1
|
Paddock K, Woolfall K, Kearney A, Pattison N, Frith L, Gamble C, Welters I, Trinder J, Young B. Learning from stakeholders to inform good practice guidance on consent to research in intensive care units: a mixed-methods study. BMJ Open 2022; 12:e066149. [PMID: 36375987 PMCID: PMC9664286 DOI: 10.1136/bmjopen-2022-066149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Obtaining informed consent from patients in intensive care units (ICUs) prior to enrolment in a study is practically and ethically complex. Decisions about the participation of critically ill patients in research often involve substitute decision makers (SDMs), such as a patient's relatives or doctors. We explored the perspectives of different stakeholder groups towards these consent procedures. DESIGN AND METHODS Mixed-methods study comprising surveys completed by ICU patients, their relatives and healthcare practitioners in 14 English ICUs, followed by qualitative interviews with a subset of survey participants. Empirical bioethics informed the analysis and synthesis of the data. Survey data were analysed using descriptive statistics of Likert responses, and analysis of interview data was informed by thematic reflective approaches. RESULTS Analysis included 1409 survey responses (ICU patients n=333, relatives n=488, healthcare practitioners n=588) and 60 interviews (ICU patients n=13, relatives n=30, healthcare practitioners n=17). Most agreed with relatives acting as SDMs based on the perception that relatives often know the patient well enough to reflect their views. While the practice of doctors serving as SDMs was supported by most survey respondents, a quarter (25%) disagreed. Views were more positive at interview and shifted markedly depending on particularities of the study. Participants also wanted reassurance that patient care was prioritised over research recruitment. Findings lend support for adaptations to consent procedures, including collaborative decision-making to correct misunderstandings of the implications of research for that patient. This empirical evidence is used to develop good practice guidance that is to be published separately. CONCLUSIONS Participants largely supported existing consent procedures, but their perspectives on these consent procedures depended on their perceptions of what the research involved and the safeguards in place. Findings point to the importance of explaining clearly what safeguards are in place to protect the patient.
Collapse
Affiliation(s)
- Katie Paddock
- Department of Childhood, Youth and Education Studies, Manchester Metropolitan University, Manchester, UK
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Anna Kearney
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Natalie Pattison
- East and North Hertfordshire National Health Service Trust, Hertfordshire, UK
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Lucy Frith
- Centre for Social Ethics and Policy, The University of Manchester, Manchester, UK
| | - Carrol Gamble
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Ingeborg Welters
- Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - John Trinder
- Ulster Hospital, Belfast, South Eastern Health & Social Services Trust, Belfast, Ireland
| | - Bridget Young
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| |
Collapse
|
2
|
Parkman AA, Foland J, Anderson B, Duquette D, Sobotka H, Lynn M, Nottingham S, Dotson WD, Kolor K, Cox SL. Public awareness of genetic nondiscrimination laws in four states and perceived importance of life insurance protections. J Genet Couns 2015; 24:512-21. [PMID: 25242499 PMCID: PMC4702480 DOI: 10.1007/s10897-014-9771-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 08/27/2014] [Indexed: 12/27/2022]
Abstract
Genetic testing has grown dramatically in the past decade and is becoming an integral part of health care. Genetic nondiscrimination laws have been passed in many states, and the Genetic Information Nondiscrimination Act (GINA) was passed at the federal level in 2008. These laws generally protect individuals from discrimination by health insurers or employers based on genetic information, including test results. In 2010, Connecticut, Michigan, Ohio, and Oregon added four questions to their Behavioral Risk Factor Surveillance System (BRFSS) survey to assess interest in genetic testing, awareness of genetic nondiscrimination laws, concern about genetic discrimination in determining life insurance eligibility and cost, and perceived importance of genetic nondiscrimination laws that address life insurance. Survey results showed that awareness of genetic nondiscrimination laws was low (less than 20 % of the adult population), while perceived importance of these types of laws was high (over 80 % of respondents rated them as very or somewhat important). Over two-thirds of respondents indicated they were very or somewhat concerned about life insurance companies using genetic test results to determine life insurance coverage and costs. Results indicate a need for more public education to raise awareness of protections provided through current genetic nondiscrimination laws. The high rate of concern about life insurance discrimination indicates an additional need for continued dialogue regarding the extent of legal protections in genetic nondiscrimination laws.
Collapse
Affiliation(s)
- Alicia A Parkman
- Genetics Program, Oregon Public Health Division, 800 NE Oregon St, Ste 370, Portland, OR, 97232, USA,
| | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Freeman BD, Bolcic-Jankovic D, Kennedy CR, LeBlanc J, Eastman A, Barillas J, Wittgen CM, Indsey K, Mahmood RS, Clarridge BR. Perspectives of Decisional Surrogates and Patients Regarding Critical Illness Genetic Research. AJOB Empir Bioeth 2015; 7:39-47. [PMID: 26752784 DOI: 10.1080/23294515.2015.1039148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Critical illness research is challenging due to disease severity and because patients are frequently incapacitated. Surrogates called upon to provide consent might not accurately represent patient preferences. Though commonplace, genetic data collection adds complexity in this context. We undertook this investigation to understand whether surrogate decision makers would be receptive to permitting participation in a critical illness genetics study and whether their decision making was consistent with that of the patient represented. METHODS We invited individuals identified as surrogates for critically ill adults, if required, as well as patients once recovered to participate in a survey designed to understand attitudes about genetic research. Associations between dependent (receptivity to participation, concordance of responses) and independent variables were tested using bivariate and multivariate logistic regression analyses. RESULTS Most of the entire surrogate sample (n=439) reported familiarity with research, including genetic research; tended to view research as useful; and were receptive to allowing their family member participate (with 39.6% and 38.1% stating that this would be "very" and "somewhat likely," respectively) even absent direct benefit. Willingness to participate was similar comparing genetic and non-genetic studies (χ2 [1,n=439]=0.00127, p=0.972), though respondents expressed worry regarding lack of confidentiality of genetic data. Responses were concordant in 70.8% of the 192 surrogate-patient pairs analyzed. In multivariate analysis, African American race was associated with less receptivity to genetic data collection (p<0.05). No factors associated with concordance of surrogate-patient response were identified. CONCLUSIONS Surrogates' receptivity to critical illness research was not influenced by whether the study entailed collection of genetic data. While more than two-thirds of surrogate-patient responses for participation in genetics research were concordant, concerns expressed regarding genetic data often related to breach of confidentiality. Emphasizing safeguards in place to minimize such breeches might prove an effective strategy for enhancing recruitment.
Collapse
|
4
|
Family decision maker perspectives on the return of genetic results in biobanking research. Genet Med 2015; 18:82-8. [PMID: 25856669 PMCID: PMC4600004 DOI: 10.1038/gim.2015.38] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 02/17/2015] [Indexed: 02/06/2023] Open
Abstract
PURPOSE There are many ethical considerations regarding the return of genetic results to biobanking participants, especially when biobanks collect samples from deceased organ and tissue donors that require the authorization of a family decision maker (FDM). This article explores FDM knowledge and opinions regarding return of genetic results in the context of the Genotype-Tissue Expression (GTEx) Project, which does not return results to participants. METHODS Data collection included a survey completed by Organ Procurement Organization requesters (n = 22) and semistructured telephone interviews with FDM (n = 55). RESULTS Nearly every FDM wanted some form of genetic results returned. Information regarding treatable diseases (94.3%) and diseases that could affect their children (84.9%) were more desirable than that regarding untreatable diseases (71.7%). Sixty percent of FDMs understood that GTEx would not return genetic results. FDMs were four times more likely to have correct knowledge of the GTEx policy when their GTEx requester reported discussing the topic with them. CONCLUSION FDMs from the GTEx project were interested in receiving genetic test results. Marked changes in the infrastructure of the GTEx would be required to alter the policy. Regardless, care must be taken to ensure that the return policy is clearly communicated with FDMs to dispel misconceptions.Genet Med 18 1, 82-88.
Collapse
|
5
|
Burstein MD, Robinson JO, Hilsenbeck SG, McGuire AL, Lau CC. Pediatric data sharing in genomic research: attitudes and preferences of parents. Pediatrics 2014; 133:690-7. [PMID: 24616359 PMCID: PMC3966500 DOI: 10.1542/peds.2013-1592] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE In the United States, data from federally funded genomics studies are stored in national databases, which may be accessible to anyone online (public release) or only to qualified researchers (restricted release). The availability of such data exposes participants to privacy risk and limits the ability to withdraw from research. This exposure is especially challenging for pediatric participants, who are enrolled in studies with parental permission. The current study examines genomic research participants' attitudes to explore differences in data sharing (DS) preferences between parents of pediatric patients and adult patients. METHODS A total of 113 parents of pediatric patients and 196 adult participants from 6 genomics studies were randomly assigned to 3 experimental consent forms. Participants were invited to a follow-up structured interview exploring DS preferences, study understanding, and attitudes. Descriptive analyses and regression models were built on responses. RESULTS Most parents (73.5%) and adult participants (90.3%) ultimately consented to broad public release. However, parents were significantly more restrictive in their data release decisions, not because of understanding or perceived benefits of participation but rather autonomy and control. Parents want to be more involved in the decision about DS and are significantly more concerned than adult participants about unknown future risks. CONCLUSIONS Parents have the same altruistic motivations and grasp of genomics studies as adult participants. However, they are more concerned about future risks to their child, which probably motivates them to choose more restrictive DS options, but only when such options are made available.
Collapse
Affiliation(s)
- Matthew D. Burstein
- Structural and Computation Biology & Molecular Biophysics Graduate Program,,Medical Scientist Training Program
| | | | | | | | - Ching C. Lau
- Structural and Computation Biology & Molecular Biophysics Graduate Program,,Dan L. Duncan Cancer Center, and,Department of Pediatrics, Hematology–Oncology Section, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
6
|
Iverson E, Celious A, Shehane E, Oerke M, Warren V, Eastman A, Kennedy CR, Freeman BD. Critical illness research involving collection of genomic data: the conundrum posed by low levels of genomic literacy among surrogate decision makers for critically ill patients. J Empir Res Hum Res Ethics 2014; 8:53-7. [PMID: 23933776 DOI: 10.1525/jer.2013.8.3.53] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Critical illness clinical trials that entail genomic data collection pose unique challenges. In this qualitative study, we found that surrogate decision makers (SDMs) for critically ill individuals, such as those who would be approached for study participation, appeared to have a limited grasp of genomic principles. We argue that low levels of genomic literacy should neither preclude nor be in conflict with the conduct of ethically rigorous clinical trials.
Collapse
Affiliation(s)
- Ellen Iverson
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | | | | | | |
Collapse
|
7
|
Iverson E, Celious A, Kennedy CR, Shehane E, Eastman A, Warren V, Freeman BD. Factors affecting stress experienced by surrogate decision makers for critically ill patients: implications for nursing practice. Intensive Crit Care Nurs 2013; 30:77-85. [PMID: 24211047 DOI: 10.1016/j.iccn.2013.08.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/30/2013] [Accepted: 08/30/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study explores surrogate decision-makers' (SDMs) challenges making decisions related to the care of patients in critical care, to (1) characterise the SDM stress, (2) identify personal, social, care-related factors influencing stress and (3) consider implications of findings to improving critical care practice. METHODOLOGY Semi-structured interviews were conducted with SDMs of critically ill patients receiving care in two tertiary care institutions. Transcripts were analysed using a grounded theory approach. Domains explored were: stress characteristics, stress mitigators, coping strategies, social networks, SDM decision-making role, decision-making concordance, knowledge of patient's preferences, experience with provider team, SDM-provider communication, patient outcome certainty. MAIN OUTCOMES We interviewed 34 SDMs. Most were female and described long-term relationships with patients. SDMs described the strain of uncertain outcomes and decision-making without clear, consistent information from providers. Decision-making anxiety was buffered by SDMs' active engagement of social networks, faith and access to clear communication from providers. CONCLUSION Stress is a very real factor influencing SDMs confidence and comfort making decisions. These findings suggest that stress can be minimised by improving communication between SDMs and medical providers. Nurses' central role in the ICU makes them uniquely poised to spearhead interventions to improve provider-SDM communication and reduce SDM decision-making anxiety.
Collapse
Affiliation(s)
- Ellen Iverson
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA.
| | - Aaron Celious
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Carie R Kennedy
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Erica Shehane
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Alexander Eastman
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Victoria Warren
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bradley D Freeman
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|