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Udoh U, Seeger R, Dewar B, Cummings E, Gocan S, Nicholls S, Fedyk M, Shepherd V, Perry J, Fahed R, Ramsay T, Brehaut J, Hill MD, Poppe AY, Menon BK, Swartz RH, Dowlatshahi D, Shamy M. Advance Consent for participation in Acute Stroke Trials (ACTION): protocol for a feasibility study. Stroke Vasc Neurol 2024:svn-2023-003029. [PMID: 39357897 DOI: 10.1136/svn-2023-003029] [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: 12/12/2023] [Accepted: 06/21/2024] [Indexed: 10/04/2024] Open
Abstract
INTRODUCTION Obtaining informed consent for research from patients in medical emergencies remains a challenge, particularly in acute stroke care as treatment must be administered quickly and patients often arrive in the hospital in a state of incapacitation. Adaptations to standard consenting approaches-such as the use of surrogate consent or deferral of consent-have significant limitations. This feasibility study aims to test a new consenting approach in acute stroke care that we call advance consent. Advance consent has the potential to render emergency trial enrolment faster, fairer and more transparent, leading to more generalisable results. METHODS AND DESIGN We will conduct a five-part study at The Ottawa Hospital, a quaternary care stroke centre: (1) administering questionnaires in the Ottawa Hospital Stroke Prevention Clinic that will examine patients' perspectives on research participation and advance consent; (2) inviting participants to consent in advance to any or both currently enrolling acute stroke trials; (3) tracking patient enrolment into these trials over 1 year; (4) administering a follow up questionnaire to participants at 1 year and (5) administering a questionnaire to participating hospital staff in order to interrogate their experiences with advance consent. Outcomes include but are not limited to eligibility rate, recruitment rate, withdrawal rate and the proportion of patients whose advance consent results in trial enrolment. CONCLUSION This study will test the feasibility of enrolling patients at risk of stroke into acute stroke trials using advance consent.
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Affiliation(s)
- Ubong Udoh
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Rena Seeger
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emma Cummings
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sophia Gocan
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Mark Fedyk
- School of Medicine, University of California, Davis, Sacramento, California, USA
| | | | - Jeff Perry
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Robert Fahed
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jamie Brehaut
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Richard H Swartz
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dar Dowlatshahi
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michel Shamy
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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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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Weintraub MI, Colello AD, Johnson SA, McClellan F, Cole SP, Benesch C, Rudolph SH, Levine SR. Informed Consent for Intravenous Tissue Plasminogen Activator in New York State Designated Stroke Centers. J Stroke Cerebrovasc Dis 2017; 26:1274-1279. [PMID: 28189569 DOI: 10.1016/j.jstrokecerebrovasdis.2017.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 01/11/2017] [Accepted: 01/25/2017] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE Our objective was to assess informed consent procedures for intravenous tissue plasminogen activator in acute stroke among New York State (NYS) Department of Health (DOH) designated stroke centers. METHODS A 13-question survey stratified by 0- to 3-hour and 3.0- to 4.5-hour treatment windows was used to determine the type of consent or if no consent was required. RESULTS Of the 117 hospitals, 111 responded (95%). All 111 hospitals provided treatment within the 3-hour window, whereas 97 (87%) provided treatment beyond the 3-hour window (P < .001). For hospitals that did provide treatment, there was a difference between the percentages of hospitals requiring consent (verbal or written) within 3 hours (82%) and beyond 3 hours (92%) (P = .04). Of the hospitals requiring consent, there was a difference in the type of consent: 31 of 91 (34%) required written consent within the 3-hour window, whereas 57 of 89 (64%) required written consent beyond the 3-hour window (P < .001). Within both treatment windows, 98% accepted a health-care proxy or surrogate in lieu of the patient. Of the hospitals with less than 500 beds, 11 of 81 (14%) did not require consent within the 3-hour treatment window, compared to hospitals with 500 or more beds where 9 of 30 (30%) did not require consent within the 3-hour treatment window (P < .05). Beyond the 3-hour treatment window, hospitals with more than 500 beds required written consent-2-fold increase "compared to less than 3 hour window" (P < .05). Fifty-five percent of the hospitals were academic, whereas 45% were nonacademic. Academic status was not related to the type of consent in either window. CONCLUSIONS Significant variability exists in the types of informed consent based on hospital bed size and treatment windows across NYS DOH designated stroke centers.
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Affiliation(s)
| | - Anna D Colello
- Stroke and Cardiac Services, New York State Department of Health, Albany, New York
| | - Samantha A Johnson
- Quality and Systems Improvement, American Heart Association/American Stroke Association, Robbinsville, New Jersey
| | - Fabienne McClellan
- Performance Improvement and Patient Safety, University North Carolina Hospitals, Chapel Hill, North Carolina
| | - Steven P Cole
- Research Design Associates, Yorktown Heights, New York
| | - Curtis Benesch
- Department of Neurology, University Rochester School of Medicine, Rochester, New York
| | - Steven H Rudolph
- Department of Neurology, Maimonides Medical Center, Brooklyn, New York
| | - Steven R Levine
- Department of Neurology, SUNY Downstate Medical Center and Kings County Medical Center, Brooklyn, New York
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Raveesh BN, Nayak RB, Kumbar SF. Preventing medico-legal issues in clinical practice. Ann Indian Acad Neurol 2016; 19:S15-S20. [PMID: 27891020 PMCID: PMC5109754 DOI: 10.4103/0972-2327.192886] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/30/2016] [Accepted: 09/04/2016] [Indexed: 11/20/2022] Open
Abstract
The medical profession is considered to be one of the noblest professions in the world. The practice of medicine is capable of rendering noble service to humanity provided due care, sincerity, efficiency, and professional skill is observed by the doctors. However, today, the patient-doctor relationship has almost diminished its fiduciary character and has become more formal and structured. Doctors are no longer regarded as infallible and beyond questioning. Corporatization of health care has made it like any other business, and the medical profession is increasingly being guided by the profit motive rather than that of service. On the other hand, a well-publicized malpractice case can ruin the doctor's career and practice. The law, like medicine, is an inexact science. One cannot predict with certainty an outcome of cases many a time. It depends on the particular facts and circumstances of the case, and also the personal notions of the judge concerned who is hearing the case. The axiom "you learn from your mistakes" is too little honored in healthcare. The best way to handle medico-legal issues is by preventing them, and this article tries to enumerate the preventive measures in safeguarding the doctor against negligence suit.
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Affiliation(s)
- Bevinahalli N. Raveesh
- Department of Psychiatry, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India
| | - Ragavendra B. Nayak
- Department of Psychiatry, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India
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Ripley BA, Tiffany D, Lehmann LS, Silverman SG. Improving the Informed Consent Conversation: A Standardized Checklist that Is Patient Centered, Quality Driven, and Legally Sound. J Vasc Interv Radiol 2015; 26:1639-46. [PMID: 26194737 DOI: 10.1016/j.jvir.2015.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 05/29/2015] [Accepted: 06/02/2015] [Indexed: 11/30/2022] Open
Abstract
The informed consent conversation is a key component of patient-centered medicine, a concept that emphasizes the importance of patients actively participating in their care. Studies reveal that many informed consent conversations throughout medical practice lack essential elements and leave patients' needs unmet. This review addresses these deficiencies, discusses solutions, and introduces a standardized checklist that values the patient's role in shared decision making during the informed consent conversation. The checklist could be particularly helpful to interventional radiologists and other consulting physicians who usually obtain informed consent early in their encounters with patients.
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Affiliation(s)
- Beth A Ripley
- Department of Radiology, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.
| | - David Tiffany
- Department of Management, California State University San Marcos, San Marcos, California
| | - Lisa S Lehmann
- Department of Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115
| | - Stuart G Silverman
- Department of Radiology, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115
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Chiong W, Kim AS, Huang IA, Farahany NA, Josephson SA. Inability to consent does not diminish the desirability of stroke thrombolysis. Ann Neurol 2014; 76:296-304. [PMID: 24980651 DOI: 10.1002/ana.24209] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 06/27/2014] [Accepted: 06/27/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Some have argued that physicians should not presume to make thrombolysis decisions for incapacitated patients with acute ischemic stroke because the risks and benefits of thrombolysis involve deeply personal values. We evaluated the influence of the inability to consent and of personal health-related values on older adults' emergency treatment preferences for both ischemic stroke and cardiac arrest. METHODS A total of 2,154 US adults age ≥50 years read vignettes in which they had either suffered an acute ischemic stroke and could be treated with thrombolysis, or had suffered a sudden cardiac arrest and could be treated with cardiopulmonary resuscitation. Participants were then asked (1) whether they would want the intervention, or (2) whether they would want to be given the intervention even if their informed consent could not be obtained. We elicited health-related values as predictors of these judgments. RESULTS Older adults were as likely to want stroke thrombolysis when unable to consent (78.1%) as when asked directly (76.2%), whereas older adults were more likely to want cardiopulmonary resuscitation when unable to consent (83.6% compared to 75.9%). Greater confidence in the medical system and reliance on statistical information in decision making were both associated with desiring thrombolysis. INTERPRETATION Older adults regard thrombolysis no less favorably when considering a situation in which they are unable to consent. These findings provide empirical support for recent professional society recommendations to treat ischemic stroke with thrombolysis in appropriate emergency circumstances under a presumption of consent.
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Affiliation(s)
- Winston Chiong
- Department of Neurology, University of California, San Francisco, San Francisco, CA
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Chiong W, Kim AS, Huang IA, Farahany NA, Josephson SA. Testing the presumption of consent to emergency treatment for acute ischemic stroke. JAMA 2014; 311:1689-91. [PMID: 24756520 PMCID: PMC4126238 DOI: 10.1001/jama.2014.3302] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Winston Chiong
- Department of Neurology, University of California San Francisco
| | - Anthony S. Kim
- Department of Neurology, University of California San Francisco
| | - Ivy A. Huang
- Department of Neurology, University of California San Francisco
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