1
|
Dickert NW. Evolving Understanding of Patients' Experiences in Acute Care Trials Without Prospective Consent. Crit Care Med 2024; 52:839-842. [PMID: 38619341 DOI: 10.1097/ccm.0000000000006221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Neal W Dickert
- Division of Cardiology, Department of Medicine, Emory Health Services Research Center, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
2
|
Ross CE, Parker MJ, Mentzelopoulos SD, Scholefield BR, Berg RA. Emergency research without prior consent in the United States, Canada, European Union and United Kingdom: How regulatory differences affect study design and implementation in cardiac arrest trials. Resusc Plus 2024; 17:100565. [PMID: 38328747 PMCID: PMC10847942 DOI: 10.1016/j.resplu.2024.100565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Aim A major barrier to performing cardiac arrest trials is the requirement for prospective informed consent, which is often infeasible during individual medical emergencies. In an effort to improve outcomes, some governments have adopted legislation permitting research without prior consent (RWPC) in these circumstances. We aimed to outline key differences between legislation in four Western locations and explore the effects of these differences on trial design and implementation in cardiac arrest research. Data sources We performed a narrative review of RWPC legislation in the United States (US), Canada, the European Union (EU) and the United Kingdom (UK). Results The primary criteria required to perform RWPC was similar across locations: the study must involve an individual medical emergency during which neither the prospective subject nor their authorized representative can provide informed consent. The US regulations were unique in their requirements for performing Community Consultation and Public Disclosure in the communities in which the research takes place. Another major difference was the requirement for consent for ongoing participation in Canada, the EU and the UK, while only notification of enrollment and the opportunity to discontinue participation are required in the US. Additionally, only Canada and the EU explicitly state that the subject or their representative may request withdrawal of their data. Conclusion Regulations governing RWPC in the US, Canada, the EU and the UK have similar goals and protections for vulnerable populations during medical emergencies. Differences in the qualifying criteria and implementation procedures exist across locations and may affect study design.
Collapse
Affiliation(s)
- Catherine E. Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Melissa J. Parker
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children’s Hospital and McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada
| | - Spyros D. Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Barnaby R. Scholefield
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Honorary Associate Professor, University of Birmingham, UK
| | - Robert A. Berg
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Dhamanaskar R, Feldman WB, Merz JF. Practicalities of Impracticability: An Interim Review of Randomized Controlled Trials. J Empir Res Hum Res Ethics 2022; 17:329-345. [PMID: 35440213 DOI: 10.1177/15562646221092663] [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: 11/17/2022]
Abstract
Impracticability is an ethical standard for waiver of informed consent in research. We examine how well the criterion of impracticability appears to have been fulfilled in a set of 36 completed randomized controlled trials (RCTs) that secured consent from some subjects or LARs and employed waivers to enroll others. These trials were identified among 155 RCTs using waivers of consent in a convenience sample drawn from 7 systematic reviews. Recruitment data were available for 19 of the 36 trials, revealing an average of 41.6% of subjects (range 0.2-98.7%, 95% CI: 24.8-58.4%) were enrolled without consent. Six trials enrolled less than 10% of subjects without consent and an overlapping set of 9 trials sought consent from all subjects or LARs at some sites while waiving consent at other sites. We question whether these trials were practicable without waivers and identify issues for consideration by investigators and ethics review boards.
Collapse
Affiliation(s)
- Roma Dhamanaskar
- Department of Health Research Methods, Evidence and Impact, 152969McMaster University Medical Centre, 1280 Main Street West, 2C Area, Hamilton, Ontario, Canada L8S 4K1
| | - William B Feldman
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, 1861Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA
| | - Jon F Merz
- Department of Medical Ethics & Health Policy, 14640Perelman School of Medicine at the University of Pennsylvania, Blockley Hall Floor 14, 423 Guardian Drive, Philadelphia, Pennsylvania 19104-4884, USA
| |
Collapse
|
5
|
Hirner S, Saunders C, Stassen W. The ethical considerations for emergency care research in low- and middle-income countries: A scoping review of the published literature. Afr J Emerg Med 2022; 12:71-76. [PMID: 35070658 PMCID: PMC8762361 DOI: 10.1016/j.afjem.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 10/26/2021] [Accepted: 12/15/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Research studies on emergency care in low- and middle-income countries (LMICs) face many ethical considerations, including obtaining valid informed consent from vulnerable patients. This study aims to describe the body of literature related to the ethical considerations associated with emergency care research in low- and middle-income settings. METHODS A scoping review was conducted to identify literature published between 2000 and 2020 related to ethical considerations associated with emergency care research in the LMIC setting. Titles and abstracts were screened in duplicate, and full texts were reviewed and extracted by the principal author. RESULTS In total, 1087 articles were identified and 17 articles were included. Major themes identified in the literature included risk versus benefit assessments, patient vulnerabilities, consent, community engagement, clinical roles, ancillary care provision, and regulation of research. Alternative models of consent are often used in emergency care research, including surrogate consent, community consent, and waiver of consent. Challenges and best practices with these alternative models of consent in LMICs are discussed. DISCUSSION Gaps remain in the literature describing the ethics of emergency care research in LMICs, including clear guidelines for protecting vulnerable patients and designing ethical consent processes. Best practices identified include community engagement for designing research studies, identifying acceptable risk profiles, and allocating benefits. Continuous and rigorous assessment of the quality of consent is also needed.
Collapse
Affiliation(s)
- Sarah Hirner
- University of Colorado School of Medicine, Aurora, Colorado USA
| | - Colleen Saunders
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
6
|
Nichol G, Zhuang R, Russell R, Holcomb JB, Kudenchuk PJ, Aufderheide TP, Morrison L, Sugarman J, Ornato JP, Callaway CW, Vaillancourt C, Bulger E, Christenson J, Daya MR, Schreiber M, Idris A, Podbielski JM, Sopko G, Wang H, Wade CE, Hoyt D, Weisfeldt ML, May S. Variation in time to notification of enrollment and rates of withdrawal in resuscitation trials conducted under exception from informed consent. Resuscitation 2021; 168:160-166. [PMID: 34384820 DOI: 10.1016/j.resuscitation.2021.07.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/19/2021] [Accepted: 07/27/2021] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Emergency research is challenging to do well as it involves time sensitive interventions in unstable patients. There is limited time to obtain informed consent from the patient or their legally authorized representative (LAR). Such research is permitted under exception from informed consent (EFIC) if specific criteria are met, including notification after enrollment. Some question whether the risks of EFIC outweighs its benefits. To date, there is limited empiric information about time to notification (TTN) and rates of withdrawal in such trials. OBJECTIVE To describe variation in TTN and rates of withdrawal among that patients enrolled in EFIC trials over a twelve-year period. DESIGN We performed post hoc descriptive analyses of data from five trials conducted under EFIC. SETTING Emergency medical services and receiving hospitals participating in the Resuscitation Outcomes Consortium in the United States and Canada. PARTICIPANTS Patients with out-of-hospital cardiac arrest or life-threatening traumatic injury. EXPOSURES Notification strategies were specified at each site before initiation of enrollment by a local institutional review board. We monitored TTN within each site centrally throughout each study's enrollment period. OUTCOMES TTN was defined as time from randomization to first-reported notification of patient or LAR of enrollment. Withdrawal was defined as patient or LAR opt out of ongoing participation at the time of notification. RESULTS Of 35,442 patients enrolled in five trials, 33,805 had cardiac arrest; and 1636 had traumatic injury. TTN varied overall and by patient outcome. Among those with cardiac arrest, TTN ranged from median (5%ile, 95%ile) of 6 (1,27) days to 28 (2, 53) days across sites. 0.3% of notified patients with cardiac arrest withdrew. Among those with traumatic injury, TTN ranged from 0 (0, 5) days to 36 (5, 68) days across sites. 7.7% of notified patients with traumatic injury withdrew. CONCLUSIONS AND RELEVANCE There is large variation in TTN in trials conducted under EFIC for emergency research. This may be due to several factors. It may or may not be modifiable. Overall rates of withdrawal are low, which suggests current practices related to EFIC are acceptable to those who have participated in emergency research.
Collapse
Affiliation(s)
- Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Departments of Medicine and Emergency Medicine, University of Washington, Seattle, WA, United States.
| | - Rui Zhuang
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Renee Russell
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - John B Holcomb
- Center for Injury Science, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Peter J Kudenchuk
- King County EMS and Departments of Medicine, University of Washington, Seattle, WA, United States
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Laurie Morrison
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Division of Emergency Medicine, Department of Medicine, University of Toronto, Ottawa, ON and Vancouver, BC, Canada
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Department of Medicine and Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, United States
| | - Joseph P Ornato
- Department of Emergency Medicine, Virginia Commonwealth University Health, Richmond, VA, United States
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Christian Vaillancourt
- Ottawa Hospital Research Institute and Department of Emergency Medicine, University of Ottawa, Ottawa, ON, United States
| | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle, WA, United States
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Providence Health Care Research Institute, Vancouver, BC, United States
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Marty Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, OR, United States
| | - Ahamed Idris
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX, United States
| | - Jeanette M Podbielski
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - George Sopko
- National Heart Lung Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Henry Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Charles E Wade
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - David Hoyt
- American College of Surgeons, Chicago, IL, United States
| | - Myron L Weisfeldt
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| |
Collapse
|
7
|
Andersen LW, Sindberg B, Holmberg M, Isbye D, Kjærgaard J, Zwisler ST, Darling S, Larsen JM, Rasmussen BS, Løfgren B, Lauridsen KG, Pælestik KB, Sølling C, Kjærgaard AG, Due-Rasmussen D, Folke F, Charlot MG, Iversen K, Schultz M, Wiberg S, Jepsen RMH, Kurth T, Donnino M, Kirkegaard H, Granfeldt A. Vasopressin and methylprednisolone for in-hospital cardiac arrest - Protocol for a randomized, double-blind, placebo-controlled trial. Resusc Plus 2021; 5:100081. [PMID: 34223347 PMCID: PMC8244400 DOI: 10.1016/j.resplu.2021.100081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To describe the clinical trial "Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest" (VAM-IHCA). METHODS The VAM-IHCA trial is an investigator-initiated, multicenter, randomized, placebo-controlled, parallel group, double-blind, superiority trial of vasopressin and methylprednisolone during adult in-hospital cardiac arrest. The study drugs consist of 40 mg methylprednisolone and 20 IU of vasopressin given as soon as possible after the first dose of adrenaline. Additional doses of vasopressin (20 IU) will be administered after each adrenaline dose for a maximum of four doses (80 IU).The primary outcome is return of spontaneous circulation and key secondary outcomes include survival and survival with a favorable neurological outcome at 30 days. 492 patients will be enrolled. The trial was registered at the EU Clinical Trials Register (EudraCT Number: 2017-004773-13) on Jan. 25, 2018 and ClinicalTrials.gov (Identifier: NCT03640949) on Aug. 21, 2018. RESULTS The trial started in October 2018 and the last patient is anticipated to be included in January 2021. The primary results will be reported after 3-months follow-up and are, therefore, anticipated in mid-2021. CONCLUSION The current article describes the design of the VAM-IHCA trial. The results from this trial will help clarify whether the combination of vasopressin and methylprednisolone when administered during in-hospital cardiac arrest improves outcomes.
Collapse
Affiliation(s)
- Lars W. Andersen
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Birthe Sindberg
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
| | - Mathias Holmberg
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
- Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Dan Isbye
- Department of Anaesthesia 6011, Rigshospitalet - University of Copenhagen, Denmark
| | - Jesper Kjærgaard
- Department of Cardiology, The Heart Centre, Rigshospitalet - University of Copenhagen, Denmark
| | - Stine T. Zwisler
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Søren Darling
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Jacob Moesgaard Larsen
- Department of Cardiology, Aalborg University Hospital, Denmark
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Bodil S. Rasmussen
- Department of Clinical Medicine, Aalborg University, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Denmark
| | - Bo Løfgren
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
- Department of Medicine, Randers Regional Hospital, Randers, Denmark
| | - Kasper Glerup Lauridsen
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
- Department of Medicine, Randers Regional Hospital, Randers, Denmark
| | - Kim B. Pælestik
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Christoffer Sølling
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Anders G. Kjærgaard
- Department of Anesthesiology and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
| | - Dorte Due-Rasmussen
- Department of Anesthesiology and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
| | - Fredrik Folke
- Copenhagen Emergency Medical Services, University of Copenhagen, Denmark
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Mette Gitz Charlot
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Emergency Medicine, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Martin Schultz
- Department of Internal Medicine, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Anesthesiology and Intensive Care, University Hospital Zealand, Køge, Denmark
| | | | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| |
Collapse
|
8
|
Kompanje EJO, van Dijck JTJM, Chalos V, van den Berg SA, Janssen PM, Nederkoorn PJ, van der Jagt M, Citerio G, Stocchetti N, Dippel DWJ, Peul WC. Informed consent procedures for emergency interventional research in patients with traumatic brain injury and ischaemic stroke. Lancet Neurol 2020; 19:1033-1042. [PMID: 33098755 DOI: 10.1016/s1474-4422(20)30276-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 11/30/2022]
Abstract
Health-care professionals and researchers have a legal and ethical responsibility to inform patients before carrying out diagnostic tests or treatment interventions as part of a clinical study. Interventional research in emergency situations can involve patients with some degree of acute cognitive impairment, as is regularly the case in traumatic brain injury and ischaemic stroke. These patients or their proxies are often unable to provide informed consent within narrow therapeutic time windows. International regulations and national laws are criticised for being inconclusive or restrictive in providing solutions. Currently accepted consent alternatives are deferred consent, exception from consent, or waiver of consent. However, these alternatives appear under-utilised despite being ethically permissible, socially acceptable, and regulatorily compliant. We anticipate that, when the requirements for medical urgency are properly balanced with legal and ethical conduct, the increased use of these alternatives has the potential to improve the efficiency and quality of future emergency interventional studies in patients with an inability to provide informed consent.
Collapse
Affiliation(s)
- Erwin J O Kompanje
- Department of Intensive Care Adult, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Ethics and Philosophy of Medicine, Erasmus University, Rotterdam, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Vicky Chalos
- Department of Public Health, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Radiology and Nuclear Science, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Sophie A van den Berg
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Neurology, Amsterdam UMC, The Netherlands
| | - Paula M Janssen
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | | | - Mathieu van der Jagt
- Department of Intensive Care Adult, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Diederik W J Dippel
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Informed consent procedures in patients with an acute inability to provide informed consent: Policy and practice in the CENTER-TBI study. J Crit Care 2020; 59:6-15. [DOI: 10.1016/j.jcrc.2020.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/22/2022]
|
11
|
Brown P, Newham R, Hewison A. To explore the experience of research nurses who obtain consent from adults in emergency settings to participate in clinical trials, either prospectively or post enrolment. J Clin Nurs 2020; 29:3054-3063. [PMID: 32441860 DOI: 10.1111/jocn.15339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/06/2020] [Accepted: 05/09/2020] [Indexed: 12/01/2022]
Abstract
AIM To explore the understanding and experiences of research nurses who obtain informed consent from adult patients participating in emergency care research. DESIGN Qualitative phenomenographic descriptive study. METHODS Ten research nurses from six hospitals in England were recruited. Data were collected using semi-structured face-to-face and telephone interviews between January 2019 and March 2019. Interviews were transcribed verbatim and analysed thematically, informed by phenomenography. COREQ was followed. RESULTS Three main themes were identified: (a) emergency research is different, (b) protecting the patient, and (c) experience and confidence with recruitment. It was found that obtaining patient consent in emergency care research was challenging and timing of the process was crucial. Nurses with more experience of emergency care were more confident in approaching patients and their families. There was variability in out-of-hours recruitment which was a consequence of the range of informed consent processes used and the different levels of engagement of clinical teams. CONCLUSION There is a variety of organisational cultures, processes and procedures which affect the way consent is obtained in emergency care research. A team approach was evident in the hospitals where consent rates were high and was more successful than those reliant solely on the presence of a research nurse. Organisations were able to recruit successfully to emergency care research studies irrespective of size and configuration. Further investigation of their models of working and strategies for engagement is needed. Experienced research nurses made a positive difference to recruitment and were more likely to approach patients to obtain consent. RELEVANCE TO CLINICAL PRACTICE The understanding and experiences of recruitment to clinical trials in emergency care research by research nurses can help identify barriers to recruitment. This study provides useful insights for healthcare practitioners, clinical trials coordinators and sponsors about how best to develop protocols and policies to increase recruitment to emergency care research.
Collapse
|
12
|
Schmicker RH, Nichol G, Callaway CW, Cheskes S, Sopko G, Wang HE. Study Monitoring in Emergency Care Trials: Lessons from the Resuscitation Outcomes Consortium Continuous Chest Compressions Trial. Acad Emerg Med 2019; 26:1152-1157. [PMID: 31148319 DOI: 10.1111/acem.13810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/02/2019] [Accepted: 05/29/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Clinical trial investigators often assemble internal study monitoring committees (SMCs) to measure individual or group adherence with trial performance benchmarks. We examined the processes and results of study monitoring in an international trial of out-of-hospital cardiac arrest. METHODS We studied SMC operations for the Resuscitation Outcomes Consortium (ROC) Continuous Chest Compressions (CCC) trial, which compared continuous with interrupted chest compressions upon survival after out-of-hospital cardiac arrest. The SMC defined trial performance benchmarks, which included compliance with the intervention, cardiopulmonary resuscitation (CPR) process data availability and timely data completion. Trial investigators received monthly performance reports. We determined rates of trial noncompliance and suspension from the trial. RESULTS ROC-CCC enrolled a total of 23,711 subjects in the primary analysis population. Across 113 enrolling agencies, the SMC monitored performance for a total 2,367 agency-months. Emergency medical services agencies were on probation for a total of 178 (7.5%) agency-months. Fifty-five agencies were placed on probation at least once, of which 78% improved their performance and were approved for continued participation in the trial. A total of 12 agencies were suspended from trial participation. Data monitoring resulted in high-quality CPR (mean chest compression fraction = 0.80), 87% CPR process availability and timely data completion (75th and 95th percentiles prehospital data = 22 and 57 days; hospital data = 58 and 118 days). CONCLUSIONS Study monitoring procedures may play an important role in ensuring the performance quality in acute care clinical trials.
Collapse
Affiliation(s)
- Robert H. Schmicker
- Clinical Trial Center Department of BiostatisticsUniversity of WashingtonSeattle WA
| | - Graham Nichol
- Departments of Medicine and Emergency Medicine University of Washington Seattle WA
| | | | - Sheldon Cheskes
- Division of Family and Community Medicine Division of Emergency Medicine University of Toronto Toronto Ontario Canada
| | - George Sopko
- National Heart, Lung, and Blood Institute Bethesda MD
| | - Henry E. Wang
- Department of Emergency Medicine The University of Texas Health Science Center at Houston Houston TX
| |
Collapse
|
13
|
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] [Grants] [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.
Collapse
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
| | | | - Carla Saenz
- Regional Program on Bioethics, Department of Health Systems and Services, Pan American Health Organization, Washington, DC, United States
| |
Collapse
|
14
|
Feldman WB, Hey SP, Kesselheim AS. A Systematic Review Of The Food And Drug Administration's 'Exception From Informed Consent' Pathway. Health Aff (Millwood) 2019; 37:1605-1614. [PMID: 30273035 DOI: 10.1377/hlthaff.2018.0501] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 1996 the Food and Drug Administration (FDA) created an "exception from informed consent" (EFIC) pathway for trials conducted on people incapacitated by life-threatening conditions with a therapeutic time window too narrow for reliable surrogate consent. The goals were to promote therapeutic innovation and encourage rigorous but ethical experimentation on this vulnerable population. To evaluate outcomes of this pathway, we reviewed the complete FDA docket of EFIC trials from the past two decades, encompassing forty-one trials. Among the 46,964 patients included in this review, ninety-six percent were enrolled without consent, and fewer than 1 percent withdrew before the primary endpoint. Two (8 percent) of the twenty-four superiority trials demonstrated a benefit from the experimental interventions. Many interventions were associated with adverse effects, including increased mortality, neurological deficits, and myocardial infarctions. Nearly one-third of US patients in EFIC trials were African American. While EFIC trials have yielded medical advances, investigators in future trials must pay better attention to managing withdrawals and ensuring fair demographic representation.
Collapse
Affiliation(s)
- William B Feldman
- William B. Feldman ( ) is a research fellow at Harvard Medical School and a fellow in the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, in Boston, Massachusetts
| | - Spencer Phillips Hey
- Spencer Phillips Hey is a faculty member and codirector of research ethics at the Harvard Center for Bioethics and a research scientist in the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital
| | - Aaron S Kesselheim
- Aaron S. Kesselheim is an associate professor of medicine at Harvard Medical School and director of the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital
| |
Collapse
|
15
|
Dickert NW, Scicluna VM, Adeoye O, Angiolillo DJ, Blankenship JC, Devireddy CM, Frankel MR, Goldkind SF, Kumar G, Ko Y, 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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/10/2018] [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.
Collapse
Affiliation(s)
- Neal W. Dickert
- Division of CardiologyDepartment of MedicineEmory University School of MedicineAtlantaGA
| | | | - Opeolu Adeoye
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOH
| | - Dominick J. Angiolillo
- Division of CardiologyDepartment of MedicineUniversity of Florida College of Medicine—JacksonvilleJacksonvilleFL
| | | | - Chandan M. Devireddy
- Division of CardiologyDepartment of MedicineEmory University School of MedicineAtlantaGA
| | | | - Sara F. Goldkind
- Research and Clinical Bioethics ConsultantGoldkind Consulting LLCPotomacMD
| | - Gautam Kumar
- Division of CardiologyDepartment of MedicineEmory University School of MedicineAtlantaGA
- Atlanta VA Medical CenterDecaturGA
| | - Yi‐An Ko
- Department of Biostatistics and BioinformaticsEmory University Rollins School of Public HealthAtlantaGA
| | - Andrea R. Mitchell
- Division of CardiologyDepartment of MedicineEmory University School of MedicineAtlantaGA
| | - Raul G. Nogueria
- Department of NeurologyEmory University School of MedicineAtlantaGA
| | - Ruth M. Parker
- Department of MedicineEmory University School of MedicineAtlantaGA
| | - Manesh R. Patel
- Division of CardiologyDepartment of MedicineDuke University School of MedicineDurhamNC
| | | | - Robert Silbergleit
- Department of Emergency MedicineUniversity of Michigan Medical SchoolAnn ArborMI
| | - Candace D. Speight
- Division of CardiologyDepartment of MedicineEmory University School of MedicineAtlantaGA
| | - Ilana Spokoyny
- Department of NeurologyCalifornia Pacific Medical CenterSan FranciscoCA
| | - Kevin P. Weinfurt
- Department of Population Health SciencesDuke University School of MedicineDurhamNC
| | - Rebecca D. Pentz
- Winship Cancer InstituteEmory University School of MedicineAtlantaGA
| |
Collapse
|
16
|
Vorholt V, Dickert NW. Uninformed refusals: objections to enrolment in clinical trials conducted under an Exception from Informed Consent for emergency research. JOURNAL OF MEDICAL ETHICS 2019; 45:18-21. [PMID: 30219797 DOI: 10.1136/medethics-2017-104736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 06/08/2023]
Abstract
Clinical trials in emergency situations present unique challenges, because they involve enrolling individuals who lack capacity to consent in the context of acute illness or injury. The US Department of Health and Human Services and Food and Drug Administration regulations allowing an Exception from Informed Consent (EFIC) in these circumstances contain requirements for community consultation, public disclosure and restrictions on study risks and benefits. In this paper, we analyse an issue raised in the regulations that has received little attention or analysis but is ethically complex. This challenge is when to solicit and honour objections to EFIC trial enrolment, including from non-legally appointed representatives. We address novel questions involving whose objections should be honoured, what level of understanding is necessary for objections to be considered valid and how hard investigators should work to offer an opportunity to object. We present a set of criteria that provide conceptual and practical guidance. We argue that objections should be honoured if they undermine one of the key assumptions that allows for the permissibility of EFIC trials: that individuals would likely not object to enrolment based on their values or preferences. We then clarify the practical implications of this approach through examination of three cases of refusal in an EFIC study.
Collapse
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
| |
Collapse
|
17
|
Chalkias A, Xanthos T, Papageorgiou E, Anania A, Beloukas A, Pavlopoulos F. Intraoperative initiation of a modified ARDSNet protocol increases survival of septic patients with severe acute respiratory distress syndrome. Heart Lung 2018; 47:616-621. [PMID: 30097303 DOI: 10.1016/j.hrtlng.2018.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To assess the intraoperative initiation and feasibility of a modified NIH-NHLBI ARDS Network Mechanical Ventilation Protocol (mARDSNet protocol) in septic patients with severe ARDS. MATERIALS AND METHODS This prospective observational study included consecutive adult septic patients with severe ARDS who underwent emergency abdominal surgery prior to intensive care unit (ICU) admission. The primary outcome was survival to hospital discharge and at 90 days. Secondary outcomes were intraoperative adverse events and ICU length of stay. RESULTS Seven patients were included. A statistically significant difference in lung compliance [ε=0.150, F(1.053, 3.158)=31.098, p=0.010] and driving pressure [ε=0.263, F(1.844, 5.532)=7.042, p=0.031] was observed with time, while plateau pressure did not changed significantly during surgery [ε=0.322, F(2.256, 6.769)=1.920, p=0.219]. Also, PEEP values were constantly increased during surgery [ε=0.252, F(1.766, 5.297)=9.994, p=0.017], with the highest values being observed towards to the end of the procedure. No intraoperative adverse events were observed. Mean (±SD) ICU length of stay was 10.43 (±2.64) days, while all patients survived to hospital discharge and at 90 days. CONCLUSIONS The intraoperative implementation of our mARDSNet protocol is feasible and may increase the survival of septic patients with severe ARDS if initiated prior to ICU admission.
Collapse
Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology and Perioperative Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larisa, Greece; Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.
| | | | - Effie Papageorgiou
- Department of BioMedical Sciences, University of West Attica, Athens, Greece
| | - Artemis Anania
- Department of Anesthesiology, Tzaneio General Hospital, Piraeus, Greece
| | - Apostolos Beloukas
- Department of BioMedical Sciences, University of West Attica, Athens, Greece; Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | | |
Collapse
|
18
|
Nolan JP, Berg RA, Callaway CW, Morrison LJ, Nadkarni V, Perkins GD, Sandroni C, Skrifvars MB, Soar J, Sunde K, Cariou A. The present and future of cardiac arrest care: international experts reach out to caregivers and healthcare authorities. Intensive Care Med 2018; 44:823-832. [DOI: 10.1007/s00134-018-5230-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 05/12/2018] [Indexed: 12/24/2022]
|
19
|
Chalkias A, Pavlopoulos F, Papageorgiou E, Tountas C, Anania A, Panteli M, Beloukas A, Xanthos T. Development and Testing of a Novel Anaesthesia Induction/Ventilation Protocol for Patients With Cardiogenic Shock Complicating Acute Myocardial Infarction. Can J Cardiol 2018; 34:1048-1058. [PMID: 30056844 DOI: 10.1016/j.cjca.2018.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 04/14/2018] [Accepted: 04/15/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cardiogenic shock is a life-threatening condition and patients might require rapid sequence induction (RSI) and mechanical ventilation. In this study, we evaluated a new RSI/mechanical ventilation protocol in patients with acute myocardial infarction complicated by cardiogenic shock. METHODS We included consecutive adult patients who were transferred to the emergency department. The RSI protocol included 5 phases: preoxygenation, pretreatment, induction/paralysis, intubation, and mechanical ventilation (PPIIM). A posteriori, we selected historical patients managed with standard RSI as a control group. The primary outcome was hemodynamic derangement or hypoxemia from enrollment until intensive care unit (ICU) admission. RESULTS We studied 31 consecutive patients who were intubated using the PPIIM protocol and 22 historical controls. We found significant differences in systolic (85.32 ± 4.23 vs 71.72 ± 7.98 mm Hg; P < 0.0001), diastolic (58.84 ± 5.84 vs 39.05 ± 5.63 mm Hg; P < 0.0001), and mean arterial pressure (67.71 ± 4.90 vs 49.90 ± 5.66 mm Hg; P < 0.0001), as well as in partial pressure of oxygen (85.80 ± 19.82 vs 164.73 ± 43.07 mm Hg; P < 0.0001) between the PPIIM and control group at 5 minutes of automated ventilation. Also, statistically significant differences were observed in diastolic (59.74 ± 4.93 vs 47.86 ± 11.47 mm Hg; P < 0.0001) and mean arterial pressure (68.65 ± 4.10 vs 60.23 ± 11.67 mm Hg; P < 0.0001), as well as in partial pressure of oxygen (119.84 ± 50.57 vs 179.50 ± 42.17 mm Hg; P < 0.0001), and partial pressure of carbon dioxide (39.81 ± 10.60 vs 31.00 ± 9.30 mm Hg; P = 0.003) between the 2 groups at ICU admission. Compared with the control group, with PPIIM more patients survived to ICU admission (100% vs 77%) and hospital discharge (71% vs 31.8%), as well as at 90 days (51.6% vs 18.2%), and at 180 days (38.7% vs 13.6%). CONCLUSIONS The PPIIM protocol allows safe intubation of acute myocardial infarction patients with cardiogenic shock and improves hemodynamic and oxygenation parameters.
Collapse
Affiliation(s)
- Athanasios Chalkias
- University of Thessaly, School of Health Sciences, Faculty of Medicine, Department of Anesthesiology and Perioperative Medicine, Larisa, Greece; Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.
| | | | - Effie Papageorgiou
- University of West Attica, Department of BioMedical Sciences, Athens, Greece
| | - Christos Tountas
- Tzaneio General Hospital, Department of Cardiology, Piraeus, Greece
| | - Artemis Anania
- Tzaneio General Hospital, Department of Anesthesiology, Piraeus, Greece
| | - Maria Panteli
- Tzaneio General Hospital, Department of Anesthesiology, Piraeus, Greece
| | - Apostolos Beloukas
- University of West Attica, Department of BioMedical Sciences, Athens, Greece; University of Liverpool, Institute of Infection and Global Health, Liverpool, United Kingdom
| | - Theodoros Xanthos
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece; European University Cyprus, School of Medicine, Nicosia, Cyprus
| |
Collapse
|
20
|
Galatianou I, Karlis G, Apostolopoulos A, Intas G, Chalari E, Gulati A, Iacovidou N, Chalkias A, Xanthos T. Body mass index and outcome of out-of-hospital cardiac arrest patients not treated by targeted temperature management. Am J Emerg Med 2017; 35:1247-1251. [DOI: 10.1016/j.ajem.2017.03.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 02/17/2017] [Accepted: 03/21/2017] [Indexed: 10/19/2022] Open
|
21
|
Bossaert L, Perkins G, Askitopoulou H, Raffay V, Greif R, Haywood K, Mentzelopoulos S, Nolan J, Van de Voorde P, Xanthos T. Ethik der Reanimation und Entscheidungen am Lebensende. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0329-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
22
|
Chalkias A, Pavlopoulos F, Koutsovasilis A, d'Aloja E, Xanthos T. Airway pressure and outcome of out-of-hospital cardiac arrest: A prospective observational study. Resuscitation 2017; 110:101-106. [DOI: 10.1016/j.resuscitation.2016.10.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/22/2016] [Accepted: 10/30/2016] [Indexed: 11/29/2022]
|
23
|
Whitesides LW, Baren JM, Biros MH, Fleischman RJ, Govindarajan PR, Jones EB, Pancioli AM, Pentz RD, Scicluna VM, Wright DW, Dickert NW. Impact of individual clinical outcomes on trial participants' perspectives on enrollment in emergency research without consent. Clin Trials 2016; 14:180-186. [PMID: 28359192 DOI: 10.1177/1740774516677276] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence suggests that patients are generally accepting of their enrollment in trials for emergency care conducted under exception from informed consent. It is unknown whether individuals with more severe initial injuries or worse clinical outcomes have different perspectives. Determining whether these differences exist may help to structure post-enrollment interactions. METHODS Primary clinical data from the Progesterone for the Treatment of Traumatic Brain Injury trial were matched to interview data from the Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study. Answers to three key questions from Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study were analyzed in the context of enrolled patients' initial injury severity (initial Glasgow Coma Scale and Injury Severity Score) and principal clinical outcomes (Extended Glasgow Outcome Scale and Extended Glasgow Outcome Scale relative to initial injury severity). The three key questions from Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study addressed participants' general attitude toward inclusion in the Progesterone for the Treatment of Traumatic Brain Injury trial (general trial inclusion), their specific attitude toward being included in Progesterone for the Treatment of Traumatic Brain Injury trial under the exception from informed consent (personal exception from informed consent enrollment), and their attitude toward the use of exception from informed consent in the Progesterone for the Treatment of Traumatic Brain Injury trial in general (general exception from informed consent enrollment). Qualitative analysis of interview transcripts was performed to provide contextualization and to determine the extent to which respondents framed their attitudes in terms of clinical experience. RESULTS Clinical data from Progesterone for the Treatment of Traumatic Brain Injury trial were available for all 74 patients represented in the Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study (including 46 patients for whom the surrogate was interviewed due to the patient's cognitive status or death). No significant difference was observed regarding acceptance of general trial inclusion or acceptance of general exception from informed consent enrollment between participants with favorable neurological outcomes and those with unfavorable outcomes relative to initial injury. Agreement with personal enrollment in Progesterone for the Treatment of Traumatic Brain Injury trial under exception from informed consent, however, was significantly higher among participants with favorable outcomes compared to those with unfavorable outcomes (89% vs 59%, p = 0.003). There was also a statistically significant relationship between more severe initial injury and increased acceptance of personal exception from informed consent enrollment ( p = 0.040) or general exception from informed consent use ( p = 0.034) in Progesterone for the Treatment of Traumatic Brain Injury trial. Many individuals referenced personal experience as a basis for their attitudes, but these references were not used to support negative views. CONCLUSION Patients and surrogates of patients with unfavorable clinical outcomes were somewhat less accepting of their own inclusion in the Progesterone for the Treatment of Traumatic Brain Injury trial under exception from informed consent than were patients or surrogates of patients with favorable clinical outcomes. These findings suggest a need to identify optimal strategies for communicating with patients and their surrogates regarding exception from informed consent enrollment when clinical outcomes are poor.
Collapse
Affiliation(s)
- Louisa W Whitesides
- 1 Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jill M Baren
- 2 Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle H Biros
- 3 Hennepin County Medical Center, Department of Emergency Medicine, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ross J Fleischman
- 4 Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Prasanthi R Govindarajan
- 5 Department of Emergency Medicine, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Elizabeth B Jones
- 6 Department of Emergency Medicine, University of Texas Medical School at Houston, Houston, TX, USA
| | - Arthur M Pancioli
- 7 Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Rebecca D Pentz
- 8 Department of Hematology and Oncology, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - David W Wright
- 10 Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Neal W Dickert
- 11 Division of Cardiology, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA.,12 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| |
Collapse
|
24
|
|
25
|
Dickert NW, Brown J, Cairns CB, Eaves-Leanos A, Goldkind SF, Kim SYH, Nichol G, O'Conor KJ, Scott JD, Sinert R, Wendler D, Wright DW, Silbergleit R. Confronting Ethical and Regulatory Challenges of Emergency Care Research With Conscious Patients. Ann Emerg Med 2016; 67:538-45. [PMID: 26707358 PMCID: PMC7749649 DOI: 10.1016/j.annemergmed.2015.10.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/20/2015] [Accepted: 10/21/2015] [Indexed: 11/28/2022]
Abstract
Barriers to informed consent are ubiquitous in the conduct of emergency care research across a wide range of conditions and clinical contexts. They are largely unavoidable; can be related to time constraints, physical symptoms, emotional stress, and cognitive impairment; and affect patients and surrogates. US regulations permit an exception from informed consent for certain clinical trials in emergency settings, but these regulations have generally been used to facilitate trials in which patients are unconscious and no surrogate is available. Most emergency care research, however, involves conscious patients, and surrogates are often available. Unfortunately, there is neither clear regulatory guidance nor established ethical standards in regard to consent in these settings. In this report-the result of a workshop convened by the National Institutes of Health Office of Emergency Care Research and Department of Bioethics to address ethical challenges in emergency care research-we clarify potential gaps in ethical understanding and federal regulations about research in emergency care in which limited involvement of patients or surrogates in enrollment decisions is possible. We propose a spectrum of approaches directed toward realistic ethical goals and a research and policy agenda for addressing these issues to facilitate clinical research necessary to improve emergency care.
Collapse
Affiliation(s)
- Neal W Dickert
- Department of Medicine, Emory University School of Medicine, Atlanta, GA; Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA.
| | - Jeremy Brown
- Office of Emergency Care Research, National Institute of General Medical Sciences, Bethesda, MD
| | | | - Aaliyah Eaves-Leanos
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; Albert Gnaegi Center for Health Care Ethics, Saint Louis University, St. Louis, MO
| | - Sara F Goldkind
- Office of the Commissioner, Food and Drug Administration, Silver Spring, MD; Research and Clinical Bioethics Consultant
| | - Scott Y H Kim
- Department of Bioethics, National Institutes of Health, Bethesda, MD
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
| | | | - Jane D Scott
- National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Richard Sinert
- Department of Emergency Medicine, State University of New York Downstate Medical Center, New York, NY
| | - David Wendler
- Department of Bioethics, National Institutes of Health, Bethesda, MD
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| |
Collapse
|
26
|
Abstract
Legal and ethical issues form an important component of modern research, related to the subject and researcher. This article seeks to briefly review the various international guidelines and regulations that exist on issues related to informed consent, confidentiality, providing incentives and various forms of research misconduct. Relevant original publications (The Declaration of Helsinki, Belmont Report, Council for International Organisations of Medical Sciences/World Health Organisation International Guidelines for Biomedical Research Involving Human Subjects, World Association of Medical Editors Recommendations on Publication Ethics Policies, International Committee of Medical Journal Editors, CoSE White Paper, International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use-Good Clinical Practice) form the literature that are relevant to the ethical and legal aspects of conducting research that researchers should abide by when conducting translational and clinical research. Researchers should note the major international guidelines and regional differences in legislation. Hence, specific ethical advice should be sought at local Ethics Review Committees.
Collapse
Affiliation(s)
- Camille Yip
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Bukit Timah, Singapore
| | - Nian-Lin Reena Han
- Division of Clinical Support Services, KK Women's and Children's Hospital, Bukit Timah, Singapore
| | - Ban Leong Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Bukit Timah, Singapore; Anesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| |
Collapse
|
27
|
Ethik der Reanimation und Entscheidungen am Lebensende. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0083-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
28
|
Bossaert LL, Perkins GD, Askitopoulou H, Raffay VI, Greif R, Haywood KL, Mentzelopoulos SD, Nolan JP, Van de Voorde P, Xanthos TT, Georgiou M, Lippert FK, Steen PA. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015; 95:302-11. [DOI: 10.1016/j.resuscitation.2015.07.033] [Citation(s) in RCA: 256] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
29
|
Dickert NW, Miller FG. Involving patients in enrolment decisions for acute myocardial infarction trials. BMJ 2015; 351:h3791. [PMID: 26223782 PMCID: PMC4707514 DOI: 10.1136/bmj.h3791] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2015] [Indexed: 11/12/2022]
Affiliation(s)
- Neal W Dickert
- Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta
| | - Franklin G Miller
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
30
|
Mentzelopoulos SD, Mantzanas M, van Belle G, Nichol G. Evolution of European Union legislation on emergency research. Resuscitation 2015; 91:84-91. [PMID: 25796997 DOI: 10.1016/j.resuscitation.2015.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/24/2015] [Accepted: 03/11/2015] [Indexed: 11/17/2022]
Abstract
AIM Emergency research is necessary to prevent exposure of patients to unvalidated clinical practice (nonmaleficence), and to improve the dismal prognosis of disorders requiring emergent treatment such as cardiac arrest (beneficence). Regulations that govern clinical research should conform to bioethical principles of respect for nonmaleficence, beneficence, autonomy, and justice. Our objectives are to review the evolution of European Union (EU) legislation on emergency research, and to identify potentially remaining problems. DATA SOURCES EU legislative sources on clinical research and medical literature describing the impact of EU Regulations on emergency research. RESULTS Article 5 of EU Directive 2001/20/EC required consent before enrolment in a research study to ensure the autonomy of potentially incapacitated research subjects. However, obtaining such consent is often impossible in emergency situations. Directive 2001/20/EC was criticized for potentially preventing emergency research. Several EU Member States addressed this problem by permitting deferred consent. International ethical guidelines supporting deferred consent were also cited by Good Clinical Practice Directive 2005/28/EC. However, Directive 2001/20/EC was not revised to achieve harmonization of EU emergency research, thus resulting in ongoing "ambiguity" as regards to emergency research legitimacy. This will be definitively addressed by applying EU Regulation No. 536/2014 and repealing Directive 2001/20/EC. The new EU Regulation permits using deferred consent under clearly specified conditions, and may foster emergency research that evaluates interventions posing minimal risk relative to standard practice. CONCLUSIONS Legislation related to emergency research in Europe has evolved to increase concordance with bioethical principles so as to increase evidence-based improvements in emergency care.
Collapse
Affiliation(s)
| | | | - Gerald van Belle
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Graham Nichol
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, USA; University of Washington-Harborview Center for Prehospital Emergency Care, Department of Medicine, University of Washington, Seattle, WA, USA.
| |
Collapse
|