-80%) preferred to be asked permission prior to trial enrolment. Reasons for involvement included wanting to be the decision maker and a desire for transparency. Willingness to enrol was affected by trial type. Fewer participants stated they would likely enrol in a CER procedural trial than in a CER trial of approved medications (p=0.012). CONCLUSIONS These findings suggest that patients prefer prospective involvement in enrolment decisions to enrolment without consent across trial types. However, their desire to participate was affected by trial type. There is a need to develop and evaluate context-sensitive approaches to consent in AMI trials that account for both the acuity of the situation and trial characteristics.
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Affiliation(s)
- Neal W Dickert
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Emory Center for Ethics, Atlanta, Georgia, USA
| | | | - Candace D Speight
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alexandra E Fehr
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Partners in Health, Butaro, Rwanda
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Ko BS, Drakos SG, Welt FGP, Shah RU. Controversies and Challenges in the Management of ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock. Interv Cardiol Clin 2017; 5:541-549. [PMID: 28582002 DOI: 10.1016/j.iccl.2016.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The prognosis in ST-elevation myocardial infarction has improved with coronary care units, revascularization, and anticoagulant strategies; however, cardiogenic shock (CS) remains a highly fatal condition. Controversies remain about optimal pharmacologic therapies, revascularization strategies, the role of mechanical circulatory support (MCS), and evidence-based patient selection. The current informed consent paradigm for clinical trials creates challenges testing treatments in CS patients, who are too ill to consent and require immediate treatment. Several trials are underway comparing revascularization strategies and MCS options. Although the prognosis is grim, careful, new and existing treatments could change the course of this condition in the coming years.
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Affiliation(s)
- Byung-Soo Ko
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA
| | - Frederick G P Welt
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA.
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