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Ambagtsheer RC, Hurley CJ, Lawless M, Braunack-Mayer A, Visvanathan R, Beilby J, Stewart S, Cornell V, Leach MJ, Taylor D, Thompson M, Dent E, Whiteway L, Archibald M, O'Rourke HM, Williams K, Chudecka A. IMPAACT: IMproving the PArticipAtion of older people in policy decision-making on common health CondiTions - a study protocol. BMJ Open 2024; 14:e075501. [PMID: 38216190 PMCID: PMC10806720 DOI: 10.1136/bmjopen-2023-075501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 12/20/2023] [Indexed: 01/14/2024] Open
Abstract
INTRODUCTION Rapid population ageing is a demographic trend being experienced and documented worldwide. While increased health screening and assessment may help mitigate the burden of illness in older people, issues such as misdiagnosis may affect access to interventions. This study aims to elicit the values and preferences of evidence-informed older people living in the community on early screening for common health conditions (cardiovascular disease, diabetes, dementia and frailty). The study will proceed in three Phases: (1) generating recommendations of older people through a series of Citizens' Juries; (2) obtaining feedback from a diverse range of stakeholder groups on the jury findings; and (3) co-designing a set of Knowledge Translation resources to facilitate implementation into research, policy and practice. Conditions were chosen to reflect common health conditions characterised by increasing prevalence with age, but which have been underexamined through a Citizens' Jury methodology. METHODS AND ANALYSIS This study will be conducted in three Phases-(1) Citizens' Juries, (2) Policy Roundtables and (3) Production of Knowledge Translation resources. First, older people aged 50+ (n=80), including those from traditionally hard-to-reach and diverse groups, will be purposively recruited to four Citizen Juries. Second, representatives from a range of key stakeholder groups, including consumers and carers, health and aged care policymakers, general practitioners, practice nurses, geriatricians, allied health practitioners, pharmaceutical companies, private health insurers and community and aged care providers (n=40) will be purposively recruited for two Policy Roundtables. Finally, two researchers and six purposively recruited consumers will co-design Knowledge Translation resources. Thematic analysis will be performed on documentation and transcripts. ETHICS AND DISSEMINATION Ethical approval has been obtained through the Torrens University Human Research Ethics Committee. Participants will give written informed consent. Findings will be disseminated through development of a policy brief and lay summary, peer-reviewed publications, conference presentations and seminars.
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Affiliation(s)
- Rachel C Ambagtsheer
- Research Centre for Public Health, Equity and Human Flourishing, Torrens University Australia, Adelaide, South Australia, Australia
| | - Catherine J Hurley
- Health Vertical, Torrens University Australia, Adelaide, South Australia, Australia
| | - Michael Lawless
- College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
| | - Annette Braunack-Mayer
- School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
- Australian Centre for Health Engagement, Evidence and Values (ACHEEV), University of Wollongong, Wollongong, New South Wales, Australia
| | - Renuka Visvanathan
- Aged and Extended Care Services, The Queen Elizabeth Hospital and Basil Hetzel Institute, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Justin Beilby
- Health Vertical, Torrens University Australia, Adelaide, South Australia, Australia
| | - Simon Stewart
- Institute of Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Victoria Cornell
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Matthew J Leach
- Faculty of Health, Southern Cross University, Lismore, New South Wales, Australia
| | - Danielle Taylor
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Mark Thompson
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Woodville, South Australia, Australia
| | - Elsa Dent
- Research Centre for Public Health, Equity and Human Flourishing, Torrens University Australia, Adelaide, South Australia, Australia
| | - Lyn Whiteway
- Lynda Whiteway, Consumer co-researcher, Kensington Gardens, South Australia, Australia
| | - Mandy Archibald
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hannah M O'Rourke
- College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kathy Williams
- Office for Ageing Well, SA Health Department for Health and Wellbeing, Adelaide, South Australia, Australia
| | - Agnieszka Chudecka
- Multicultural Aged Care SA Inc, Torrensville, South Australia, Australia
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Miranda A, Rubovits E, Mudar R, Leung V, Raj M. Where are caregivers in the clinical trial? Evaluation of caregiver responsibilities in Alzheimer's disease and related dementias clinical trials. Alzheimers Dement 2023; 19:5316-5322. [PMID: 37594028 DOI: 10.1002/alz.13418] [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: 04/26/2023] [Revised: 06/20/2023] [Accepted: 07/12/2023] [Indexed: 08/19/2023]
Abstract
INTRODUCTION Family caregivers of persons with Alzheimer's disease and related dementias (ADRD) have significant responsibilities within health care. They may identify relevant clinical trials and support decision-making about their relative's participation. The objectives of this study were to (a) evaluate the responsibilities of caregivers related to their relative's participation in ADRD clinical trials and (b) examine how these responsibilities are communicated on clinicaltrials.gov. METHODS We reviewed ADRD clinical trials completed between 1990 and 2021 using clinicaltrials.gov. RESULTS Less than half of clinical trial study information pages included caregiver responsibilities. Nine caregiver responsibilities were provided among those with information (e.g., giving consent, caregiver training and education, monitoring patient's response to intervention, communicating with study team). DISCUSSION ADRD clinical trial study information pages should consistently include caregiver responsibilities to help caregivers better prepare for trial responsibilities. This enhanced engagement with caregivers could also facilitate recruitment and retention, including participants from diverse communities. HIGHLIGHTS Alzheimer's disease and related dementias (ADRD) clinical trial study information does not consistently include caregiver responsibilities. Caregiver responsibilities in clinical trials span communication, monitoring, and transportation. Robust information provision to caregivers could support participant recruitment and retention. Meaningfully engaging caregivers could support recruitment of diverse participants.
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Affiliation(s)
- Armando Miranda
- College of Applied Health Sciences, University of Illinois Urbana Champaign, Champaign, Illinois, USA
| | - Eve Rubovits
- College of Applied Health Sciences, University of Illinois Urbana Champaign, Champaign, Illinois, USA
| | - Raksha Mudar
- College of Applied Health Sciences, University of Illinois Urbana Champaign, Champaign, Illinois, USA
| | - Vania Leung
- Division of Geriatrics, University of Illinois Chicago, Chicago, Illinois, USA
| | - Minakshi Raj
- College of Applied Health Sciences, University of Illinois Urbana Champaign, Champaign, Illinois, USA
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Shapiro LN, Gray MF, Freitag C, Taneja P, Kariya H, Crane PK, O'Hare AM, Vig EK, Taylor JS. Expanding the ethnographic toolkit: Using medical documents to include kinless older adults living with dementia in qualitative research. J Aging Stud 2023; 65:101140. [PMID: 37268383 DOI: 10.1016/j.jaging.2023.101140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 06/04/2023]
Abstract
Ethnographic research with cognitively impaired older adults can be challenging, in part because cognitive impairment raises questions about the ability to provide informed consent. Relying on proxy consent is a commonly used strategy, but often excludes people with dementia who lack close kin (de Medeiros, Girling, & Berlinger, 2022). In this paper, we describe how we have analyzed existing research data from a well-established and ongoing prospective cohort study, the Adult Changes in Thought Study, along with unstructured text from the medical records of participants who had no living spouse or adult children when they developed dementia, as a way of studying the circumstances, life trajectories, caregiving resources, and care needs of this vulnerable and difficult-to-research group. In this article, we detail this methodology, exploring what can and cannot be gleaned from it, what the ethical implications may be, and how and whether this type of research can be considered ethnographic. In conclusion, we argue that collaborative interdisciplinary research using existing, longitudinal research data and text from medical records deserves to be considered as a potentially useful addition to the ethnographic toolkit. We anticipate that this is a methodology that could be applied more broadly, and paired with more traditional ethnographic methods, might be one way to make research with this population more inclusive.
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Affiliation(s)
- Lily N Shapiro
- Kaiser Permanente Washington Health Research Institute, USA.
| | | | | | | | | | | | - Ann M O'Hare
- University of Washington and VA Puget Sound Health Care System, USA
| | - Elizabeth K Vig
- University of Washington and VA Puget Sound Health Care System, USA
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Mozersky J, Solomon ED, Baldwin K, Wroblewski M, Parsons M, Goodman M, DuBois JM. Barriers to Using Legally Authorized Representatives in Clinical Research with Older Adults. J Alzheimers Dis Rep 2023; 7:135-149. [PMID: 36891257 PMCID: PMC9986706 DOI: 10.3233/adr-220103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/09/2023] [Indexed: 02/10/2023] Open
Abstract
Background Older adults are at increased risk of cognitive impairments including Alzheimer's disease dementia. Legally authorized representatives (LARs) can provide informed consent when a participant is no longer able to, but little is known about barriers to incorporating them in research. Objective Explore reasons for not asking and documenting participant decisions to appoint LARs among researchers conducting clinical intervention trials studying older adults or individuals with cognitive impairments. Methods Mixed method design consisting of a survey (N = 1,284) and qualitative interviews (N = 40) regarding barriers to incorporating LARs. Participants were principal investigators and clinical research coordinators. Results 37% (N = 469) had not asked and documented participant decisions about appointing LARs in the prior year. They had significantly lower confidence in resources available to incorporate LARs and lower positive attitudes compared to their counterparts who had done so. The majority (83%) had no trials studying individuals with cognitive impairments and reported LARs were not applicable. A minority (17%) had at least one trial studying individuals with cognitive impairments and reported being unaware of LARs. Qualitative findings indicate discomfort broaching a sensitive topic especially with individuals who are not yet impaired. Conclusion Resources and education to increase awareness and knowledge of LARs are needed. Researchers studying older adults should, at minimum, have the knowledge and resources to incorporate LARs when necessary. Stigma and discomfort discussing LARs will need to be overcome, as early proactive discussions before a participant loses decisional capacity could enhance participant autonomy and facilitate recruitment and retention of older adults to research.
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Affiliation(s)
- Jessica Mozersky
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Erin D. Solomon
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Kari Baldwin
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew Wroblewski
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Meredith Parsons
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Melody Goodman
- School of Global Public Health, New York University, New York, NY, USA
| | - James M. DuBois
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
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Cannovo N, Scendoni R, Fede MM, Siotto F, Fedeli P, Cingolani M. Nursing Home and Vaccination Consent: The Italian Perspective. Vaccines (Basel) 2021; 9:vaccines9050429. [PMID: 33923367 PMCID: PMC8145437 DOI: 10.3390/vaccines9050429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 11/16/2022] Open
Abstract
Since the beginning of the Covid-19 pandemic, many countries have begun vaccination campaigns, with different methods and timelines, with the goal of vaccinating over 75% of the population and thus achieving herd immunity. Initially it was necessary to identity the categories of citizens who should be the first to receive the vaccines, on the basis of scientific evidence. On the basis of this information, elderly residents in nursing homes and the staff who care for them should be the highest priority subjects for vaccination. In this context, obtaining informed consent to Covid-19 vaccination presents a considerable challenge, as the advanced age and frequent comorbidities of a significant number of the residents may mean that they are incapable of expressing consent themselves. The legislation of various Western nations substantially agrees on the general principle that those capable of judgement must be asked for their consent for healthcare services, and that even those with psychological weaknesses that limit their full ability to decide must be involved in these decision-making processes. The article can help systematize the processes to be implemented to protect the health of individuals as members of a close and fragile community.
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Affiliation(s)
- Nunzia Cannovo
- Federico II University Ethics Committee, 80131 Naples, Italy;
| | - Roberto Scendoni
- Law Department, Legal Medicine Section, Macerata University, 62100 Macerata, Italy; (R.S.); (M.M.F.)
| | - Marzia Maria Fede
- Law Department, Legal Medicine Section, Macerata University, 62100 Macerata, Italy; (R.S.); (M.M.F.)
| | - Federico Siotto
- School of Law, Labour Law, Camerino University, 62032 Camerino, Italy;
| | - Piergiorgio Fedeli
- School of Law, Legal Medicine, Camerino University, 62032 Camerino, Italy;
| | - Mariano Cingolani
- Law Department, Legal Medicine Section, Macerata University, 62100 Macerata, Italy; (R.S.); (M.M.F.)
- Correspondence:
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Shepherd V. Advances and challenges in conducting ethical trials involving populations lacking capacity to consent: A decade in review. Contemp Clin Trials 2020; 95:106054. [PMID: 32526281 PMCID: PMC7832147 DOI: 10.1016/j.cct.2020.106054] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/21/2020] [Accepted: 06/03/2020] [Indexed: 01/28/2023]
Abstract
Informed consent is an essential requirement prior to clinical trial participation, however some 'vulnerable' groups, such as people with cognitive impairments and those in medical emergency situations, may lack decisional capacity to consent. This raises ethical and practical challenges when designing and conducting clinical trials involving these populations, who are frequently excluded as a result. Despite recent advances in improving informed consent processes, there has been far less attention paid to the enrolment of adults lacking capacity. Exclusion criteria are an important determinant of the external validity of clinical trial results. The exclusion of these populations, and consent-based recruitment biases which arise from the challenges of identifying and involving surrogate decision-makers, leads to trials which are not representative of the clinical population. This article discusses the involvement of adults who lack decisional capacity to consent in clinical trials and presents the advances over the previous decade and the remaining ethical challenges for the inclusion of this under-represented population in research.
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Affiliation(s)
- Victoria Shepherd
- Centre for Trials Research, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK.
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Waljee AK, Ryan KA, Krenz CD, Ioannou GN, Beste LA, Tincopa MA, Saini SD, Su GL, Arasim ME, Roman PT, Nallamothu BK, De Vries R. Eliciting patient views on the allocation of limited healthcare resources: a deliberation on hepatitis C treatment in the Veterans Health Administration. BMC Health Serv Res 2020; 20:369. [PMID: 32357873 PMCID: PMC7193376 DOI: 10.1186/s12913-020-05211-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In response to the development of highly effective but expensive new medications, policymakers, payors, and health systems are considering novel and pragmatic ways to provide these medications to patients. One approach is to target these treatments to those most likely to benefit. However, to maximize the fairness of these policies, and the acceptance of their implementation, the values and beliefs of patients should be considered. The provision of treatments for chronic hepatitis C (CHC) in the resource-constrained context of the Veterans Health Administration (VHA) offered a real-world example of this situation, providing the opportunity to test the value of using Democratic Deliberation (DD) methods to solicit the informed opinions of laypeople on this complex issue. METHODS We recruited Veterans (n = 30) from the VHA to attend a DD session. Following educational presentations from content experts, participants engaged in facilitated small group discussions to: 1) identify strategies to overcome CHC treatment barriers and 2) evaluate, vote on, and modify/improve two CHC treatment policies - "first come, first served" (FCFS) and "sickest first" (SF). We used transcripts and facilitators' notes to identify key themes from the small group discussions. Additionally, participants completed pre- and post-DD surveys. RESULTS Most participants endorsed the SF policy over the FCFS policy, emphasizing the ethical and medical appropriateness of treating the sickest first. Concerns about SF centered on the difficulty of implementation (e.g., how is "sickest" determined?) and unfairness to other Veterans. Proposed modifications focused on: 1) the need to consider additional health factors, 2) taking behavior and lifestyle into account, 3) offering education and support, 4) improving access, and 5) facilitating better decision-making. CONCLUSIONS DD offered a robust and useful method for addressing the allocation of the scarce resource of CHC treatment. Participants were able to develop a modified version of the SF policy and offered diverse recommendations to promote fairness and improve quality of care for Veterans. DD is an effective approach for incorporating patient preferences and gaining valuable insights for critical healthcare policy decisions in resource-limited environments.
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Affiliation(s)
- Akbar K. Waljee
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
- Michigan Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI 48109-5362 USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), 2800 Plymouth Road, North Campus Research Complex (NCRC), Building 16, Ann Arbor, MI 48109-2800 USA
| | - Kerry A. Ryan
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Bldg. 14, G016, Ann Arbor, MI 48109-2800 USA
| | - Chris D. Krenz
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Bldg. 14, G016, Ann Arbor, MI 48109-2800 USA
| | - George N. Ioannou
- Veterans Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108 USA
- Division of Gastroenterology, Department of Medicine, University of Washington, 1959 NE Pacific St., Box 356424, Seattle, WA 98195-6424 USA
| | - Lauren A. Beste
- Division of Gastroenterology, Department of Medicine, University of Washington, 1959 NE Pacific St., Box 356424, Seattle, WA 98195-6424 USA
- Division of General Internal Medicine, University of Washington, Harborview Medical Center, 325 Ninth Ave, Box 359780, Seattle, WA 98104 USA
| | - Monica A. Tincopa
- Michigan Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI 48109-5362 USA
| | - Sameer D. Saini
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
- Michigan Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI 48109-5362 USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), 2800 Plymouth Road, North Campus Research Complex (NCRC), Building 16, Ann Arbor, MI 48109-2800 USA
| | - Grace L. Su
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
- Michigan Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI 48109-5362 USA
| | - Maria E. Arasim
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
| | - Patti T. Roman
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
| | - Brahmajee K. Nallamothu
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), 2800 Plymouth Road, North Campus Research Complex (NCRC), Building 16, Ann Arbor, MI 48109-2800 USA
- Michigan Medicine, Department of Internal Medicine, Division of Cardiovascular Medicine, 1500 East Medical Center Drive, SPC 5856, Ann Arbor, MI 48109-5362 USA
| | - Raymond De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Bldg. 14, G016, Ann Arbor, MI 48109-2800 USA
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Jagsi R, Griffith KA, Jones RD, Krenz C, Gornick M, Spence R, De Vries R, Hawley ST, Zon R, Bolte S, Sadeghi N, Schilsky RL, Bradbury AR. Effect of Public Deliberation on Patient Attitudes Regarding Consent and Data Use in a Learning Health Care System for Oncology. J Clin Oncol 2019; 37:3203-3211. [PMID: 31577472 DOI: 10.1200/jco.19.01693] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE We sought to generate informed and considered opinions regarding acceptable secondary uses of deidentified health information and consent models for oncology learning health care systems. METHODS Day-long democratic deliberation sessions included 217 patients with cancer at four geographically and sociodemographically diverse sites. Patients completed three surveys (at baseline, immediately after deliberation, and 1-month follow-up). RESULTS Participants were 67.3% female, 21.7% black, and 6.0% Hispanic. The most notable changes in perceptions after deliberation related to use of deidentified medical-record data by insurance companies. After discussion, 72.3% of participants felt comfortable if the purpose was to make sure patients receive recommended care (v 79.5% at baseline; P = .03); 24.9% felt comfortable if the purpose was to determine eligibility for coverage or reimbursement (v 50.9% at baseline; P < .001). The most notable change about secondary research use related to believing it was important that doctors ask patients at least once whether researchers can use deidentified medical-records data for future research. The proportion endorsing high importance decreased from baseline (82.2%) to 68.7% immediately after discussion (P < .001), and remained decreased at 73.1% (P = .01) at follow-up. At follow-up, non-Hispanic whites were more likely to consider it highly important to be able to conduct medical research with deidentified electronic health records (96.8% v 87.7%; P = .01) and less likely to consider it highly important for doctors to get a patient's permission each time deidentified medical record information is used for research (23.2% v 51.6%; P < .001). CONCLUSION This research confirms that most patients wish to be asked before deidentified medical records are used for research. Policies designed to realize the potential benefits of learning health care systems can, and should be, grounded in informed and considered public opinion.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Robin Zon
- Michiana Hematology-Oncology PC, Mishawaka, IN
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Bravo G, Trottier L, Rodrigue C, Arcand M, Downie J, Dubois MF, Kaasalainen S, Hertogh CM, Pautex S, Van den Block L. Comparing the attitudes of four groups of stakeholders from Quebec, Canada, toward extending medical aid in dying to incompetent patients with dementia. Int J Geriatr Psychiatry 2019; 34:1078-1086. [PMID: 31034669 DOI: 10.1002/gps.5111] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/17/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The Canadian province of Quebec has recently legalized medical aid in dying (MAID) for competent patients who satisfy strictly defined criteria. The province is considering extending the practice to incompetent patients. We compared the attitudes of four groups of stakeholders toward extending MAID to incompetent patients with dementia. METHODS We conducted a province-wide postal survey in random samples of older adults, informal caregivers of persons with dementia, nurses, and physicians caring for patients with dementia. Clinical vignettes featuring a patient with Alzheimer's disease were used to measure the acceptability of extending MAID to incompetent patients with dementia. Vignettes varied according to the stage of the disease (advanced or terminal) and type of request (written or oral only). We used the generalized estimating equation (GEE) approach to compare attitudes across groups and vignettes. RESULTS Response rates ranged from 25% for physicians to 69% for informal caregivers. In all four groups, the proportion of respondents who felt it was acceptable to extend MAID to an incompetent patient with dementia was highest when the patient was at the terminal stage, showed signs of distress, and had written a MAID request prior to losing capacity. In those circumstances, this proportion ranged from 71% among physicians to 91% among informal caregivers. CONCLUSION We found high support in Quebec for extending the current MAID legislation to incompetent patients with dementia who have reached the terminal stage, appear to be suffering, and had requested MAID in writing while still competent.
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Affiliation(s)
- Gina Bravo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada.,Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Lise Trottier
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Claudie Rodrigue
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marcel Arcand
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Quebec, Canada.,Department of Family Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jocelyn Downie
- Schulich School of Law, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Marie-France Dubois
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada.,Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Sharon Kaasalainen
- Department of Family Medicine, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Cees M Hertogh
- Department of General Practice and Elderly Care Medicine, EMGO+ Institute for Health and Care Research, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Sophie Pautex
- Department of Community Medicine and Primary Care, Geneva University Hospital, Geneva, Switzerland
| | - Lieve Van den Block
- VUB-UGhent End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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10
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Shepherd V, Hood K, Sheehan M, Griffith R, Jordan A, Wood F. Ethical understandings of proxy decision making for research involving adults lacking capacity: A systematic review (framework synthesis) of empirical research. AJOB Empir Bioeth 2018; 9:267-286. [PMID: 30321110 DOI: 10.1080/23294515.2018.1513097] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Research involving adults lacking mental capacity relies on the involvement of a proxy or surrogate, although this raises a number of ethical concerns. Empirical studies have examined attitudes towards proxy decision-making, proxies' authority as decision-makers, decision accuracy, and other relevant factors. However, a comprehensive evidence-based account of proxy decision-making is lacking. This systematic review provides a synthesis of the empirical data reporting the ethical issues surrounding decisions made by research proxies, and the development of a conceptual framework of proxy decision-making for research. METHODS A systematic review was conducted according to PRISMA guidelines. Databases including MEDLINE, EMBASE, and CINAHL were searched using a combination of search terms, and empirical data from eligible studies were retrieved. The review followed the framework synthesis approach to refine and develop a conceptual framework. RESULTS Thirty-four studies were included in the review. Two dimensions of proxy decision-making emerged. The ethical framing criteria of decision-making used by proxies: use of a substituted judgement, use of a best interests approach, combination of substituted judgement and best interests, and 'something else', and the active elements of proxy decision-making: 'knowing the person', patient-proxy relationship, accuracy of the decision, and balancing risks, benefits and burdens, and attitudes towards proxy decision-making. Interactions between the framing criteria and the elements of decision-making are complex and contextually-situated. CONCLUSIONS The findings from this systematic review challenge the accepted reductionist account of proxy decision-making. Decision-making by research proxies is highly contextualized and multifactorial in nature. The choice of proxy and the relational features of decision-making play a fundamental role: both in providing the proxy's authority as decision-maker, and guiding the decision-making process. The conceptual framework describes the relationship between the framing criteria used by the proxy, and the active elements of decision-making. Further work to develop, and empirically test the proposed framework is needed.
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Affiliation(s)
- Victoria Shepherd
- a Division of Population Medicine , Cardiff University , Cardiff , UK
- b Centre for Trials Research , Cardiff University , Cardiff , UK
| | - Kerenza Hood
- b Centre for Trials Research , Cardiff University , Cardiff , UK
| | - Mark Sheehan
- c Ethox Centre , University of Oxford, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery , Oxford , UK
| | - Richard Griffith
- d College of Human and Health Sciences , Swansea University , Swansea , UK
| | - Amber Jordan
- a Division of Population Medicine , Cardiff University , Cardiff , UK
| | - Fiona Wood
- a Division of Population Medicine , Cardiff University , Cardiff , UK
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Morain SR, Whicher DM, Kass NE, Faden RR. Deliberative Engagement Methods for Patient-Centered Outcomes Research. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2018; 10:545-552. [PMID: 28374286 DOI: 10.1007/s40271-017-0238-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There is growing emphasis on eliciting and incorporating stakeholder perspectives into health research and public policy development. The deliberative engagement session (DES) method provides one approach to elicit informed preferences from patients and other stakeholders on policy issues. DES involves day-long interaction with participants, including short plenary presentations followed by small group discussion. While interest in DES methods is expanding, practical guidance for researchers on this method remains limited. In this paper, we describe the DES method and its contemporary relevance for health policy research, illustrate how to conduct a DES using an example of a recent patient-centered outcomes research (PCOR) study with which we were involved, and discuss strengths and challenges of using this approach. DES methods generate rich data, reduce the risk of eliciting uniformed preferences or non-attitudes, and increase the likelihood of eliciting informed, reflective preferences. However, they are resource-intensive, and thus generally require trading away a larger, more representative sample. Despite these limitations, the DES method, when carefully designed, is well-suited for engaging stakeholders in research on complex health policy issues.
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Affiliation(s)
- Stephanie R Morain
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 310D, Houston, TX, 77030, USA.
| | - Danielle M Whicher
- Patient Centered Outcomes Research Institute, 1919 M Street, NW, Suite 250, Washington, DC, 20036, USA
| | - Nancy E Kass
- Johns Hopkins Berman Institute of Bioethics and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 1809 Ashland Ave, Baltimore, MD, 21205, USA
| | - Ruth R Faden
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Ave, Baltimore, MD, 21205, USA
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12
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Sonnicksen J. Dementia and representative democracy: Exploring challenges and implications for democratic citizenship. DEMENTIA 2016; 15:330-42. [DOI: 10.1177/1471301216638998] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite growing recognition of the rights of people with dementia for full citizenship, issues related to democracy, whether from theoretical or practical perspectives, remain neglected. Especially since discourses on dementia have expanded to this rights-based approach, it is imperative to begin to examine the meanings and practices of democracy within a context of dementia. Accordingly, the purpose of this article is to assess implications of dementia in the context of democracy. Rather than surveying the variety of democratic concepts, it will focus the analytical framework on representative democracy and then outline several challenges to and for representative democracy and citizens with dementia. The intention is to begin to identify paths for ensuring representation, inclusion and participation for those who have dementia.
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Chenoweth L, Vickland V, Stein-Parbury J, Jeon YH, Kenny P, Brodaty H. Computer modeling with randomized-controlled trial data informs the development of person-centered aged care homes. Neurodegener Dis Manag 2015; 5:403-12. [PMID: 26477894 DOI: 10.2217/nmt.15.40] [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: 11/21/2022] Open
Abstract
AIM To answer questions on the essential components (services, operations and resources) of a person-centered aged care home (iHome) using computer simulation. MATERIALS & METHODS iHome was developed with AnyLogic software using extant study data obtained from 60 Australian aged care homes, 900+ clients and 700+ aged care staff. Bayesian analysis of simulated trial data will determine the influence of different iHome characteristics on care service quality and client outcomes. Interim results: A person-centered aged care home (socio-cultural context) and care/lifestyle services (interactional environment) can produce positive outcomes for aged care clients (subjective experiences) in the simulated environment. CONCLUSION Further testing will define essential characteristics of a person-centered care home.
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Affiliation(s)
- Lynn Chenoweth
- Faculty of Health, University of Technology Sydney, Professor of Nursing, Centre for Health Brain Ageing, University of New South Wales, Sydney, Australia
| | - Victor Vickland
- Dementia Collaborative Research Centre, School of Psychiatry, University of New South Wales, Sydney, Australia
| | | | - Yun-Hee Jeon
- Sydney Nursing School, The University of Sydney, New South Wales, Australia
| | - Patricia Kenny
- Centre for Health Economics Research & Evaluation, University of Technology, Sydney, Australia
| | - Henry Brodaty
- Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia; Scientia Professor of Ageing and Mental Health, University of New South Wales, Sydney, Australia
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Porteri C, Petrini C. Research involving subjects with Alzheimer's disease in Italy: the possible role of family members. BMC Med Ethics 2015; 16:12. [PMID: 25888878 PMCID: PMC4357192 DOI: 10.1186/s12910-015-0009-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 02/19/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Alzheimer's disease is a very common, progressive and still incurable disease. Future possibilities for its cure lie in the promotion of research that will increase our knowledge of the disorder's causes and lead to the discovery of effective remedies. Such research will necessarily involve individuals suffering from Alzheimer's disease. This raises the controversial issue of whether patients with Alzheimer's disease are competent to give their consent for research participation. DISCUSSION We discuss the case of subjects with Alzheimer's disease who may have impaired decision-making capacity and who could be involved in research protocols, taking into consideration aspects of the Italian normative framework, which requires a court-appointed legal representative for patients who are not able to give consent and does not recognise the legal value of advance directives. We show that this normative framework risks preventing individuals with Alzheimer's disease from taking part in research and that a new policy that favours research while promoting respect for patients' well-being and rights needs to be implemented. SUMMARY We believe that concerns about the difficulty of obtaining fully valid consent of patients with Alzheimer's disease should not prevent them from participating in clinical trials and benefiting from scientific progress. Therefore, we argue that the requirement for patients to have a legal representative may not be the best solution in all countries and clinical situations, and suggest promoting the role of patients' family members in the decision-making process. In addition, we outline the possible role of advance directives and ethics committees.
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Affiliation(s)
- Corinna Porteri
- Bioethics Unit, IRCCS Centro San Giovanni di Dio Fatebenefratelli, Via Pilastroni 4, 25125, Brescia, Italy.
| | - Carlo Petrini
- Bioethics Unit, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy.
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Danis M, Wendler D, Kim S. Acceptable Approaches to Enrolling Adults Who Cannot Consent in More Than Minimal Risk Research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:70-71. [PMID: 26479115 PMCID: PMC4849531 DOI: 10.1080/15265161.2015.1075806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
| | | | - Scott Kim
- a National Institutes of Health Clinical Center
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Gornick MC, Ryan KA, Kim SYH. Impact of non-welfare interests on willingness to donate to biobanks: an experimental survey. J Empir Res Hum Res Ethics 2014; 9:22-33. [PMID: 25747294 DOI: 10.1177/1556264614544277] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The ethical debate surrounding biobanks has focused on protecting donors' welfare and privacy. However, little attention has been given to the ethical significance of donor interests that go beyond privacy and welfare (non-welfare interests [NWIs]), such as their concerns about the moral or religious implications of researchers using their donated samples. Using an experimental survey design with 1,276 participants recruited via Amazon Mechanical Turk (MTurk), we studied the potential impact of eight NWI scenarios on people's attitudes toward research studies being performed on samples donated to biobanks by assessing willingness to donate, attitudes toward disclosure of NWIs, impact of timing and format of disclosure (number of NWIs disclosed on a page), and participant factors associated with willingness to donate. Baseline willingness to donate to biobanks prior to any mention of NWIs was comparable with previous studies, at 85% to 89%. Most participants wanted NWI disclosures prior to donation to biobanks, but far fewer favored specific consent. Overall pattern of responses showed that as participants receive more information about NWIs, willingness to donate decreases in a scenario dependent manner. Specifically, NWI concerns about profit seeking research and insurance risk assessment had the strongest impact, even greater than controversial issues such as reproductive research, regardless of political, religious, and most other characteristics of respondents. Based on the results, a schema of NWI types is proposed that could be used for further research and policy discussions.
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Affiliation(s)
- Michele C Gornick
- VA Ann Arbor Center for Clinical Management Research, MI, USA University of Michigan, Ann Arbor, USA
| | | | - Scott Y H Kim
- University of Michigan, Ann Arbor, USA National Institutes of Health, Bethesda, MD, USA
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Lee L. My moral compass and ethical decision making in public health. Public Health 2014; 128:579-81. [DOI: 10.1016/j.puhe.2014.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 04/01/2014] [Accepted: 04/02/2014] [Indexed: 10/25/2022]
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The use of citizens' juries in health policy decision-making: A systematic review. Soc Sci Med 2014; 109:1-9. [DOI: 10.1016/j.socscimed.2014.03.005] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 01/30/2014] [Accepted: 03/06/2014] [Indexed: 11/22/2022]
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De Vries R, Ryan KA, Stanczyk A, Appelbaum PS, Damschroder L, Knopman DS, Kim SYH. Public's approach to surrogate consent for dementia research: cautious pragmatism. Am J Geriatr Psychiatry 2013; 21:364-72. [PMID: 23498383 PMCID: PMC3357450 DOI: 10.1016/j.jagp.2012.11.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 07/27/2011] [Accepted: 10/20/2011] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To describe how members of the older general public deliberate with one another in finding solutions to the dilemma of involving persons with decisional incapacity in dementia research. DESIGN, SETTING, AND PARTICIPANTS One hundred sixty persons age 50 years and older who participated in an all-day deliberative democracy session on the ethics of surrogate consent for dementia research. The deliberative democracy day consisted of both extensive, interactive education with experts in clinical research and ethics, as well as small group deliberations. MEASUREMENTS Audiotaped small group deliberations were transcribed and analyzed and the main thematic elements were coded. RESULTS During deliberation, participants acknowledged the limitations of advanced research directives and discussed ways to improve their use. Although there was consensus about the necessity of surrogate consent, the participants recognized potential pitfalls and looked for ways to safeguard the process. Participants supporting surrogate consent for research emphasized societal and individual benefits, the importance of assent, and trust in surrogates and the oversight system. Other participants felt that the high risk of some research scenarios was not sufficiently offset by benefits to patients or society. CONCLUSIONS Members of the older general public are able to make use of in-depth education and peer deliberation to provide reasoned and informed opinions on the ethical use of surrogate consent for dementia research. The public's approach to surrogate consent is one of cautious pragmatism: an overall trust in science and future surrogates with awareness of the potential pitfalls, suggesting that their trust cannot be taken for granted.
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Affiliation(s)
- Raymond De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kerry A. Ryan
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Aimee Stanczyk
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Paul S. Appelbaum
- Division of Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Laura Damschroder
- Health Services Research and Development, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA
| | | | - Scott Y. H. Kim
- Center for Bioethics and Social Sciences in Medicine and Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Kim SYH, Kim HM, Ryan KA, Appelbaum PS, Knopman DS, Damschroder L, De Vries R. How important is 'accuracy' of surrogate decision-making for research participation? PLoS One 2013; 8:e54790. [PMID: 23382969 PMCID: PMC3561414 DOI: 10.1371/journal.pone.0054790] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 12/14/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is a longstanding concern about the accuracy of surrogate consent in representing the health care and research preferences of those who lose their ability to decide for themselves. We sought informed, deliberative views of the older general public (≥50 years old) regarding their willingness to participate in dementia research and to grant leeway to future surrogates to choose an option contrary to their stated wishes. METHODOLOGY/PRINCIPAL FINDINGS 503 persons aged 50+ recruited by random digit dialing were randomly assigned to one of three groups: deliberation, education, or control. The deliberation group attended an all-day education/peer deliberation session; the education group received written information only. Participants were surveyed at baseline, after the deliberation session (or equivalent time), and one month after the session, regarding their willingness to participate in dementia research and to give leeway to surrogates, regarding studies of varying risk-benefit profiles (a lumbar puncture study, a drug randomized controlled trial, a vaccine randomized controlled trial, and an early phase gene transfer trial). At baseline, 48% (gene transfer scenario) to 92% (drug RCT) were willing to participate in future dementia research. A majority of respondents (57-71% depending on scenario) were willing to give leeway to future surrogate decision-makers. Democratic deliberation increased willingness to participate in all scenarios, to grant leeway in 3 of 4 scenarios (lumbar puncture, vaccine, and gene transfer), and to enroll loved ones in research in all scenarios. On average, respondents were more willing to volunteer themselves for research than to enroll their loved ones. CONCLUSIONS/SIGNIFICANCE Most people were willing to grant leeway to their surrogates, and this willingness was either sustained or increased after democratic deliberation, suggesting that the attitude toward leeway is a reliable opinion. Eliciting a person's current preferences about future research participation should also involve eliciting his or her leeway preferences.
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Affiliation(s)
- Scott Y H Kim
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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Comfort with proxy consent to research involving decisionally impaired older adults: do type of proxy and risk-benefit profile matter? Int Psychogeriatr 2011; 23:1479-88. [PMID: 21429277 DOI: 10.1017/s1041610211000433] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Dementia research often requires the participation of people with dementia. Obtaining informed consent is problematic when potential participants lack the capacity to provide it. We investigated comfort with proxy consent to research involving older adults deemed incapable of this decision, and examined if comfort varies with the type of proxy and the study's risk-benefit profile. METHODS We surveyed random samples of five relevant groups (older adults, informal caregivers, physicians, researchers in aging, and Research Ethics Board members) from four Canadian provinces. Respondents were presented with scenarios involving four types of proxies (non-assigned, designated in a healthcare advance directive with or without instructions specific to research participation, and court-appointed). Given a series of risk-benefit profiles, respondents indicated whether they were comfortable with proxy consent to research for each scenario. RESULTS Two percent of the respondents felt proxy consent should never be allowed. In all groups, comfort depended far more on the risk-benefit profile associated with the research scenario than with type of proxy. For research involving little or no risk and potential personal benefits, over 90% of the respondents felt comfortable with substitute consent by a designated or court-appointed proxy while 80% were at ease with a non-assigned proxy. For studies involving serious risks with potentially greater personal benefits, older adults and informal caregivers were less comfortable with proxy consent. CONCLUSIONS A large majority of Canadians are comfortable with proxy consent for low-risk research. Further work is needed to establish what kinds of research are considered to be low risk.
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Kim SYH, Kim HM, Knopman DS, De Vries R, Damschroder L, Appelbaum PS. Effect of public deliberation on attitudes toward surrogate consent for dementia research. Neurology 2011; 77:2097-104. [PMID: 21975207 DOI: 10.1212/wnl.0b013e31823648cb] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the informed, deliberative views of the older general public toward a policy of allowing surrogate consent for Alzheimer disease (AD) research. METHODS A total of 503 persons aged 50+ recruited by random digit dialing were randomly assigned to 1 of 3 groups: deliberation, education, or control. The deliberation group attended an all-day education/peer deliberation session; the education group received written information only. Participants were surveyed at baseline, after deliberation session (or equivalent time), and 1 month after the session, regarding their attitudes toward a policy of allowing surrogate consent for research studies of varying risks and potential benefits (a lumbar puncture study, a drug randomized controlled trial, a vaccine randomized controlled trial, and an early phase gene transfer trial). RESULTS At baseline, a policy of surrogate consent for AD research was supported by 55%-91%, depending on the scenario. The education group had a transient increase in support for one research scenario after receiving the information materials. In the deliberation group, support for surrogate consent was higher after deliberation for all scenarios (67% to 97%), with much of the increase sustained 1 month after the deliberation session. No changes occurred in the control group. The study's limitations include self-selection of participants due to the demanding nature of attendance at the deliberation sessions. CONCLUSIONS This sample of the older general public generally supported a policy of surrogate consent for AD research at baseline. Their support increased with democratic deliberation involving informed, in-depth exploration of the relevant scientific and ethical issues.
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Affiliation(s)
- S Y H Kim
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor 48109, USA
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Abstract
Clinical research on Alzheimer disease (AD) is much needed but requires the participation of patients with substantial cognitive impairment who have difficulty providing informed consent. Despite decades of debate, policies regulating such research are not well-defined. Although numerous studies have underscored the difficulties of obtaining informed consent for clinical research from patients compromised by AD, there is also increasing evidence that such individuals and their surrogates can make decisions about research participation that are consistent with the patients' values. Policy discussions and future research should consider how the ethical reservations about enrolling incapacitated patients in research could be mitigated by developing ways to promote the congruence between surrogates' decisions and patients' values.
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Affiliation(s)
- Scott Y H Kim
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, 300 North Ingalls 7C27, Ann Arbor, Michigan 48109, USA.
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Dubois J, Bante H, Hadley WB. Ethics in Psychiatric Research: A Review of 25 Years of NIH-funded Empirical Research Projects. AJOB PRIMARY RESEARCH 2011; 2:5-17. [PMID: 23259152 PMCID: PMC3524581 DOI: 10.1080/21507716.2011.631514] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND: This paper reviews the past 25 years of empirical research funded by the National Institutes of Health (NIH) on matters of ethics in psychiatric research. METHODS: Using the NIH RePORTER and Medline databases, we identified 43 grants and 77 publications that involved the empirical study of a matter of ethics in research involving mental health service users. RESULTS: These articles provide original and useful information on important topics, most especially the capacity to consent and the voluntariness of consent. For example, participants who share a diagnosis vary widely in levels of cognitive impairment that correlate with decisional capacity, and capacity to consent can be enhanced easily using iterative consent processes. Few articles address matters of justice or benefits in research, particularly from the perspectives of participants. No articles address matters of privacy, confidentiality, or researcher professionalism. CONCLUSIONS: Despite the usefulness of data from the studies conducted to date, current research on research ethics in psychiatry does not adequately address the concerns of service users as expressed in recent publications.
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Affiliation(s)
- James Dubois
- Saint Louis University - Gnaegi Center for Health Care Ethics, 221 North Grand Blvd, St. Louis, Missouri 63103,
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De Vries R, Stanczyk A, Wall IF, Uhlmann R, Damschroder LJ, Kim SY. Assessing the quality of democratic deliberation: a case study of public deliberation on the ethics of surrogate consent for research. Soc Sci Med 2010; 70:1896-1903. [PMID: 20378225 PMCID: PMC2866810 DOI: 10.1016/j.socscimed.2010.02.031] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 02/17/2010] [Accepted: 02/22/2010] [Indexed: 10/19/2022]
Abstract
"Deliberative democracy" is an increasingly popular method for soliciting public input on health care policies. There are a number of ways of organizing deliberative democracy (DD) sessions, but they generally involve gathering a group of citizens, supplying them with information relevant to the policy in question, giving them time to interact with each other and with experts in the policy area, and collecting their informed and considered opinions. As the method has become more widely used, some have questioned the quality of the public input it generates. Although theorists of DD agree that "good" input - i.e., input that is the product of careful and thorough reflection - is an essential aspect of useful and effective deliberation, few have actually measured the quality of deliberative sessions. As part of a DD project organized to help guide policies on the morally complex question of allowing surrogate permission to enroll persons with dementia in medical research, we developed and tested measures of "quality of deliberation." After a brief discussion of the substantive results of our research - survey data from participants in the DD sessions and control groups showed a significant change in participants' attitudes toward surrogate consent - we examine the process by which this change occurred, describing and assessing the characteristics of our DD sessions. We use both quantitative and qualitative data from our DD sessions, conducted in southeastern Michigan, United States, to examine four dimensions of the quality of deliberation: 1) equal participation by all members of the session, 2) respect for the opinions of others, 3) a willingness to adopt a societal perspective on the issue in question (rather than a focus on what is best for participants as individuals), and 4) reasoned justification of one's positions. We demonstrate that DD can be reliably used to elicit opinions of the public and show how analysis of the quality of deliberations can offer insight into the ways opinions about ethical dilemmas are formed and changed.
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Affiliation(s)
- Raymond De Vries
- University of Michigan, Bioethics Program, Ann Arbor, 300 North Ingalls Street, MI, USA.
| | - Aimee Stanczyk
- University of Michigan, Bioethics Program, Ann Arbor, 300 North Ingalls Street, MI, USA
| | - Ian F Wall
- University of Michigan, Bioethics Program, Ann Arbor, 300 North Ingalls Street, MI, USA
| | - Rebecca Uhlmann
- University of Michigan, Bioethics Program, Ann Arbor, 300 North Ingalls Street, MI, USA
| | - Laura J Damschroder
- Ann Arbor VA Health Services Research and Development Center for Clinical Management Research, USA
| | - Scott Y Kim
- University of Michigan, Bioethics Program, Ann Arbor, 300 North Ingalls Street, MI, USA
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Kim SYH, Wall IF, Stanczyk A, De Vries R. Assessing the public's views in research ethics controversies: deliberative democracy and bioethics as natural allies. J Empir Res Hum Res Ethics 2010; 4:3-16. [PMID: 19919315 DOI: 10.1525/jer.2009.4.4.3] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In a liberal democracy, policy decisions regarding ethical controversies, including those in research ethics, should incorporate the opinions of its citizens. Eliciting informed and well-considered ethical opinions can be challenging. The issues may not be widely familiar and they may involve complex scientific, legal, historical, and ethical dimensions. Traditional surveys risk eliciting superficial and uninformed opinions that may be of dubious quality for policy formation. We argue that the theory and practice of deliberative democracy (DD) is especially useful in overcoming such inadequacies. We explain DD theory and practice, discuss the rationale for using DD methods in research ethics, and illustrate in depth the use of a DD method for a longstanding research ethics controversy involving research based on surrogate consent. The potential pitfalls of DD and the means of minimizing them as well as future research directions are also discussed.
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