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Lochmann M, Girodet M, Despax J, Baudry V, Duranti J, Mastroianni B, Vanacker H, Vinceneux A, Brahmi M, Renard O, Verlingue L, Amini-Adle M, Swalduz A, Gautier J, Ducimetière F, Anota A, Cassier PA, Chvetzoff G, Christophe V. Qualitative evaluation of motives for acceptance or refusal of early palliative care in patients included in early-phase clinical trials in a French comprehensive cancer center: the PALPHA study. Support Care Cancer 2024; 32:353. [PMID: 38748187 DOI: 10.1007/s00520-024-08535-x] [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: 12/14/2023] [Accepted: 04/29/2024] [Indexed: 06/18/2024]
Abstract
PURPOSE The integration of palliative care (PC) into oncological management is recommended well before the end of life. It improves quality of life and symptom control and reduces the aggressiveness of end-of-life care. However, its appropriate timing is still debated. Entry into an early-phase clinical trial (ECT) represents hopes for the patient when standard treatments have failed. It is an opportune moment to integrate PC to preserve the patient's general health status. The objective of this study was to evaluate the motives for acceptance or refusal of early PC management in patients included in an ECT. METHODS Patients eligible to enter an ECT were identified and concomitant PC was proposed. All patients received exploratory interviews conducted by a researcher. Their contents were analyzed in a double-blind thematic analysis with a self-determination model. RESULTS Motives for acceptance (PC acceptors: n = 27) were both intrinsic (e.g., pain relief, psychological support, anticipation of the future) and extrinsic (e.g., trust in the medical profession, for a relative, to support the advance of research). Motives for refusal (PC refusers: n = 3) were solely intrinsic (e.g., PC associated with death, negative representation of psychological support, no need for additional care, claim of independence). CONCLUSIONS The motives of acceptors and refusers are not internalized in the same way and call for different autonomy needs. Acceptors and refusers are influenced by opposite representations of PC and a different perception of mixed management.
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Affiliation(s)
- Mathilde Lochmann
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France.
| | - Magali Girodet
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
- Evaluation Médicale et Sarcomes (EMS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Johanna Despax
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Valentine Baudry
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Julie Duranti
- Département Interdisciplinaire des Soins de Support en Oncologie, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex 08, France
| | - Bénédicte Mastroianni
- Département Interdisciplinaire des Soins de Support en Oncologie, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex 08, France
| | - Hélène Vanacker
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Armelle Vinceneux
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Mehdi Brahmi
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Olivier Renard
- Département Interdisciplinaire des Soins de Support en Oncologie, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex 08, France
| | - Loïc Verlingue
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Mona Amini-Adle
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Aurélie Swalduz
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Julien Gautier
- Direction de la Recherche Clinique et de l'Innovation (DRCI), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Françoise Ducimetière
- Evaluation Médicale et Sarcomes (EMS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Amélie Anota
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
- Direction de la Recherche Clinique et de l'Innovation (DRCI), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Philippe A Cassier
- Département de Cancérologie Médicale, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
| | - Gisèle Chvetzoff
- Département Interdisciplinaire des Soins de Support en Oncologie, Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex 08, France
| | - Véronique Christophe
- Département des Sciences Humaines et Sociales (SHS), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
- Centre de Recherche sur le Cancer de Lyon (CRCL), Centre Léon Bérard, 28 Rue Laënnec, 69373, Lyon Cedex, France
- Université Claude Bernard Lyon 1 (UCBL), 43 Bd du 11 Novembre 1918, 69100, Villeurbanne, France
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2
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Wu C, Wang N, Wang Q, Wang C, Wei Z, Wu Z, Yu S, Jiang X. Participants' understanding of informed consent in clinical trials: A systematic review and updated meta-analysis. PLoS One 2024; 19:e0295784. [PMID: 38166097 PMCID: PMC10760836 DOI: 10.1371/journal.pone.0295784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/29/2023] [Indexed: 01/04/2024] Open
Abstract
Obtaining written informed consent from participants before enrolment in a study is essential. A previous study showed that only 50% of the participants in clinical trials understood the components of informed consent, and the methods of participants' understanding of informed consent were controversial. This updated meta-analysis aimed to estimate the proportion of participants in clinical trials who understand the different informed consent components. PubMed, EMBASE, the Cochrane Library, and Scopus were searched till April 2023. Therapeutic misconception, ability to name one risk, knowing that treatments were being compared, and understanding the nature of the study, the purpose of the study, the risks and side-effects, the direct benefits, placebo, randomization, voluntariness, freedom to withdraw, the availability of alternative treatment if withdrawn from the trial, confidentiality, compensation, or comprehension were evaluated. This meta-analysis included 117 studies (155 datasets; 22,118 participants). The understanding of the risks and side-effects was investigated in the largest number of studies (n = 100), whereas comparehension was investigated in the smallest number (n = 11). The highest proportions were 97.5%(95% confidence interval (CI): 97.1-97.9) for confidentiality, 95.9% (95% confidence interval (CI): 95.4-96.4) for compensation, 91.4% (95% CI: 90.7-92.1) for the nature of study, 68.1% (95% CI: 51.6-84.6) for knowing that treatments were being compared, and 67.3% (95% CI: 56.6-78) for voluntary nature of participants. The smallest proportions were the concept of placebo (4.8%, 95%CI: 4.4-5.2) and randomization(39.4%, 95%CI: 38.3-40.4). Our findings suggested that most participants understood the fundamental components of informed consent (study confidentiality, nature, compensation, voluntariness, and freedom to withdraw). The understanding of other components, such as placebo and randomization was less satisfactory.
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Affiliation(s)
- Chengai Wu
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Na Wang
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Qianqian Wang
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Chao Wang
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Zhenjie Wei
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Zhimin Wu
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Shunan Yu
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Xieyuan Jiang
- Beijing Jishuitan Hospital, Capital Medical University, Beijing Research Institute of Traumatology and Orthopaedics, Beijing, China
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3
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King-Kallimanis BL, Ferris A, Dropkin L, Molina M, Redway L, Gerber DE, Grant TL, Roy UB. Initial Steps in Creating a Patient-Centric Addendum to Clinical Trial Informed Consent Forms. JTO Clin Res Rep 2023; 4:100575. [PMID: 37842324 PMCID: PMC10568273 DOI: 10.1016/j.jtocrr.2023.100575] [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] [Received: 04/24/2023] [Revised: 08/27/2023] [Accepted: 09/04/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction The purpose of the informed consent form (ICF) is to outline the risks and benefits of an interventional clinical trial to potential participants. The aim of this study was to explore the feasibility of a short addendum to the ICF, summarizing key points most relevant to potential participants. Methods A sample of 20 ICFs was reviewed against the requirements of the U.S. federal regulation documents and assessed for readability. Alongside the ICF review, we conducted focus groups and one-on-one interviews with people with lung cancer (n = 9) to learn what information was most important when considering participation in a clinical trial using a hypothetical phase 3 ICF. Results The 20 ICFs reviewed were from phases 1 to 3, expanded-access, and single-patient trials covering predominantly NSCLC; 60% were global. The mean length of the ICFs was 21 (range: 15-34) pages. The average reading level was tenth grade whereas the average U.S. reading level was eighth grade. Readability varied by section, the "purpose of the study" section had the highest reading level. In the qualitative research component, participants were "overwhelmed" by the hypothetical ICF. Participants were also asked to list information for the addendum; their suggestions broadly map to federal regulations. An addendum with reference to sections in the ICF for additional details was well received. Conclusions The variations in ICF architecture and readability make it difficult for patients to make an informed decision to participate in a clinical trial. Implications extend beyond lung cancer, highlighting key areas for ICF improvements and providing a roadmap for developing a patient-centric addendum.
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Affiliation(s)
| | | | | | | | | | - David E. Gerber
- Harold C. Simmons Comprehensive Cancer Center, University of Texas (UT) Southwestern Medical Center, Dallas, Texas
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Patterson KN, Deans KJ, Minneci PC. Shared decision-making in pediatric surgery: An overview of its application for the treatment of uncomplicated appendicitis. J Pediatr Surg 2023; 58:729-734. [PMID: 36379750 DOI: 10.1016/j.jpedsurg.2022.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/17/2022] [Accepted: 10/12/2022] [Indexed: 11/15/2022]
Abstract
Nonoperative management (NOM) of uncomplicated appendicitis is a safe and effective treatment alternative to surgery that may be preferred by some families. Surgery and NOM differ significantly in their associated risks and benefits. Choosing a treatment for acute appendicitis requires patients and their caregivers to make timely, informed decisions that allow for incorporation of personal perspectives, values, and preferences. This article will address the concept of shared decision-making and establish its role in patient-centered care. It will demonstrate the effectiveness of shared decision-making in a high acuity surgical setting for children and highlight how the choice for management of acute appendicitis may be impacted by patients' and families' individualized circumstances and values.
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Affiliation(s)
- Kelli N Patterson
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Katherine J Deans
- Department of Surgery, Nemours Children's Health Delaware, 1600 Rockland Rd, Wilimington, DE 19803, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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5
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Parental attitudes towards choosing between operative and nonoperative management of pediatric acute appendicitis. J Pediatr Surg 2022; 57:1592-1598. [PMID: 34872734 DOI: 10.1016/j.jpedsurg.2021.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/18/2021] [Accepted: 10/25/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Making healthcare decisions for children can be challenging for parents or guardians. We aimed to characterize the decision-making preferences and stress of parents or guardians who were offered both appendectomy or nonoperative management (NOM) for children with acute appendicitis. METHODS Criteria was developed for offering operative or NOM for patients. At the time of decision, parents or guardians completed a survey assessing their understanding of treatment options, stress and preferences in being given the choice. An outpatient follow-up survey was later administered to evaluate post-decision satisfaction. RESULTS A total of 45 respondents were included in the study. More than 95% endorsed understanding of the risks/benefits of the options and felt supported and satisfied with their decision. Half felt the process was more than minimally stressful, 77% felt the decision was easy to make, 89% liked being asked and 95% preferred to make the decision themselves with varying degrees of input from their physician. Of the 62% of parents or guardians who completed the follow-up survey, >90% were satisfied with their decision and one respondent regretted their choice. DISCUSSION When offered the choice between operative and NOM of acute appendicitis, half of parents or guardians felt greater than minimal stress. The majority endorsed adequate understanding of the options, felt it was an easy decision, and maintained the desire to be the primary decision maker for their child. Our study provides preliminary data on parental or guardian attitudes towards shared decision-making in the surgical setting. Follow-up studies should focus on identifying predictors for those who feel increased stress and difficulty with decision-making. LEVEL OF EVIDENCE III.
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6
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Escritt K, Mann M, Nelson A, Harrop E. Hope and meaning-making in phase 1 oncology trials: a systematic review and thematic synthesis of qualitative evidence on patient-participant experiences. Trials 2022; 23:409. [PMID: 35578308 PMCID: PMC9112562 DOI: 10.1186/s13063-022-06306-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background Phase 1 drug trials are popular treatment options for patients with advanced disease, despite the greater levels of uncertainty associated with them. However, their meaning and consequences for patient-participants remains under-explored. This review synthesises the qualitative evidence of patients’ experiences of participating in phase 1 oncology trials, exploring their decisions to take part and the impacts of these trials on patient wellbeing. Methods A comprehensive literature search involving medical subject headings (MeSH) and keywords was undertaken in the following databases: MEDLINE, EMBASE, PsycINFO, Scopus, CINAHL, and Cochrane CENTRAL, with supplementary searches also conducted. Studies were independently screened for inclusion by two researchers. Included studies were critically appraised and data extracted using standardised forms. Qualitative results were analysed using thematic synthesis. Results Three main themes were identified across 13 studies: decision-making and joining the trial; experiences of taking part in the trial and hope and coping. Patients primarily joined trials hoping for therapeutic benefits, sentiments which prevailed and shaped their experiences across their trial journey. Rather than indicate therapeutic misconception based on poor understanding, patient perspectives more commonly pointed to differences between hope and expectation and cultural narratives of staying positive, trying everything and trusting in experts. Conclusions These findings challenge information-based models of consent, favouring coping frameworks which account for the role of hope and meaning-making during serious illness. Personalised consideration of existential and quality-of-life matters before and during trials is recommended, including palliative and supportive care alternatives to active treatment. Review Registration The review was registered with PROSPERO international prospective register of systematic reviews (CRD 42020163250). Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06306-9.
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7
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Chvetzoff G, Girodet M, Despax J, Baudry V, Duranti J, Mastroianni B, Vanacker H, Vinceneux A, Brahmi M, Renard O, Gautier J, Britel M, Ducimetière F, Anota A, Cassier P, Christophe V. Reasons for acceptance and refusal of early palliative care in patients included in early-phase clinical trials in a regional comprehensive cancer centre in France: protocol for a qualitative study. BMJ Open 2022; 12:e060317. [PMID: 35459679 PMCID: PMC9036432 DOI: 10.1136/bmjopen-2021-060317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION A few studies have highlighted the potential synergy between early palliative care and inclusion in an early-phase clinical trial that may improve quality of life, reduce symptoms of exhaustion related to the side effects of treatment and allow patients to complete their treatment protocol. The primary objective of this qualitative study is to evaluate the reasons for acceptance or refusal of early palliative care in patients included in early-phase clinical trials. METHOD AND ANALYSIS All patients from the Centre Léon Bérard (Comprehensive Cancer Centre in Lyon, France) who consent to one of the early-phase clinical trials proposed at the centre will be invited to participate in this study. The cohort will consist of a subgroup (n=20) of patients who accept palliative care together with their clinical trial, and a second subgroup (n=20) of patients who decline it. Patients will be interviewed in exploratory interviews conducted by a psychology researcher before the start of their clinical trial. The interviews will be audio-recorded. Patients will also be asked to complete quality of life and anxiety/depression questionnaires both before the beginning of the treatment and at the end of their clinical trial. The content of the interviews will be analysed thematically. Descriptive and comparative statistical analysis of both cohorts will also be conducted. ETHICS AND DISSEMINATION Personal data will be collected and processed in accordance with the laws and regulations in force. All patients will give informed consent to participate. This study complies with reference methodology MR004 of the Commission Nationale de l'Informatique et des Libertés. The protocol has received the validation of an ethics committee (Groupe de Réflexion Ethique du CLB, number: 2020-006). The results will be disseminated through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT04717440.
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Affiliation(s)
- Gisele Chvetzoff
- Department of Oncology Patient Support Care, Centre Léon Bérard, Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Universite Claude Bernard Lyon 1, Lyon, France
| | - Magali Girodet
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Universite Claude Bernard Lyon 1, Lyon, France
- Department of Human and Social Sciences, Centre Léon Bérard, Lyon, France
| | - Johanna Despax
- Sciences Humaines et Sociales, Centre Léon Bérard, Lyon, France
| | - Valentine Baudry
- Department of Human and Social Sciences, Centre Léon Bérard, Lyon, France
| | - Julie Duranti
- Department of Oncology Patient Support Care, Centre Léon Bérard, Lyon, France
| | | | - Hélène Vanacker
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | | | - Mehdi Brahmi
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Olivier Renard
- Department of Oncology Patient Support Care, Centre Léon Bérard, Lyon, France
| | - Julien Gautier
- Clinical Research and Innovation Department, Centre Léon Bérard, Lyon, France
| | - Manon Britel
- Department of Human and Social Sciences, Centre Léon Bérard, Lyon, France
| | | | - Amélie Anota
- Department of Human and Social Sciences, Centre Léon Bérard, Lyon, France
- Clinical Research and Innovation Department, Centre Léon Bérard, Lyon, France
| | - Philippe Cassier
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Véronique Christophe
- Department of Human and Social Sciences, Centre Léon Bérard, Lyon, France
- CNRS, UMR 9193, SCALab Cognitives and Affectives Sciences, University of Lille, Lille, France
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A Gregersen T, Birkelund R, Wolderslund M, Dahl Steffensen K, Ammentorp J. Patients' experiences of the decision-making process for clinical trial participation. Nurs Health Sci 2022; 24:65-72. [PMID: 35212102 PMCID: PMC9314595 DOI: 10.1111/nhs.12933] [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] [Received: 11/11/2021] [Revised: 02/21/2022] [Accepted: 02/21/2022] [Indexed: 12/04/2022]
Abstract
Clinical decision‐making about participating in a clinical trial is a complex process influenced by overwhelming information about prognosis, disease, and treatment options. The study aimed to explore patients' experiences of the decision‐making process when patients are presented with the opportunity to participate in a cancer clinical trial and to shed light on how patients experience the health communication, the nurse's role, and the physician's role. A qualitative study design was applied. Nine patients with advanced cancer were interviewed after being informed about their treatment options. Data were analyzed using thematic analysis. The results showed that patients made treatment decisions mainly guided by their emotions and trust in the physician. Furthermore, the physicians had a great impact on the decisions, and the nurse's role was associated with conversations about how to manage life. The study highlights the importance of talking about prognosis and addressing the patient's existential issues, particularly in this context of advanced cancer. The study elucidates a need for healthcare professionals to engage in health communication about life when it is coming to an end.
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Affiliation(s)
- Trine A Gregersen
- Centre for Research in Patient Communication, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences University of Southern Denmark, Odense, Denmark
| | - Regner Birkelund
- Department of Regional Health Research, Faculty of Health Sciences University of Southern Denmark, Odense, Denmark
| | - Maiken Wolderslund
- Centre for Research in Patient Communication, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences University of Southern Denmark, Odense, Denmark
| | - Karina Dahl Steffensen
- Department of Regional Health Research, Faculty of Health Sciences University of Southern Denmark, Odense, Denmark.,Department of Oncology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark.,Center for Shared Decision Making, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark
| | - Jette Ammentorp
- Centre for Research in Patient Communication, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences University of Southern Denmark, Odense, Denmark
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Keruakous AR, Day S, Garcia-Ramiu K, Yarbrough M, Asch AS. Research Staff Perspectives on Cancer Clinical Trials and Barriers to Recruitment: A Qualitative Research. Cureus 2021; 13:e17202. [PMID: 34540430 PMCID: PMC8439775 DOI: 10.7759/cureus.17202] [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] [Accepted: 08/15/2021] [Indexed: 12/02/2022] Open
Abstract
Background Clinical trials are key elements of the processes that account for many of the recent advances in cancer care. Unfortunately, they are becoming more challenging to conduct. Furthermore, a large number of clinical trials in oncology close early due to poor accrual. To identify opportunities for continued improvement in clinical trial enrollment, we sought to identify the obstacles encountered by our clinical trial research staff in these activities. Methods This is a prospective qualitative study, using Grounded Theory Methodology that was concluded at Stephenson Cancer Center (SCC). SCC has been the lead accruer to National Cancer Institute-Lead Academic Participating Sites (NCI-LAPS) trials over the past three years, and in addition, fields investigator-initiated and industry-sponsored trials. We conducted a survey of our research staff including all research nurses and disease site coordinators who participate in recruitment, screening, consenting, data collection, and compliance for interventional clinical trials. We then performed a follow-up meeting with our research coordinators to clarify responses. The study objectives were to highlight common barriers to recruiting adult cancer patients, encountered by research coordinators from all disease sites and to propose effective solutions to identified barriers. Results We are reporting our results of investigating barriers to clinical trials enrollment from a new perspective. The most commonly reported obstacles for clinical trials enrollment from our research staff's perspective were categorized into five themes: clinical trials protocol, communication barriers and cultural beliefs, financial barriers, patients' comorbidities and performance status, and physicians’ commitment. Conclusions Although assessing barriers encountered by clinical research staff is an infrequently used metric for improving clinical trial enrollment, it provides an important perspective in the field. Implementing interventions to improve clinical trial feasibility and accrual is critical to improving cancer care.
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Affiliation(s)
- Amany R Keruakous
- Hematology and Medical Oncology, Augusta University Medical College of Georgia, Augusta, USA.,Hematology and Medical Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Silas Day
- Hematology and Medical Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Kenny Garcia-Ramiu
- Hematology and Medical Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Melissa Yarbrough
- Hematology and Medical Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Adam S Asch
- Hematology and Medical Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
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10
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Recall of clinical trial participation and attrition rates in survivors of acute respiratory distress syndrome. J Crit Care 2021; 64:160-164. [PMID: 33906105 PMCID: PMC8222163 DOI: 10.1016/j.jcrc.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE To measure the rate of recall of study participation and study attrition in survivors of acute respiratory distress syndrome(ARDS). MATERIALS/METHODS In this ancillary study of the Re-evaluation of Systemic Early neuromuscular blockade(ROSE) trial, we measured the rate of study participation recall 3 months following discharge and subsequent study attrition at 6 months. We compared patient and hospital characteristics, and long-term outcomes by recall. As surrogate decision-makers provided initial consent, we measured the rate of patient reconsent and its association with study recall. RESULTS Of 487 patients evaluated, recall status was determined in 386(82.7%). Among these, 287(74.4%) patients recalled participation in the ROSE trial, while 99(25.6%) did not. There was no significant difference in 6-month attrition among patients who recalled study participation (9.1%) and those who did not (12.1%) (p = 0.38). Patient characteristics were similar between groups, except SOFA scores, ventilator-free days, and length of stay. 330(68%) were reconsented. Compared to those not reconsented, significantly more patients who were reconsented recalled study participation(78% vs. 66%;p = 0.01). CONCLUSIONS One in 4 ARDS survivors do not recall their participation in a clinical trial during hospitalization 3 months following hospital discharge, which did not influence 6-month attrition. However, more patients recall study participation if reconsent is obtained.
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11
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Jaffe K, Korthuis T, Richardson L. 'This could be my last chance': Therapeutic optimism in a randomised controlled trial for substance use disorders. SOCIOLOGY OF HEALTH & ILLNESS 2021; 43:1286-1300. [PMID: 34117637 DOI: 10.1111/1467-9566.13297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/21/2021] [Accepted: 04/26/2021] [Indexed: 06/12/2023]
Abstract
In randomised controlled trials (RCTs), 'therapeutic optimism' describes a participant's belief they will benefit from the study treatment, despite the express goal of RCTs to test unknown aspects of interventions. Harbouring such expectations may interfere with RCT participation experiences, particularly among marginalised populations, such as people with substance use disorders (PSUD) who may experience social and structural barriers to participation that also increase their vulnerability to therapeutic optimism. However, little research explores therapeutic optimism within substance use trials. Thus, we conducted a nested qualitative study within an RCT testing a treatment for alcohol and opioid use disorders in HIV clinics. Using interviews with 22 participants in Vancouver, Canada, analysis revealed themes relevant to therapeutic optimism, that were specifically linked to intrinsic (e.g. health-related) or extrinsic motivations (e.g. stipend). First, compared to extrinsically motivated participants, intrinsically motivated participants held high expectations for the trial and attributed greater agency to the study medication. Second, intrinsically motivated participants expressing therapeutic optimism anticipated marked changes in their lives from the study/medication. Finally, some participants predicted the treatment would solve substance-related issues in their communities. These findings highlight the interplay between therapeutic optimism and complex interpretations of RCT objectives among PSUD.
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Affiliation(s)
- Kaitlyn Jaffe
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Sociology, University of British Columbia, Vancouver, BC, Canada
| | - Todd Korthuis
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Lindsey Richardson
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Sociology, University of British Columbia, Vancouver, BC, Canada
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12
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O'Sullivan L, Crowley R, McAuliffe É, Doran P. Contributory factors to the evolution of the concept and practice of informed consent in clinical research: A narrative review. Contemp Clin Trials Commun 2020; 19:100634. [PMID: 33024880 PMCID: PMC7528065 DOI: 10.1016/j.conctc.2020.100634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/31/2020] [Accepted: 08/09/2020] [Indexed: 12/02/2022] Open
Abstract
Informed consent can be defined as a freely-given decision or agreement following disclosure of relevant information. This review explores how legislation surrounding informed consent has impacted upon clinical research practices, with a focus on clinical trials involving individuals with the capacity to give consent in the non-emergency setting. We also highlight the challenges which remain with the informed consent process, including those which exist in the era of data protection legislation and genetic research. Modern ethicists agree that informed consent encompasses three principal factors: disclosure of information, capacity for decision making, and voluntariness. In the context of clinical research, informed consent is now required by regulatory and ethical frameworks as well as by law, and various guidelines govern the practice of informed consent, including the Declaration of Helsinki and the Good Clinical Practice Guidelines. Historically, however, researchers acted paternalistically and included participants in research without their knowledge or consent. Following societal and political revolution, an autonomy model of consent became prevalent, and individuals became free to make individual choices about whether to participate. Despite this, it is also recognized that an individual's community has a role in supporting their decision making, and this may be a strong influence, particularly within some societies. Research scandals and controversies and whistle-blowers which exposed unethical practices in the area of informed consent also contributed to changes in societal attitudes and legislation changed as a result. Medical journals also have an established, although indirect, role in strengthening good practices surrounding informed consent.
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Affiliation(s)
- Lydia O'Sullivan
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Health Research Board-Trials Methodology Research Network, National University of Ireland, Galway, Ireland
- School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - Rachel Crowley
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Department of Endocrinology, Saint Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Éilish McAuliffe
- School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - Peter Doran
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Health Research Board-Trials Methodology Research Network, National University of Ireland, Galway, Ireland
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13
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Chapman N, McWhirter R, Armstrong MK, Fonseca R, Campbell JA, Nelson M, Schultz MG, Sharman JE. Self-directed multimedia process for delivering participant informed consent. BMJ Open 2020; 10:e036977. [PMID: 32713850 PMCID: PMC7383955 DOI: 10.1136/bmjopen-2020-036977] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Obtaining informed consent is a cornerstone requirement of conducting ethical research. Traditional paper-based consent is often excessively lengthy and may fail to achieve the desired participant understanding of study requirements. Multimedia tools including video and audio may be a useful alternative. This study aimed to determine the efficacy, usability and acceptability of self-directed multimedia delivery of participant consent. DESIGN It is a single-centre, randomised, prospective study to determine the efficacy, usability and acceptability of a self-directed multimedia consent process (intervention) compared with the traditional paper-based approach (control). The intervention was free of research staff, with computer-based finger-signed consent. SETTING Pathology blood collection services in Tasmania, Australia. PARTICIPANTS 298 participants (63±8 years; 51% female individuals) referred from general practice were randomised to intervention (n=146) and control (n=152). OUTCOME MEASURES Efficacy, usability and acceptability of the allocated consent process were assessed by a questionnaire. RESULTS All participants successfully completed the allocated interventions. Efficacy parameters were higher among intervention participants, including a better understanding of study requirements compared with controls (p<0.05 all). Intervention participants were more likely to engage with the study information and spend more time on the consent process (p=<0.001 and p=0.006, respectively). Both groups reported similar levels of acceptability, although more control participants reported that the study information was too long (24% vs 14%; p=0.020). CONCLUSION A self-directed multimedia consent process is effective for achieving participant understanding and obtaining consent free of research staff. Thus, multimedia represents a viable method to reduce the burden on researchers, meet participant needs and achieve informed consent in clinical research.
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Affiliation(s)
- Niamh Chapman
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Rebekah McWhirter
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Faculty of Law, Centre for Law and Genetics, University of Tasmania, Hobart, Tasmania, Australia
| | - Matthew K Armstrong
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Ricardo Fonseca
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Julie A Campbell
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Mark Nelson
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Martin G Schultz
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - James E Sharman
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
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14
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Barakat LP, Stevens E, Li Y, Reilly A, Deatrick JA, Goldstein NE, Schwartz LA. Evaluation of the Pediatric Research Participation Questionnaire for Measuring Attitudes Toward Cancer Clinical Trials Among Adolescents and Young Adults. J Adolesc Young Adult Oncol 2019; 8:423-433. [PMID: 31025898 PMCID: PMC8666797 DOI: 10.1089/jayao.2018.0144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose: Reasons for the relatively low rates of adolescent and young adults (AYA) enrollment in cancer clinical trials in the United States require further empirical examination. In addition to structural factors such as lack of access and insurance barriers, attitudes toward clinical trials may be important to consider. This study aimed to evaluate and validate the Pediatric Research Participation Questionnaire (PRPQ)-a measure of attitudes to clinical trials adapted for AYA (15-29) with cancer and their caregivers. Methods: One hundred twenty-four AYA and 94 caregivers completed the PRPQ-AYA and measures of clinical trial knowledge and developmental/emotional maturity. Factor analysis evaluated the PRPQ-AYA structure, interitem reliability was computed, and Pearson correlations examined associations of validation measures with factor scores and computed scores reflecting perceived barriers, perceived benefits, and decision balance. Results: Confirmatory factor analysis did not confirm the prior PRPQ factor structure. Exploratory factor analysis suggested a new four-factor structure for: AYA (1) trust/mistrust, (2) barriers/costs, (3) support for participation, and (4) incentives; and caregivers (1) trust/access, (2) mistrust/costs, (3) support for participation, and (4) risks to AYA. Factor scores and barriers, benefits, and decision balance scores demonstrated acceptable interitem reliability and were significantly correlated with clinical trial knowledge and emotional maturity in the expected direction. Conclusion: PRPQ-AYA factor structure for AYA and caregivers varied and should be interpreted cautiously due to limited power. Simple solutions of perceived benefits, perceived barriers, and decision balance were reliable and valid and provide important information to address and engage AYA through the clinical trial informed consent process.
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Affiliation(s)
- Lamia P. Barakat
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Evelyn Stevens
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yimei Li
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Anne Reilly
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Janet A. Deatrick
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | | | - Lisa A. Schwartz
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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15
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Minneci PC, Cooper JN, Leonhart K, Nacion K, Sulkowski J, Porter K, Wei L, Deans KJ. Effects of a Patient Activation Tool on Decision Making Between Surgery and Nonoperative Management for Pediatric Appendicitis: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e195009. [PMID: 31173118 PMCID: PMC6563561 DOI: 10.1001/jamanetworkopen.2019.5009] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/12/2019] [Indexed: 12/22/2022] Open
Abstract
Importance Strategies to activate and engage patients and caregivers in shared decision making in the acute care setting may result in improved outcomes. Objective To determine whether a patient activation tool (PAT) can improve decision-making and patient-centered outcomes among pediatric patients and their caregivers who choose between surgery and nonoperative management for their child's appendicitis. Design, Setting, and Participants This single-blind, randomized clinical trial collected data from a single tertiary children's hospital from March 1, 2014, through April 30, 2016, with 1-year follow-up completed on May 1, 2017. Two hundred of 236 eligible children and adolescents aged 7 to 17 years with uncomplicated appendicitis enrolled with their caregivers. After receiving the randomized clinical intervention, caregivers chose surgery or nonoperative management. Data were analyzed from March 1, 2014, through May 1, 2017. Interventions Randomization to a scripted standardized surgical consultation that emphasized patient choice or a scripted standardized surgical consultation plus the PAT (a tablet-based tool that presents each treatment, encourages participation in medical decision making, and aims at alleviating decisional uncertainty). Main Outcomes and Measures Decisional self-efficacy immediately after treatment decision, health care satisfaction at discharge, and disability days for the child at 1-year follow-up. Results Among 200 participants (median age, 12 years [interquartile range (IQR), 9-15 years]; 120 [60.0%] male), 98 were randomized to the PAT and 102 to the standardized consultation groups. The percentages choosing nonoperative management were similar (standardized consultation group, 42 of 102 [41.2%]; PAT group, 31 of 98 [31.6%]; P = .19). Immediate decisional self-efficacy was similar in the standardized consultation and PAT groups (median score, 100 [IQR, 97.7-100] vs 100 [IQR, 95.5-100]; P = .03), which was not significant at the planned significance level of P = .02. Total scores on health care satisfaction at discharge were similar (median, 99 [IQR, 94.7-100] vs 98 [IQR, 91.7-100]; P = .27). Disability days at 1-year follow-up were also similar (median, 6 [IQR, 2-11] vs 5 [IQR, 2-15]; P = .67). No difference in the failure rate of nonoperative management at 1 year (13 of 38 [34.2%] vs 11 of 30 [36.7%]; P > .99) or in the rate of complicated appendicitis 30 days after discharge (7 of 68 [10.3%] vs 9 of 71 [12.7%]; P = .79) occurred. Conclusions and Relevance In this study, a technology-based PAT did not improve measures of decision making for pediatric patients and caregivers needing to make an urgent treatment decision between surgery and nonoperative management for appendicitis. However, the overall high scores in both groups suggest that pediatric patients and caregivers can process information in the acute care setting and effectively participate in an informed shared decision-making process around the need for surgery. Trial Registration ClinicalTrials.gov identifier: NCT02110485.
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Affiliation(s)
- Peter C. Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Karen Leonhart
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Kristine Nacion
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Jason Sulkowski
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Kyle Porter
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus
| | - Lai Wei
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
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16
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Kaye DK, Chongwe G, Sewankambo NK. Ethical tensions in the informed consent process for randomized clinical trials in emergency obstetric and newborn care in low and middle-income countries. BMC Med Ethics 2019; 20:27. [PMID: 31029121 PMCID: PMC6486986 DOI: 10.1186/s12910-019-0363-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 04/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is unanimous agreement regarding the need to ethically conduct research for improving therapy for patients admitted to hospital with acute conditions, including in emergency obstetric care. We present a conceptual analysis of ethical tensions inherent in the informed consent process for randomized clinical trials for emergency obstetric care and suggest ways in which these could be mitigated. DISCUSSION A valid consenting process, leading to an informed consent, is a cornerstone of this aspect necessary for preservation and maintenance of respect for autonomy and dignity. In emergency obstetric care research, obtaining informed consent can be problematic, leading to ethical tension between different moral considerations. Potential participants may be vulnerable due to severity of disease, powerlessness or impaired decisional capacity. Time for the consent process is limited, and some interventions have a narrow therapeutic window. These factors create ethical tension in allowing potentially beneficial research while avoiding potential harms and maintaining respect for dignity, human rights, justice and autonomy of the participants. CONCLUSION Informed consent in emergency obstetric care in low- and middle-income countries poses numerous ethical challenges. Allowing research on vulnerable populations while maintaining respect for participant dignity and autonomy, protecting participants from potential harms and promoting justice underlie the ethical tensions in the research in emergency obstetric and newborn care. Those involved in research conduct or oversight have a duty of fair inclusion, to avoid denying participants the right to participate and to any potential research benefits.
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Affiliation(s)
- Dan K Kaye
- College of Health Sciences, Department of Obstetrics and Gynecology, Makerere University, P.O. Box 7072, Kampala, Uganda.
- Johns Hopkins University, Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, 21205, USA.
| | - Gershom Chongwe
- Johns Hopkins University, Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, 21205, USA
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, P.O. Box 50110, Lusaka, Zambia
| | - Nelson K Sewankambo
- College of Health Sciences, Department of Medicine, Makerere University, P.O. Box 7072, Kampala, Uganda
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17
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Nathe JM, Krakow EF. The Challenges of Informed Consent in High-Stakes, Randomized Oncology Trials: A Systematic Review. MDM Policy Pract 2019; 4:2381468319840322. [PMID: 30944886 PMCID: PMC6440043 DOI: 10.1177/2381468319840322] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 12/05/2018] [Indexed: 02/05/2023] Open
Abstract
Importance. Oncology trials often entail high-stakes interventions where potential for morbidity and fatal side effects, and for life-prolongation or cure, intensify bioethical issues surrounding informed consent. These challenges are compounded in multistage randomized trials, which are prevalent in oncology. Objective. We sought to elucidate the major barriers to informed consent in high-stakes oncology trials in general and the best consent practices for multistage randomized trials. Evidence Review. We queried PubMed for original studies published from January 1, 1990, to April 5, 2018, that focused on readability, quality, complexity or length of consent documents, motivation and sickness level of participants, or interventions and enhancements that influence informed consent for high-stakes oncologic interventions. Exclusion criteria included articles focused on populations outside industrialized countries, minors or other vulnerable populations, physician preferences, cancer screening and prevention, or recruitment strategies. Additional articles were identified through comprehensive bibliographic review. Findings. Twenty-seven articles were retained; 19 enrolled participants and 8 examined samples of consent documents. Methodologic quality was variable. This body of literature identified certain challenges that can be readily remedied. For example, the average length of the consent forms has increased 10-fold from 1987 to 2010, and patient understanding was shown to be inversely proportional to page count; shortening forms, or providing a concise summary as mandated by the revised Common Rule, might help. However, barriers to understanding that stem from deeply ingrained and flawed sociocultural perceptions of medical research seem more difficult to surmount. Although no studies specifically addressed problems posed by multiple sequential randomizations (such as change in risk-benefit ratio due to time-varying treatment responses or organ toxicities), the findings are likely applicable and especially relevant in that context. Concrete suggestions for improvement are proposed.
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18
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Gregersen TA, Birkelund R, Wolderslund M, Netsey‐Afedo ML, Steffensen KD, Ammentorp J. What matters in clinical trial decision‐making: a systematic review of interviews exploring cancer patients’ experiences. Scand J Caring Sci 2019; 33:266-278. [DOI: 10.1111/scs.12637] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 11/13/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Trine A. Gregersen
- Department of Oncology Lillebaelt Hospital Vejle Denmark
- Health Services Research Unit Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
| | - Regner Birkelund
- Health Services Research Unit Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
| | - Maiken Wolderslund
- Health Services Research Unit Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
| | - Mette Løwe Netsey‐Afedo
- Health Services Research Unit Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
- Urological Research Center Lillebaelt Hospital Vejle Denmark
| | - Karina Dahl Steffensen
- Department of Oncology Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
- Center for Shared Decision Making Lillebaelt Hospital Vejle Denmark
| | - Jette Ammentorp
- Health Services Research Unit Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
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Fisher A, Andreasson A, Chrysos A, Lally J, Mamasoula C, Exley C, Wilkinson J, Qian J, Watson G, Lewington O, Chadwick T, McColl E, Pearce M, Mann K, McMeekin N, Vale L, Tsui S, Yonan N, Simon A, Marczin N, Mascaro J, Dark J. An observational study of Donor Ex Vivo Lung Perfusion in UK lung transplantation: DEVELOP-UK. Health Technol Assess 2018; 20:1-276. [PMID: 27897967 DOI: 10.3310/hta20850] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Many patients awaiting lung transplantation die before a donor organ becomes available. Ex vivo lung perfusion (EVLP) allows initially unusable donor lungs to be assessed and reconditioned for clinical use. OBJECTIVE The objective of the Donor Ex Vivo Lung Perfusion in UK lung transplantation study was to evaluate the clinical effectiveness and cost-effectiveness of EVLP in increasing UK lung transplant activity. DESIGN A multicentre, unblinded, non-randomised, non-inferiority observational study to compare transplant outcomes between EVLP-assessed and standard donor lungs. SETTING Multicentre study involving all five UK officially designated NHS adult lung transplant centres. PARTICIPANTS Patients aged ≥ 18 years with advanced lung disease accepted onto the lung transplant waiting list. INTERVENTION The study intervention was EVLP assessment of donor lungs before determining suitability for transplantation. MAIN OUTCOME MEASURES The primary outcome measure was survival during the first 12 months following lung transplantation. Secondary outcome measures were patient-centred outcomes that are influenced by the effectiveness of lung transplantation and that contribute to the health-care costs. RESULTS Lungs from 53 donors unsuitable for standard transplant were assessed with EVLP, of which 18 (34%) were subsequently transplanted. A total of 184 participants received standard donor lungs. Owing to the early closure of the study, a non-inferiority analysis was not conducted. The Kaplan-Meier estimate of survival at 12 months was 0.67 [95% confidence interval (CI) 0.40 to 0.83] for the EVLP arm and 0.80 (95% CI 0.74 to 0.85) for the standard arm. The hazard ratio for overall 12-month survival in the EVLP arm relative to the standard arm was 1.96 (95% CI 0.83 to 4.67). Patients in the EVLP arm required ventilation for a longer period and stayed longer in an intensive therapy unit (ITU) than patients in the standard arm, but duration of overall hospital stay was similar in both groups. There was a higher rate of very early grade 3 primary graft dysfunction (PGD) in the EVLP arm, but rates of PGD did not differ between groups after 72 hours. The requirement for extracorporeal membrane oxygenation (ECMO) support was higher in the EVLP arm (7/18, 38.8%) than in the standard arm (6/184, 3.2%). There were no major differences in rates of chest radiograph abnormalities, infection, lung function or rejection by 12 months. The cost of EVLP transplants is approximately £35,000 higher than the cost of standard transplants, as a result of the cost of the EVLP procedure, and the increased ECMO use and ITU stay. Predictors of cost were quality of life on joining the waiting list, type of transplant and number of lungs transplanted. An exploratory model comparing a NHS lung transplant service that includes EVLP and standard lung transplants with one including only standard lung transplants resulted in an incremental cost-effectiveness ratio of £73,000. Interviews showed that patients had a good understanding of the need for, and the processes of, EVLP. If EVLP can increase the number of usable donor lungs and reduce waiting, it is likely to be acceptable to those waiting for lung transplantation. Study limitations include small numbers in the EVLP arm, limiting analysis to descriptive statistics and the EVLP protocol change during the study. CONCLUSIONS Overall, one-third of donor lungs subjected to EVLP were deemed suitable for transplant. Estimated survival over 12 months was lower than in the standard group, but the data were also consistent with no difference in survival between groups. Patients receiving these additional transplants experience a higher rate of early graft injury and need for unplanned ECMO support, at increased cost. The small number of participants in the EVLP arm because of early study termination limits the robustness of these conclusions. The reason for the increased PGD rates, high ECMO requirement and possible differences in lung injury between EVLP protocols needs evaluation. TRIAL REGISTRATION Current Controlled Trials ISRCTN44922411. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 85. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Andrew Fisher
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Anders Andreasson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Alexandros Chrysos
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Lally
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Jessica Qian
- Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Gillian Watson
- Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | - Thomas Chadwick
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.,Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Mark Pearce
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Kay Mann
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nicola McMeekin
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Tsui
- Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Nizar Yonan
- University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Andre Simon
- Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Nandor Marczin
- Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Jorge Mascaro
- Queen Elizabeth Hospital NHS Foundation Trust, Birmingham, UK
| | - John Dark
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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20
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Grootens-Wiegers P, Hein IM, van den Broek JM, de Vries MC. Medical decision-making in children and adolescents: developmental and neuroscientific aspects. BMC Pediatr 2017; 17:120. [PMID: 28482854 PMCID: PMC5422908 DOI: 10.1186/s12887-017-0869-x] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 04/22/2017] [Indexed: 12/16/2022] Open
Abstract
Background Various international laws and guidelines stress the importance of respecting the developing autonomy of children and involving minors in decision-making regarding treatment and research participation. However, no universal agreement exists as to at what age minors should be deemed decision-making competent. Minors of the same age may show different levels of maturity. In addition, patients deemed rational conversation-partners as a child can suddenly become noncompliant as an adolescent. Age, context and development all play a role in decision-making competence. In this article we adopt a perspective on competence that specifically focuses on the impact of brain development on the child’s decision-making process. Main body We believe that the discussion on decision-making competence of minors can greatly benefit from a multidisciplinary approach. We adopted such an approach in order to contribute to the understanding on how to deal with children in decision-making situations. Evidence emerging from neuroscience research concerning the developing brain structures in minors is combined with insights from various other fields, such as psychology, decision-making science and ethics. Four capacities have been described that are required for (medical) decision-making: (1) communicating a choice; (2) understanding; (3) reasoning; and (4) appreciation. Each capacity is related to a number of specific skills and abilities that need to be sufficiently developed to support the capacity. Based on this approach it can be concluded that at the age of 12 children can have the capacity to be decision-making competent. However, this age coincides with the onset of adolescence. Early development of the brain’s reward system combined with late development of the control system diminishes decision-making competence in adolescents in specific contexts. We conclude that even adolescents possessing capacities required for decision-making, may need support of facilitating environmental factors. Conclusion This paper intends to offer insight in neuroscientific mechanisms underlying the medical decision-making capacities in minors and to stimulate practices for optimal involvement of minors. Developing minors become increasingly capable of decision-making, but the neurobiological development in adolescence affects competence in specific contexts. Adequate support should be offered in order to create a context in which minors can make competently make decisions. Electronic supplementary material The online version of this article (doi:10.1186/s12887-017-0869-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Petronella Grootens-Wiegers
- Science Communication and Society, Leiden University, Leiden, The Netherlands. .,Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.
| | - Irma M Hein
- Child and Adolescent Psychiatry and de Bascule, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Jos M van den Broek
- Science Communication and Society, Leiden University, Leiden, The Netherlands.,Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands.,Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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21
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Grieselhuber NR, Kodner IJ, Brown D, Yu J. Confronting the therapeutic misconception. Surgery 2017; 162:183-187. [PMID: 29125122 DOI: 10.1016/j.surg.2017.01.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/17/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Nicole R Grieselhuber
- Division of Hematology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ira J Kodner
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Douglas Brown
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Jennifer Yu
- Department of Surgery, Washington University School of Medicine, St. Louis, MO.
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Schumacher A, Sikov WM, Quesenberry MI, Safran H, Khurshid H, Mitchell KM, Olszewski AJ. Informed consent in oncology clinical trials: A Brown University Oncology Research Group prospective cross-sectional pilot study. PLoS One 2017; 12:e0172957. [PMID: 28235011 PMCID: PMC5325585 DOI: 10.1371/journal.pone.0172957] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 02/13/2017] [Indexed: 11/18/2022] Open
Abstract
Background Informed consent forms (ICFs) for oncology clinical trials have grown increasingly longer and more complex. We evaluated objective understanding of critical components of informed consent among patients enrolling in contemporary trials of conventional or novel biologic/targeted therapies. Methods We evaluated ICFs for cancer clinical trials for length and readability, and patients registered on those studies were asked to complete a validated 14-question survey assessing their understanding of key characteristics of the trial. Mean scores were compared in groups defined by trial and patient characteristics. Results Fifty patients, of whom half participated in trials of immunotherapy or biologic/targeted agents and half in trials of conventional therapy, completed the survey. On average, ICFs for industry-originated trials (N = 9 trials) were significantly longer (P < .0001) and had lower Flesch ease-of-reading scores (P = .003) than investigator-initiated trials (N = 11). At least 80% of patients incorrectly responded to three key questions which addressed the experimental nature of their trial therapy, its purported efficacy and potential risks relative to alternative treatments. The mean objective understanding score was 76.9±8.8, but it was statistically significantly lower for patients who had not completed high school (P = .011). The scores did not differ significantly by type of cancer therapy (P = .12) or trial sponsor (P = .38). Conclusions Many participants enrolled on cancer trials had poor understanding of essential elements of their trial. In order to ensure true informed consent, innovative approaches, such as expanded in-person counseling adapted to the patient’s education level or cultural characteristics should be evaluated across socio-demographic groups. Trial registration Clinicaltrials.gov NCT01772511
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Affiliation(s)
- Andrew Schumacher
- The Brown University Oncology Research Group, Providence, Rhode Island, United States of America
| | - William M. Sikov
- The Brown University Oncology Research Group, Providence, Rhode Island, United States of America
| | - Matthew I. Quesenberry
- The Brown University Oncology Research Group, Providence, Rhode Island, United States of America
| | - Howard Safran
- The Brown University Oncology Research Group, Providence, Rhode Island, United States of America
| | - Humera Khurshid
- The Brown University Oncology Research Group, Providence, Rhode Island, United States of America
| | - Kristen M. Mitchell
- The Brown University Oncology Research Group, Providence, Rhode Island, United States of America
| | - Adam J. Olszewski
- The Brown University Oncology Research Group, Providence, Rhode Island, United States of America
- * E-mail:
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Abstract
Requests for observation experiences are common in the emergency department and other medical settings. There is little guidance in the literature or in professional societies' polices about who should be granted this privilege. This article reviews the ethical and legal issues that should be taken into account when one decides whether to allow observers in the medical setting. At the heart of the issue is patient privacy. This article recommends that institutions have policies in place that address these activities and suggests content for such policies.
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Affiliation(s)
- Joel M Geiderman
- Ruth and Harry Roman Emergency Department, Department of Emergency Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
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24
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Education Level, Primary Language, and Comprehension of the Informed Consent Process. J Empir Res Hum Res Ethics 2016; 2:69-79. [DOI: 10.1525/jer.2007.2.4.69] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To obtain information on how persons from diverse backgrounds experience the informed consent process, we surveyed adults with a wide variety of educational levels and different primary languages (English, Spanish, or Vietnamese) who had recently enrolled in a study requiring written informed consent. Of the 100 participants, 62 were non-White, 43 had less than a high school education, and 60 had a primary language other than English. The median score for comprehension was 62% (IQR 50–76%); the median satisfaction score was 86% (IQR 71–100%). In multivariate analysis, only educational level was significantly associated with comprehension and satisfaction with the informed consent process ( p < 0.001). Comprehension and satisfaction with the informed consent process were markedly lower among persons with lower educational levels.
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Thong IS, Foo MY, Sum MY, Capps B, Lee TS, Ho C, Sim K. Therapeutic Misconception in Psychiatry Research: A Systematic Review. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2016; 14:17-25. [PMID: 26792036 PMCID: PMC4730932 DOI: 10.9758/cpn.2016.14.1.17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 11/18/2022]
Abstract
Therapeutic misconception (TM) denotes the phenomenon in which research subjects conflate research purpose, protocols and procedures with clinical treatment. We examined the prevalence, contributory factors, clinical associations, impact, and collated solutions on TM within psychiatric research, and made suggestions going ahead. Literature search for relevant empirical research papers was conducted until February 2015. Eighty-eight reports were extracted, of which 31 were selected, summarised into different headings for discussion of implications and collated solutions of TM. We found variable and high rates of TM (ranging from 12.5% to 86%) in some psychiatry research populations. Contributory factors to TM included perceived medical roles of researchers, media, research setting and subject factors. Greater TM in affective, neurodevelopmental and psychotic spectrum conditions were associated with demographic variables (such as lower education, increased age), clinical factors (such as poor insight, cognitive deficits, increased symptoms, poorer self-rated quality of health), and social functioning (such as decreased independence). Inattention to TM may lead to frustration, negative impression and abandonment of participation in psychiatry research. Strategies such as the employment of a neutral educator during the informed consent process and education modules may be effective in addressing TM. Further research is warranted to examine the different TM facets, specific clinical correlates and more effective management strategies.
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Affiliation(s)
- Ivan Sk Thong
- The College of Arts and Sciences, University at Buffalo, Buffalo, New York, USA
| | - Meng Yee Foo
- The College of Arts and Sciences, University at Buffalo, Buffalo, New York, USA
| | - Min Yi Sum
- Research Division, Institute of Mental Health, Singapore, Singapore
| | - Benjamin Capps
- Department of Bioethics, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tih-Shih Lee
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Calvin Ho
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kang Sim
- Research Division, Institute of Mental Health, Singapore, Singapore.,Department of General Psychiatry, Institute of Mental Health, Singapore, Singapore
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Becnel LB, Pereira S, Drummond JA, Gingras MC, Covington KR, Kovar CL, Doddapaneni HV, Hu J, Muzny D, McGuire AL, Wheeler DA, Gibbs RA. An open access pilot freely sharing cancer genomic data from participants in Texas. Sci Data 2016; 3:160010. [PMID: 26882539 PMCID: PMC4755126 DOI: 10.1038/sdata.2016.10] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/15/2016] [Indexed: 12/22/2022] Open
Abstract
Genomic data sharing in cancer has been restricted to aggregate or controlled-access initiatives to protect the privacy of research participants. By limiting access to these data, it has been argued that the autonomy of individuals who decide to participate in data sharing efforts has been superseded and the utility of the data as research and educational tools reduced. In a pilot Open Access (OA) project from the CPRIT-funded Texas Cancer Research Biobank, many Texas cancer patients were willing to openly share genomic data from tumor and normal matched pair specimens. For the first time, genetic data from 7 human cancer cases with matched normal are freely available without requirement for data use agreements nor any major restriction except that end users cannot attempt to re-identify the participants (http://txcrb.org/open.html).
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Affiliation(s)
- Lauren B Becnel
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Stacey Pereira
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Jennifer A Drummond
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Marie-Claude Gingras
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Kyle R Covington
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Christie L Kovar
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas 77030, USA
| | | | - Jianhong Hu
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Donna Muzny
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas 77030, USA
| | - David A Wheeler
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Richard A Gibbs
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas 77030, USA
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Wall L, Farmer ZL, Webb MW, Dixon MD, Nooka A, Pentz RD. Description of the types and content of phase 1 clinical trial consent conversations in practice. Clin Trials 2015; 12:567-74. [PMID: 26319116 DOI: 10.1177/1740774515601679] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND OR AIMS All agree that informed consent is a process, but past research has focused content analyses on post-consent or on one conversation in the consent series. Our aim was to identify and describe the content of different types of consent conversations. METHODS We conducted a secondary analysis of 38 adult oncology phase 1 consent conversations, which were audio-recorded, transcribed, coded, and qualitatively analyzed for type and content. RESULTS Four types of consent conversations were identified: (1) priming, (2) patient-centered options, (3) trial centered, and (4) decision made. The analysis provided a robust description of the content discussed in each type of conversation. Two themes, supportive care and prognosis, were rarely mentioned. Four themes clustered in the patient-centered (type 2) conversations: affirmation of honesty, comfort, progression, and offer of supportive care. CONCLUSION We identified and described four types of consent conversations. Our novel findings include (1) four different types of conversations with one (priming) not mentioned before and (2) a change of focus from describing the content of one phase 1 consent conversation to describing the content of different types. These in-depth descriptions provide the foundation for future research to determine whether the four types of conversations occur in sequence, thus describing the structure of the consent process and providing the basis for coaching interventions to alert physicians to the appropriate content for each type of conversation. A switch from a focus on one conversation to the types of conversations in the process may better align the consent conversations with the iterative process of shared decision making.
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Affiliation(s)
- Louisa Wall
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | | | - Ajay Nooka
- Emory University School of Medicine, Atlanta, GA, USA
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Lux MP, Hildebrandt T, Knetzger SM, Schrauder MG, Jud SM, Hein A, Rauh C, Fasching PA, Beckmann MW, Thiel FC. Knowledge and attitudes regarding medical research studies among patients with breast cancer and gynecological diseases. BMC Cancer 2015; 15:587. [PMID: 26272451 PMCID: PMC4535277 DOI: 10.1186/s12885-015-1584-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 07/27/2015] [Indexed: 11/10/2022] Open
Abstract
Background Medical research studies are becoming increasingly important for optimizing the prevention, diagnosis and treatment of illnesses. Participation in research studies can have many benefits for patients. In randomized and controlled clinical studies, they can receive the best possible medical care currently available. However, only a small proportion of patients nowadays are treated within the framework of medical research. The primary endpoint of this study was to discover what level of knowledge patients have about clinical studies and how they currently perceive them, in order to identify ways of optimizing the information provided about studies from the patients’ point of view. Methods The study included 2546 patients (breast cancer 21.6 %, gynecological cancer 8.3 %, obstetrics 32.7 %, endometriosis 7.8 %, fertility treatment 3.2 %, other benign gynecological illnesses 19.2 %, no information for 7.2 %) in the outpatient clinic (45.2 %) and in the in-patient sector (54.8 %) at the Department of Gynecology at Erlangen University Hospital and associated centers. In the single-center study, conducted between January 2011 and January 2012, the patients were asked about their level of knowledge regarding the background to medical research studies and the ways in which they are carried out and used. The patients were also asked how they perceived medical studies and how they thought study conditions might be optimized. The three-page questionnaire was included in the feedback sheet received by patients as part of the hospital’s quality management system. Results As a whole, the group only had moderate knowledge about clinical studies. A majority of the respondents considered that studies were valuable (91.6 %), but only a few were also willing to take part in them (58.4 %). Knowledge and willingness to participate strongly depended on age (P < 0.001), educational level (P < 0.001) and patient group (P < 0.001). Most patients would prefer to decide about participating in studies through a discussion with their outpatient physicians. Conclusions The information that patients have about clinical studies affects whether they participate in them. It is therefore extremely important for patients to be well informed, for their anxieties about participation to be relieved, and for the benefits of participation to be explained to them.
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Affiliation(s)
- Michael P Lux
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Thomas Hildebrandt
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Sandra-Maria Knetzger
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Michael G Schrauder
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Sebastian M Jud
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Alexander Hein
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Claudia Rauh
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Peter A Fasching
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Matthias W Beckmann
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Falk C Thiel
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich Alexander University, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
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Cleret de Langavant L, Sudraud S, Verny C, Krystkowiak P, Simonin C, Damier P, Demonet JF, Supiot F, Rialland A, Schmitz D, Maison P, Youssov K, Bachoud-Lévi AC. Longitudinal study of informed consent in innovative therapy research: experience and provisional recommendations from a multicenter trial of intracerebral grafting. PLoS One 2015; 10:e0128209. [PMID: 26010368 PMCID: PMC4444138 DOI: 10.1371/journal.pone.0128209] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/23/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is an urgent need to assess and improve the consent process in clinical trials of innovative therapies for neurodegenerative disorders. METHODS We performed a longitudinal study of the consent of Huntington's disease patients during the Multicenter Fetal Cell Intracerebral Grafting Trial in Huntington's Disease (MIG-HD) in France and Belgium. Patients and their proxies completed a consent questionnaire at inclusion, before signing the consent form and after one year of follow-up, before randomization and transplantation. The questionnaire explored understanding of the protocol, satisfaction with the information delivered, reasons for participating in the trial and expectations regarding the transplant. Forty-six Huntington's disease patients and 27 proxies completed the questionnaire at inclusion, and 27 Huntington's disease patients and 16 proxies one year later. RESULTS The comprehension score was high and similar for Huntington's disease patients and proxies at inclusion (72.6% vs 77.8%; P > 0.1) but only decreased in HD patients after one year. The information satisfaction score was high (73.5% vs 66.5%; P > 0.1) and correlated with understanding in both patients and proxies. The motivation and expectation profiles were similar in patients and proxies and remained unchanged after one year. CONCLUSIONS Cognitively impaired patients with Huntington's disease were capable of consenting to participation in this trial. This consent procedure has presumably strengthened their understanding and should be proposed before signing the consent form in future gene or cell therapy trials for neurodegenerative disorders. Because of the potential cognitive decline, proxies should be designated as provisional surrogate decision-makers, even in competent patients.
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Affiliation(s)
- Laurent Cleret de Langavant
- AP-HP, Hôpital Henri Mondor, Centre de Référence—Maladie de Huntington, Neurologie cognitive, Créteil, France
- Université Paris Est, Faculté de médecine, Créteil, France
- INSERM U955, Equipe 01, Neuropsychologie Interventionnelle, Créteil, France
- Département d’Etudes Cognitives, Ecole Normale Supérieure, PSL Research University, Paris, France
| | - Sophie Sudraud
- AP-HP, Hôpital Henri Mondor, Centre de Référence—Maladie de Huntington, Neurologie cognitive, Créteil, France
- Université Paris Est, Faculté de médecine, Créteil, France
- INSERM U955, Equipe 01, Neuropsychologie Interventionnelle, Créteil, France
| | - Christophe Verny
- CHU d'Angers, Centre de Référence des Maladies Neurogénétiques, service de neurologie, Angers, France
- UMR CNRS 6214 INSERM U1083, CHU d'Angers, Angers, France
| | - Pierre Krystkowiak
- CHU d’Amiens, service de neurologie, Amiens, France
- EA 4559, Laboratoire de Neurosciences Fonctionnelles et Pathologies, Université de Picardie Jules Verne, Amiens, France
| | - Clémence Simonin
- Université Lille Nord de France, Lille, France
- INSERM UMR837, Institut de Recherches sur le Cancer de Lille (IRCL), Lille, France
- CHRU Lille, Département de Neurologie et des Mouvements Anormaux, Lille, France
| | - Philippe Damier
- CHU Nantes, Service de Neurologie, Nantes, France
- UFR Médecine, Université de Nantes, Nantes, France
| | - Jean-François Demonet
- Leenaards Memory Centre, Clinical Neuroscience Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- INSERM U825, Université de Toulouse, Toulouse, France
| | - Frédéric Supiot
- Cliniques Universitaires de Bruxelles Hôpital Erasme, Bruxelles, Belgique
| | - Amandine Rialland
- AP-HP, Hôpital Henri Mondor, Unité de Recherche Clinique, Creteil, France
| | - David Schmitz
- AP-HP, Hôpital Henri Mondor, Unité de Recherche Clinique, Creteil, France
| | - Patrick Maison
- AP-HP, Hôpital Henri Mondor, Unité de Recherche Clinique, Creteil, France
| | - Katia Youssov
- AP-HP, Hôpital Henri Mondor, Centre de Référence—Maladie de Huntington, Neurologie cognitive, Créteil, France
- Université Paris Est, Faculté de médecine, Créteil, France
- INSERM U955, Equipe 01, Neuropsychologie Interventionnelle, Créteil, France
- Département d’Etudes Cognitives, Ecole Normale Supérieure, PSL Research University, Paris, France
| | - Anne-Catherine Bachoud-Lévi
- AP-HP, Hôpital Henri Mondor, Centre de Référence—Maladie de Huntington, Neurologie cognitive, Créteil, France
- Université Paris Est, Faculté de médecine, Créteil, France
- INSERM U955, Equipe 01, Neuropsychologie Interventionnelle, Créteil, France
- Département d’Etudes Cognitives, Ecole Normale Supérieure, PSL Research University, Paris, France
- * E-mail:
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Tam NT, Huy NT, Thoa LTB, Long NP, Trang NTH, Hirayama K, Karbwang J. Participants' understanding of informed consent in clinical trials over three decades: systematic review and meta-analysis. Bull World Health Organ 2015; 93:186-98H. [PMID: 25883410 PMCID: PMC4371493 DOI: 10.2471/blt.14.141390] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 10/29/2014] [Accepted: 11/26/2014] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To estimate the proportion of participants in clinical trials who understand different components of informed consent. METHODS Relevant studies were identified by a systematic review of PubMed, Scopus and Google Scholar and by manually reviewing reference lists for publications up to October 2013. A meta-analysis of study results was performed using a random-effects model to take account of heterogeneity. FINDINGS The analysis included 103 studies evaluating 135 cohorts of participants. The pooled proportion of participants who understood components of informed consent was 75.8% for freedom to withdraw at any time, 74.7% for the nature of study, 74.7% for the voluntary nature of participation, 74.0% for potential benefits, 69.6% for the study's purpose, 67.0% for potential risks and side-effects, 66.2% for confidentiality, 64.1% for the availability of alternative treatment if withdrawn, 62.9% for knowing that treatments were being compared, 53.3% for placebo and 52.1% for randomization. Most participants, 62.4%, had no therapeutic misconceptions and 54.9% could name at least one risk. Subgroup and meta-regression analyses identified covariates, such as age, educational level, critical illness, the study phase and location, that significantly affected understanding and indicated that the proportion of participants who understood informed consent had not increased over 30 years. CONCLUSION The proportion of participants in clinical trials who understood different components of informed consent varied from 52.1% to 75.8%. Investigators could do more to help participants achieve a complete understanding.
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Affiliation(s)
- Nguyen Thanh Tam
- Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | - Nguyen Tien Huy
- Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Le Thi Bich Thoa
- Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | - Nguyen Phuoc Long
- Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | | | - Kenji Hirayama
- Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Nagasaki, Japan
| | - Juntra Karbwang
- Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
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Kass NE, Taylor HA, Ali J, Hallez K, Chaisson L. A pilot study of simple interventions to improve informed consent in clinical research: feasibility, approach, and results. Clin Trials 2014; 12:54-66. [PMID: 25475879 DOI: 10.1177/1740774514560831] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Research suggests that participants do not always adequately understand studies. While some consent interventions increase understanding, methodologic challenges have been raised in studying consent outside of actual trial settings. This study examined the feasibility of testing two consent interventions in actual studies and measured effectiveness of interventions in improving understanding. METHODS Participants enrolling in any of eight ongoing clinical trials were sequentially assigned to one of three different informed consent strategies for enrollment in their clinical trial. Control participants received standard consent procedures for their trial. Participants in the first intervention arm received a bulleted fact sheet summarizing key study information. Participants in the second intervention arm received the bulleted fact sheet and also engaged in a feedback Q&A session. Later, patients answered closed- and open-ended questions to assess patient understanding and literacy. Descriptive statistics, Wilcoxon -Mann -Whitney and Kruskal-Wallis tests were generated to assess correlations; regression analysis determined predictors of understanding. RESULTS 144 participants enrolled. Using regression analysis, participants receiving the second intervention scored 7.6 percentage points higher (p = .02) on open-ended questions about understanding than participants in the control, although unadjusted comparisons did not reach statistical significance. CONCLUSIONS Our study supports the hypothesis that patients receiving both bulleted fact sheets and a Q&A session had higher understanding compared to standard consent. Fact sheets and short structured dialog are quick to administer and easy to replicate across studies and should be tested in larger samples.
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Affiliation(s)
- Nancy E Kass
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Holly A Taylor
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Joseph Ali
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
| | - Kristina Hallez
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
| | - Lelia Chaisson
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
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Colli A, Pagliaro L, Duca P. The ethical problem of randomization. Intern Emerg Med 2014; 9:799-804. [PMID: 25194693 DOI: 10.1007/s11739-014-1118-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/12/2014] [Indexed: 01/06/2023]
Abstract
The Fondazione Umberto Veronesi ethics committee recently published a statement concerning the inherent ethical issues of randomized clinical trials (RCTs), mainly focusing on randomization, raising many questions, and suggesting possible solutions. The main concern is that the patients enrolled in a RCT are used to improve medical knowledge, but they cannot be the beneficiaries of the results of the trials in which they are participating. Possible solutions come from a wider use of clinical and administrative databases, and an early termination of trials. We discuss this statement, emphasizing that the scientific and ethical reason for embarking on a clinical trial is uncertainty. The uncertainty regarding the comparative benefits and harms of each compared treatment (clinical equipoise) warrants equity in allocation. Randomization allows one to obtain unbiased evidence that we cannot know in advance. The expected probability of a new treatment to be successful describes the limits within which a study can be acceptable both from an ethical as well as a scientific point of view. Most people accept enrollment in a RCT if the probability of success of the experimental treatment is between 50 and 70%. The assumption and concern that there is a conflict between "scientific" and "ethical" aspects of a clinical trial due to randomization should at least be mitigated, considering that only scientifically sounded studies can be considered ethical. Randomization remains the appropriate approach to ensure the study's internal validity. Different aspects seem to be more important, from the ethical point of view, considering RCT and their publication.
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Affiliation(s)
- Agostino Colli
- Medical Department, Ospedale A Manzoni AO Provincia di Lecco, Via Eremo 9/11, 23900, Lecco, Italy,
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Niemansburg SL, Teraa M, Hesam H, van Delden JJM, Verhaar MC, Bredenoord AL. Stem cell trials for cardiovascular medicine: ethical rationale. Tissue Eng Part A 2014; 20:2567-74. [PMID: 24164351 PMCID: PMC4195508 DOI: 10.1089/ten.tea.2013.0332] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 10/24/2013] [Indexed: 12/29/2022] Open
Abstract
Stem cell-based interventions provide new treatment prospects for many disease conditions, including cardiovascular disorders. Clinical trials are necessary to collect adequate evidence on (long-term) safety and efficacy of novel interventions such as stem cells, but the design and launch of clinical trials, from first-in-human studies to larger randomized controlled trials (RCTs), is scientifically and ethically challenging. Stem cells are different from traditional pharmaceuticals, surgical procedures, and medical devices in the following ways: the novelty and complexity of stem cells, the invasiveness of the procedures, and the novel aim of regeneration. These specifics, combined with the characteristics of the study population, will have an impact on the design and ethics of RCTs. The recently closed JUVENTAS trial will serve as an example to identify the (interwoven) scientific and ethical challenges in the design and launch of stem cell RCTs. The JUVENTAS trial has investigated the efficacy of autologous bone marrow cells in end-stage vascular patients, in a double-blind sham-controlled design. We first describe the choices, considerations, and experiences of the JUVENTAS team. Subsequently, we identify the main ethical and scientific challenges and discuss what is important to consider in the design of future stem cell RCTs: assessment of risks and benefits, the choice for outcome measures, the choice for the comparator, the appropriate selection of participants, and adequate informed consent. Additionally, the stem cell field is highly in the spotlight due to the (commercial) interests and expectations. This warrants a cautious pace of translation and scrupulous set up of clinical trials, as failures could put the field in a negative light. At the same time, knowledge from clinical trials is necessary for the field to progress. We conclude that in the scientifically and ethically challenging field of stem cell RCTs, researchers and clinicians have to maneuver between the Skylla of hyper accelerated translation without rigorously conducted RCTs and the Charybdis of the missed opportunity of valuable knowledge.
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Affiliation(s)
- Sophie L Niemansburg
- 1 Department of Medical Humanities, Julius Center, University Medical Center Utercht , The Netherlands
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Abstract
The Orphan Drug Act seeks to meet a utilitarian goal of advancing therapeutic options for patients with rare diseases. However, data show that orphan drugs are often approved with more limited premarket testing than that carried out for nonorphan drugs and consequently expose patients to more risk and less certain efficacy. Therefore, the ethical principles of justice and beneficence may require attention to informed consent among patients receiving the drugs and greater investment in postmarket surveillance and confirmational testing.
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Groves MD, Plummer AB. Helping patients make the best decision regarding duration of temozolomide chemotherapy treatment. Continuum (Minneap Minn) 2012; 18:421-5. [PMID: 22810137 DOI: 10.1212/01.con.0000413668.65668.4a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Outcomes for patients with glioblastoma have improved with the addition of temozolomide (TMZ) chemotherapy to radiation therapy followed by adjuvant TMZ for up to 1 year. Patients often wish to continue chemotherapy after the standard 1-year course. Whether to continue or to stop TMZ is a complex and stressful decision for the patient and family, and the decision should be based on a discussion of the known risks and benefits of each choice.
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Flamm AL, Pentz RD. Communicating about phase I trials: objective disclosures are only a first step. Oncologist 2012; 17:466-8. [PMID: 22491003 DOI: 10.1634/theoncologist.2012-0107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Pentz RD, White M, Harvey RD, Farmer ZL, Liu Y, Lewis C, Dashevskaya O, Owonikoko T, Khuri FR. Therapeutic misconception, misestimation, and optimism in participants enrolled in phase 1 trials. Cancer 2012; 118:4571-8. [PMID: 22294385 DOI: 10.1002/cncr.27397] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 11/16/2011] [Accepted: 12/01/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Ethical concerns about phase 1 trials persist. Important conceptual advances have been made in understanding concepts used to describe misunderstanding. However, a systematic, empirical evaluation of the frequency of misunderstanding incorporating recent developments is lacking. METHODS The authors queried 95 participants in phase 1 trials to provide a more sophisticated estimate of the proportion who had therapeutic misconception (TM), defined as misunderstanding the research purpose or how research differs from individualized care, and therapeutic misestimation (TMis), defined as incorrectly estimating the chance of a research trial benefit as >20% or underestimating risk as 0%. RESULTS Sixty-five of 95 respondents (68.4%) had TM, which was associated in a multivariate analysis with lower education and family income (P = .008 and P = .001, respectively), but TM was not associated with the vulnerability of having hardly any treatment options. Eighty-nine of 95 respondents (94%) had TMis, although only 18% reported this was a factual estimate. Although the risks of investigational agents and those exacerbated by research, such as uncertain outcomes, were mentioned (39% and 41% of respondents, respectively), risks novel to research, such as research biopsies, were rarely mentioned (3% of respondents). Although most of these respondents believed that their chance of benefit was greater and that their risk was lower than the population chance (optimists) (54.6%), a substantial minority of respondents (37.6%) were pessimists. CONCLUSIONS TM continues to be prevalent. Estimates of personal benefit were not usually meant to report facts, it remains unknown whether respondents in the current study had TMis. Although they are not more vulnerable, phase 1 participants need improved understanding of key TM concepts, with attention to risks that are not present in standard of care.
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Affiliation(s)
- Rebecca D Pentz
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA.
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Gupta UC, Kharawala S. Informed consent in psychiatry clinical research: A conceptual review of issues, challenges, and recommendations. Perspect Clin Res 2012; 3:8-15. [PMID: 22347696 PMCID: PMC3275995 DOI: 10.4103/2229-3485.92301] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Obtaining informed consent in psychiatry clinical research involving subjects with diminished mental abilities and impaired consent capacity has been a challenge for researchers, posing many ethical concerns and procedural hurdles due to participants' cognitive deficits and impaired ability to judge reality. Regulations seem inadequate and provide limited guidance, not sufficient to address all the ethical issues inherent in different situations related to obtaining consent from decisionally impaired persons. Researchers are struggling to find a balance between risk-benefit ratio, research advancement, and autonomy of study subjects. Inspired to improve the consent process in psychiatry clinical research, many studies have been conducted focusing on various informed consent-related ethical concerns, with the aim of developing appropriate strategies and optimizing the informed consent procedure in psychiatry clinical research, overcoming the ethical concerns. This article critically reviews the various ethical issues and consent challenges, their underlying reasons, and investigates the appropriate strategies and practices needed to be adopted while obtaining informed consent from subjects with impaired consent capacity, participating in psychiatry clinical research.
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Affiliation(s)
- Umesh Chandra Gupta
- Sr. Research Scientist, Medical Affairs and Clinical Research, Fresenius Kabi India Pvt. Ltd., Gurgaon, India
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Schmidt RJ. Informing our elders about dialysis: is an age-attuned approach warranted? Clin J Am Soc Nephrol 2011; 7:185-91. [PMID: 22173860 DOI: 10.2215/cjn.10401011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
As the fastest growing sector of the incident ESRD population, older patients constitute a group for which renal replacement therapy has special implications. Older CKD patients have unique needs by virtue of advanced age, high prevalence of comorbid conditions, slower progression of renal disease, and reduced survival. Burdens and risks attendant to dialysis may be amplified in the older patient and patients with impaired functional status or comorbid conditions, and therefore, dialysis may confer little to no survival benefit. Rates of dialysis withdrawal are highest among the oldest patients, raising the possibility that the standard content of informed consent for dialysis warrants an age-sensitive approach that is attuned to the very different balance of pros and cons of dialysis for older patients with multiple comorbidities and younger patients with limited comorbidity. Informed consent for older patients should include presentation of risks, benefits, and burdens associated with dialysis, age-specific estimates of prognosis with and without dialysis, and potential for loss of independence and decline in functional status with initiation of dialysis. In this article, medical evidence and clinical practice guidelines relevant to advance care planning for the older patient with CKD are reviewed, issues to consider in the dialogue with older patients contemplating dialysis are presented, and recommendations for an age-attuned approach to informed consent for older CKD patients are made.
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Affiliation(s)
- Rebecca J Schmidt
- Section of Nephrology, West Virginia University School of Medicine, 1 Medical Center Drive, Box 9165, Morgantown, WV 26506, USA.
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41
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Truong TH, Weeks JC, Cook EF, Joffe S. Outcomes of informed consent among parents of children in cancer clinical trials. Pediatr Blood Cancer 2011; 57:998-1004. [PMID: 21280199 DOI: 10.1002/pbc.22983] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Accepted: 11/23/2010] [Indexed: 11/05/2022]
Abstract
BACKGROUND Clinical trials are central to pediatric oncology, yet the process and outcomes of informed consent are poorly understood. We evaluated correlates of understanding among parents of pediatric trial participants, and explored differences in the process and outcome of informed consent between parents and a comparison group of adult participants. PROCEDURE We administered the Quality of Informed Consent (QuIC) to parents of children who were newly enrolled onto a cancer trial. We identified independent correlates of knowledge among parents, and compared parents' knowledge to that of a contemporaneous group of adult participants, using multiple linear regression models. RESULTS Parents (n = 47) were less likely than adult participants (n = 204) to report having enough time to learn about the trial (64% vs. 87%, P = 0.001) or sufficient opportunity for questions (79% vs. 93%, P = 0.01), and reported lower overall satisfaction with the consent process (71% vs. 90%, P = 0.002). The mean parental knowledge score was 73.6 (95% confidence interval [CI] 69.5-77.8, theoretical maximum 100). Knowledge did not differ between parents and adult trial participants. In multivariate analysis, two predictors were significantly associated with higher parent knowledge scores: consent sought by the study's principal investigator (increment 13.6, CI 2.7-24.6) and physician-reported poor prognosis (increment 13.8, 95% CI 5.4-22.1). CONCLUSIONS Although we observed no differences in knowledge between parents of pediatric cancer trial participants and their adult counterparts, parents report more problems with the informed consent process for their trials. The increased prevalence of problems is likely due to clinical and contextual differences between pediatric and adult trials.
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Affiliation(s)
- Tony H Truong
- Division of Haematology/Oncology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Valadas A, Coelho M, Mestre T, Guedes LC, Finisterra M, Noronha A, Rosa MM, Sampaio C, Ferreira JJ. What motivates Parkinson’s disease patients to enter clinical trials? Parkinsonism Relat Disord 2011; 17:667-71. [PMID: 21715213 DOI: 10.1016/j.parkreldis.2011.05.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 05/23/2011] [Accepted: 05/30/2011] [Indexed: 11/25/2022]
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Tait RC, Chibnall JT, Iltis A, Wall A, Deshields TL. Assessment of consent capability in psychiatric and medical studies. J Empir Res Hum Res Ethics 2011; 6:39-50. [PMID: 21460586 DOI: 10.1525/jer.2011.6.1.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In order to evaluate psychiatric factors that potentially influence assessment of consent capacity, 195 IRB members read summaries of hypothetical medical (cancer vs. neuropathic pain) and psychiatric trials. They then rated research participants' capacity for consent (capable or not capable), autonomy, and decisional abilities, as well as the legal risk to the institution of the study. Levels of depression information varied across the medical disorders. Significantly fewer IRB members judged participants in the depression trial to possess adequate capacity for consent relative to 4 of 6 medical conditions; legal risk to the institution also was rated higher in the psychiatric study. While IRB members judged participants in depression trials to have less capacity for consent and to pose higher levels of institutional risk than medical trial participants, the addition of increasing information regarding depressive co-morbidities had little or no effect on judgments of medical studies. Implications are discussed relative to the apparent overprotection of participants in psychiatric trials and underprotection of those in medical trials.
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Affiliation(s)
- Raymond C Tait
- Department of Neurology & Psychiatry, Saint Louis University School of Medecine, St Louis, MO 63104, USA.
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Goldberg DS. Eschewing definitions of the therapeutic misconception: a family resemblance analysis. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2011; 36:296-320. [PMID: 21606116 DOI: 10.1093/jmp/jhr014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Twenty-five years after the term "therapeutic misconception' (TM) first entered the literature, most commentators agree that it remains widespread. However, the majority of scholarly attention has focused on the reasons why a patient cum human subject might confuse the goals of research with the goals of therapy. Although this paper addresses the social and cultural factors that seem to animate the TM among subjects, it also fills a niche in the literature by examining why investigators too might operate under a similar confusion. In framing these issues, the paper expressly adopts a Wittgensteinian approach to evaluating the TM, suggesting that interlocutors do not need any analytic definition of the TM to use the term meaningfully in thinking about the moral implications of the TM in practice.
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Affiliation(s)
- Daniel S Goldberg
- Department of Bioethics and Interdisciplinary Studies, The Brody School of Medicine, East Carolina University, Greenville, NC 27858, USA.
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BEADLE G, MENGERSEN K, MOYNIHAN S, YATES P. Perceptions of the ethical conduct of cancer trials by oncology nurses. Eur J Cancer Care (Engl) 2011; 20:585-92. [DOI: 10.1111/j.1365-2354.2011.01251.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Silverman H. Protecting vulnerable research subjects in critical care trials: enhancing the informed consent process and recommendations for safeguards. Ann Intensive Care 2011; 1:8. [PMID: 21906335 PMCID: PMC3224458 DOI: 10.1186/2110-5820-1-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 04/13/2011] [Indexed: 11/24/2022] Open
Abstract
Although critically ill patients represent a vulnerable group of individuals, guidelines in research ethics assert that ethically acceptable research may proceed with such vulnerable subjects if additional safeguards are in place to minimize the risk of harm and exploitation. Such safeguards include the proper obtainment of informed consent that avoids the presence of the therapeutic misconception and the assessment of decisional capacity in critically ill patients recruited for research. Also discussed in this review are additional safeguards for such vulnerable subjects, as well as the issues involved with proxy consent. Heightened awareness to principles of ethics and provision of additional safeguards to enhance protections of vulnerable subjects would help to maintain the public trust in the research endeavor.
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Affiliation(s)
- Henry Silverman
- University of Maryland School of Medicine, 110 South Paca Street; 2nd floor, Baltimore, Maryland, USA 21201, USA.
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Competing for patients: an ethical framework for recruiting patients with brain tumors into clinical trials. J Neurooncol 2011; 104:623-7. [DOI: 10.1007/s11060-011-0536-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Accepted: 01/31/2011] [Indexed: 11/26/2022]
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Horner J, Minifie FD. Research ethics I: Responsible conduct of research (RCR)--historical and contemporary issues pertaining to human and animal experimentation. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2011; 54:S303-S329. [PMID: 21081677 DOI: 10.1044/1092-4388(2010/09-0265)] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
PURPOSE In this series of articles--Research Ethics I, Research Ethics II, and Research Ethics III--the authors provide a comprehensive review of the 9 core domains for the responsible conduct of research (RCR) as articulated by the Office of Research Integrity. In Research Ethics I, they present a historical overview of the evolution of RCR in the United States then examine the evolution of human and animal experimentation from the birth of scientific medicine through World War II to the present day. METHOD They relied on authoritative documents, both historical and contemporary, insightful commentary, and empirical research in order to identify current issues and controversies of potential interest to both faculty and students. CONCLUSIONS The authors have written this article from a historical perspective because they think all readers interested in RCR should appreciate how the history of science and all the good--and harm--it has produced can inform how researchers practice responsible research in the 21st century and beyond.
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Affiliation(s)
- Jennifer Horner
- College of Health Sciences and Professions, Ohio University, W380 Grover Center, Athens, OH 45701, USA.
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Agoritsas T, Perneger TV. Patient-reported conformity of informed consent procedures and participation in clinical research. QJM 2011; 104:151-9. [PMID: 20861149 DOI: 10.1093/qjmed/hcq172] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is growing evidence that the quality of informed consent in clinical research is often sub-optimal. AIMS To explore the conformity of patient recruitment with recommended informed consent procedures among patients who were invited to participate in a clinical study at a general teaching hospital, and to examine the association between consent procedures and the patients' decision to participate. DESIGN AND METHODS All inpatients discharged during a 1-month period were invited to complete a mailed survey in which they reported whether they were invited to participate in a study and whether 13 recommended elements of informed consent actually occurred. RESULTS Among 1303 respondents, 265 (20.3%) reported that they had been invited to participate in a study, and 191 (72.1%) accepted. While the majority of potential participants were fully informed about practical issues related to the study (e.g. what their participation would consist in), <50% were informed of possible risks or benefits, and only 20% about the origin of the study funds. Only 60% reported satisfactory answers to items assessing the overall information process (e.g. explanations were easy to understand). Older and sicker patients reported lower levels of conformity with informed consent procedures, as did patients who refused to participate in a study. CONCLUSION Our results confirm that informed consent procedures fail to meet standards for many patients. In particular, consent information should be adapted to the needs of older and sicker patients. Improving the quality of informed consent may increase patients' participation in clinical research.
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Affiliation(s)
- T Agoritsas
- Division of Clinical Epidemiology, University Hospitals of Geneva, Gabrielle Perret-Gentil 6, 1211 Geneva 14, Switzerland.
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Sand K, Kaasa S, Loge JH. The Understanding of Informed Consent Information—Definitions and Measurements in Empirical Studies. ACTA ACUST UNITED AC 2010. [DOI: 10.1080/21507711003771405] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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