Informed consent: optimism versus reality

Does the standard medical procedure consent process meet the criteria required for informed consent? - A concept analysis

BACKGROUND

Informed consent is a complex process that is legally required before any surgical procedure.

PURPOSE

The purpose of this manuscript was to perform a concept analysis of the informed consent process.

METHODS

The use of dimensional analysis identified three separate yet related perspectives of the informed consent process: legal, health care, and patients. A database search using the Cumulative Index to Nursing and Allied Health Literature and PubMed were performed.

FINDINGS

A total of 27 publications were reviewed. The legal perspective addresses the requirement of informed consent, which starts with the discussion between the health care provider and the patient undergoing the surgical procedure and ends with a signature on a piece of paper. The health care perspective also addresses the legal requirement but incorporates the goals and objectives of the individual initiating the informed consent discussion. The patients' perspectives also incorporate goals and objectives; however, they differ from that of the health care provider in that they go beyond what happens in the operating room or during hospitalization.

DISCUSSION

Viewing informed consent through these different yet related perspectives provides insight into this complex process and may enhance the researcher's ability to understand and improve the informed consent process.

An evaluation of patient informed consent for dental extractions

Dental practitioners are well versed in informing patients of the risks and benefits associated with dental extractions. The purpose of this service evaluation was to determine whether patients understood and recalled information relevant to their planned oral surgery procedure, prior to second stage consent.A questionnaire was distributed to patients who were attending for their elective treatment appointment. This explored their ability to recall the planned intervention, the modality of treatment (local anaesthetic, intravenous sedation, or general anaesthetic), understanding of alternative treatment options and the risks associated with the procedure. Completed responses were received from 29 of the distributed questionnaires (response rate=58%). The majority of patients were not aware of the following risks with their procedure: pain, bleeding, bruising, swelling, infection, damage to adjacent structures.Despite a well-documented consent form and comprehensive discussion, we identified that patients may not comprehend or recollect the risks associated with their dental extraction. As dental professionals we have a duty to seek ways to facilitate patient understanding and maximise their autonomy.

Informed consent challenges and strategies: A qualitative study of the orthodontists' perspective

OBJECTIVE

To identify the barriers and strategies perceived by orthodontists when obtaining consent from their adult patients concerning patients' comprehension or recollection of treatment information.

SETTINGS AND SAMPLE POPULATION

The sample comprised 12 orthodontists working in 8 different cities in Alberta, Canada.

METHODS

An exploratory investigation using qualitative inquiry was conducted. Participants were recruited through a combination of purposive, maximum variation and snowball sampling. Data were collected through audio-recorded, semi-structured interviews until saturation was reached. Then, data were analysed using thematic analysis. Quality and credibility were achieved by employing member checks, memo writing and analyst triangulation strategies.

RESULTS

Two major themes were identified, with subthemes: (1) Challenges that may interfere with patients' comprehension and recollection of treatment information (i. patients' internal barriers, ii. patients' external barriers and iii. financial barriers); and (2) strategies to optimize information delivery and communication (i. tailoring the content to be delivered, ii. communication fashion, iii. communication timing and iv. being accommodative).

CONCLUSION

The participants reported barriers that may be overlooked in the daily routine of orthodontic practices. Information is provided that may guide orthodontists to overcome or minimize these challenges, increase patient comprehension and improve the quality of informed consent processes.

Exploring how newly qualified dentists perceive certain legal and ethical issues in view of the GDC standards

Introduction This study focuses on how the legal and ethical requirements presented by the General Dental Council (GDC) in their Standards for the dental team (2013) document are perceived by newly qualified dentists; that is, those who have been qualified for less than five years.Aim The aim of the study was to investigate how the GDC guidance and the set standards for the dental team are perceived and understood by newly qualified dental practitioners, and how the guidance and the standards influence clinicians' decision-making. The study explored the newly qualified dentists' exposure to law and ethics, the GDC and their regulatory document, together with the clinical and non-clinical influence of this regulation on daily practice.Methods Empirical qualitative data were collected using semi-structured interviews of nine newly qualified dentists, with an average of 80 minutes for each interview. The data were analysed using thematic analysis.Results Three main themes were identified through the newly qualified dentists' perceptions of the GDC selected standards. These included sense of fear, morale and the business of dental practice, with further subthemes identified.Conclusion Results from this study present an opportunity and a challenge, as there is some fear and uncertainty among newly qualified dentists about the application of some of the GDC standards in practice. Further training in law and ethics as well as additional support for newly qualified dental practitioners is needed.

Informed Consent in Pediatric Anesthesia: A Narrative Review

Informed consent for pediatric anesthesia challenges practitioners to navigate complex ethical, medical, and legal ambiguities. A patient's status as a minor does not negate the importance of his or her participation in the decision-making process but, rather, necessitates a nuanced evaluation of age and development to involve the patient to an appropriate extent. Given the complexities involved with pediatric informed consent in anesthesia practice and research, it is important to understand the experience of key stakeholders involved. For this review, we searched Medline, the Cochrane database, PROSPERO, and Clinicaltrials.gov for studies involving pediatric anesthesia informed consent. Inclusion and exclusion criteria were designed to select for studies that included issues related to informed consent as primary outcomes. The following data were extracted from included studies: title, authors, date of publication, study type, intervention, data collection method, participant type (ie, parent, pediatric patient, anesthesia provider), number of participants, pediatric patient age range, and primary outcome measures. Twenty-two articles were included for final review: studies of informed consent in pediatric anesthesia span many aspects of informed consent. Parental understanding has been studied most often (7/22 studies), followed by parental preferences (5/22 studies) and provider-related outcomes (5/22 studies) such as time spent interacting with patients, subjective reporting on amount of training related to informed consent, and provider satisfaction with the informed consent process. Outcomes pertaining to pediatric patients themselves constitute the smallest number of studies, including child anxiety (1/22), child understanding (1/22), and child refusal (1/22). Among the parties involved, parents have been most frequently identified as the subjects of these studies (2719/3805 subjects across all included studies, or 71% of all subjects). Pediatric patients are the least frequently involved subjects of studies that investigate informed consent in pediatric anesthesia (493/3805, or 13% of all subjects). Anesthesia providers and investigators have been study subjects (593/3805, or 16% of all subjects) for a range of topics including time spent interacting with patient, nature of informed consent conversation in relation to trainee status, satisfaction with informed consent process, and priorities for informed consent content. The aim of the present narrative review is to summarize the work that has been done on informed consent for pediatric anesthesia.

Informed consent comprehension and recollection in adult dental patients: A systematic review

BACKGROUND

Patients' ability to recollect and comprehend treatment information plays a fundamental role in their decision making.

TYPES OF STUDIES REVIEWED

The authors considered original studies assessing recollection or comprehension of dental informed consent in adults. The authors searched 6 electronic databases and partial gray literature and hand searched and cross-checked reference lists published through April 2015. The authors assessed the risk of bias in the included studies via different validated tools according to the study design.

RESULTS

Nineteen studies were included: 5 randomized clinical trials, 8 cross-sectional studies, 3 qualitative studies, 2 mixed-methods studies, and 1 case series. Conventional informed consent processes yielded comprehension results of 27% to 85% and recollection of 20% to 86%, whereas informed consent processes enhanced by additional media ranged from 44% to 93% for comprehension and from 30% to 94% for recollection. Patient self-reported understanding ranged positively, with most patients feeling that they understood all or almost all the information presented. Results of qualitative data analyses indicated that patients did not always understand explanations, although dentists thought they did. Some patients firmly stated that they did not receive any related information. Only a few patients were able to remember complications related to their treatment options.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Results of this systematic review should alert dentists that although patients in general report that they understand information given to them, they may have limited comprehension. Additional media may improve conventional informed consent processes in dentistry in a meaningful way.

Informed consent for emergency surgery--how much do parents truly remember?

BACKGROUND/PURPOSE

The purpose of this study was to evaluate parental retention of possible surgical complications in children undergoing emergency laparoscopic appendectomy.

METHODS

A prospective pilot study involving parents whose children had emergency laparoscopic appendectomy was performed. Parents were counseled regarding 7 potential complications of laparoscopic appendectomy. They were asked to recall this list immediately after the consent process (immediate recall, IR) and before discharge from inpatient stay (delayed recall, DR). A score (0-7) was awarded indicating the number of correct answers. For each recall, parents were also reminded on complications they omitted (prompted recall). One surgeon administered all consents in person. Demographic data were collected. Data were reported as median (range).

RESULTS

Twenty-one mothers and 10 fathers were recruited, aged 42 years (30-54). Nine (29%) had university or post-graduate education. Score for IR was 2 (0-6). Five (16%) parents scored 0. Upon prompting after IR, 20 (65%) parents had no impression of at least 1 complication. Score for DR was 2 (0-7), while 7 (23%) parents scored 0. At prompting after DR, 25 (81%) had no memory of at least one complication. Eight (26%) demonstrated improved DR scores. Scores were not affected by patient demographics or time between interviews.

CONCLUSIONS

There is poor parental retention of information provided during operative consent. Hence, proper documentation of this process is essential.

Mothers' perceptions of their child's enrollment in a randomized clinical trial: poor understanding, vulnerability and contradictory feelings

Background

Little is known about the views of mothers when their children are invited to participate in randomized clinical trials (RCTs) investigating medicines and/or invasive procedures. Our goal was to understand mothers’ perceptions of the processes of informed consent and randomization in a RCT that divided uncooperative children into three intervention groups (physical restraint, sedation, and general anesthesia) for dental rehabilitation.

Methods

This is a qualitative study based on semi-structured interviews with mothers accompanying children under 3 years old presenting severe early childhood caries. Their responses were analyzed using content analysis.

Results

We identified one major theme from 15 mothers’ responses – “Understanding of, attitudes toward, and feelings about consenting to participate in a RCT involving advanced behavior guidance techniques and about randomization” – that was derived from the following subcategories: confusion in defining techniques, questions after signing the consent form, lack of knowledge about the techniques, acceptance or questioning of the drawing, sharing responsibility with the child during the drawing, and feelings of faith in God, fear, powerlessness to choose, and relief from or an increase in pressure.

Conclusions

Despite mothers’ misunderstanding, vulnerability, and contradictory feelings, they were willing to overlook their thoughts in order to complete their children’s dental treatment.

The role of informed consent in risks recall in otorhinolaryngology surgeries: verbal (nonintervention) vs written (intervention) summaries of risks

BACKGROUND

Informed consent is a phrase often used in the law to indicate that the consent a person gives meets certain minimum standards. It relies on patients' ability to understand risk information. Evidence suggests that people may extract the gist of any risk information to make medical decisions. Existing evidence also suggests that there is an inverse relationship between the perception of risk and the perception of benefit. Informed consent is the method by which fully informed, rational persons may be involved in choices about their health care.

AIM

The aims of this study were to study how much patients remember of the risks discussed with them about their otolaryngologic surgery and to evaluate whether a simple intervention, the addition of an information handout, improves their recall.

METHODS

This was a prospective study carried out between January and December 2009 in the Department of Otorhinolaryngology, University of Ilorin teaching hospital. Fifty patients undergoing a variety of otorhinolaryngologic procedures, including mastoidectomy, tympanoplasty, nasal polypectomy, rhinotomy, maxillectomy, and laryngoscopy, were verbally consented by the operating surgeon with a standard checklist of potential surgical complications and adverse effects. Three surgeons participated in the study. Patients were stratified into 2 groups: a higher education group and a lower education group. Within each group, patients were randomized to either a control group, consisting of a verbal explanation only, or an intervention group, which added a written handout to the verbal explanation. A follow-up telephone interview was conducted at an average of 20.6 days (range, 14-53 days) to survey for recall of the complications discussed. The main outcome measure is risk recall. This was analyzed by education level and written sheet intervention. Other parameters examined were patient demographics and time elapsed from when the consent was obtained.

RESULTS

Of the 50 patients involved in the study, 30 were men and 20 were women, with male/female ratio of 1.5:1.0. The average age was 43 years (range, 16-76 years). With respect to educational status, 26 patients had the equivalent of high school or less (group 1), and 24 had some degree of postsecondary training (group 2). Overall recall of potential complications was 56%. Those who received the handout recalled 67% of the complications overall, whereas those who did not receive the handout remembered 51% of the complications. The difference was significant recall of the specific risks varied considerably. For those with potential risk of facial nerve paralysis, 88% of them recalled, which was the highest in the study. This was followed by hearing loss (85%) and nasal adhesion (23%). The least were anesthetic reactions (4%) and hoarseness (2%). Those who received the handout recalled 62% of the complications overall, whereas those who did not receive the handout remembered 51% the complications.

CONCLUSION

The addition of a handout significantly alters recall of potential complications of otorhinolaryngologic surgery with the recall of specific risk highest for facial nerve paralysis.

[Terms of informed consent for users of dental clinics in Brazil: legal and ethical issues]

The consent of patient before the beginning of any procedure has to be a respected condition, without any exception. It is necessary the patients to be aware of their health status, their specific needs, the intention of each treatment, the alternatives plans (including no treatment), to know their prognostic, risks, consequences, limitations, and to be aware of their responsibilities and those of your dentist, resulting in the success of the treatment. The Informed Consent (TCLE) aims to fortify and to clarify the position of the patient, being established the rights and duties of both parts - patient and professional. The integral knowledge of the treatment will minimize the anxiety of the patient and treatment complications, and promote greater quality of dental services and improve the satisfaction of both dentist and patient. However, there are few articles in Brazil about this, but there are some ethics problems involving dental clinics regarding this document of information for the patient. Therefore, the aim of this work is to carry through a critical revision on the subject demonstrating the importance of the TCLE in the Brazilian dental clinics.

Bioética: esclarecimento e fonoaudiologia

OBJETIVOS: determinar o esclarecimento dos responsáveis sobre a terapia Fonoaudiológica realizada em suas crianças; verificar o auto-julgamento de participação destes na decisão sobre o tipo de terapia realizada em seu menor; e verificar a interferência do nível de escolaridade do responsável sobre o esclarecimento destes quanto à terapia fonoaudiológica realizada em suas crianças. MÉTODOS: a amostra constitui-se de 33 estagiários de Fonoaudiologia e 33 responsáveis por crianças entre dois e 12 anos de idade, atendidas no ambulatório de Fonoaudiologia, que foram abordados por meio de um formulário estruturado aplicado sob forma de entrevista. Para análise dos dados utilizou-se o teste do Qui-quadrado e o teste de Pearson, através do programa Minitab 13. RESULTADOS: observou-se que a maioria dos responsáveis (95%) descreveu ter participado na decisão da terapia fonoaudiológica de suas crianças. Entretanto, apenas 39,4% acertaram sobre o tratamento fonoaudiológico realizado. No que se refere à escolaridade verificou-se que o percentual de acertos foi maior para os indivíduos com segundo grau completo (60%) do que para indivíduos com primeiro grau incompleto (30%), entretanto, não foi possível observar diferenças estatisticamente significantes (p=0,36). CONCLUSÕES: a maioria dos responsáveis demonstrou não estar devidamente esclarecida quanto à terapia Fonoaudiológica realizada em seus menores, uma vez que relatou atitudes passivas frente ao processo de decisão, e, o esclarecimento desses responsáveis tendeu a ser maior para indivíduos com mais escolaridade.

An audit of the level of knowledge and understanding of informed consent amongst consultant orthodontists in England, Wales and Northern Ireland

OBJECTIVE

To determine the level of knowledge and understanding of informed consent amongst consultant orthodontists.

DESIGN

A questionnaire which covered a range of legal issues on informed consent as it pertains to clinical practice in three of the four nations of the United Kingdom.

SETTING

Hospital orthodontic departments in England, Wales, and Northern Ireland.

SUBJECTS AND METHODS

A questionnaire was initially issued to 14 consultant orthodontists working in the East of England as a regional audit project on informed consent in 2005. After the completion of the audit in 2006, the pilot data were used to refine the questionnaire for wider circulation. The project was then submitted to the British Orthodontic Society (BOS) clinical effectiveness committee which subsequently gave its endorsement for national circulation. The questionnaire was then sent to 216 other consultants in June 2007, with two further postings to non-responders before the survey was closed four months later. The standard required for clinical practice to be lawful is that all of the questions should be answered correctly.

RESULTS

Of the 233 consultant orthodontists who were invited to participate, 183 complied (78.5%) and 50 did not (21.5%). Of those who responded, 179 answered the questionnaire (76.8%) while four had either resigned or retired (1.7%). Out of the 21 answers to the 11 questions that were posed, the mean, median and mode correct response rates were 12 (57%), 11 (52%), and 10 (48%) respectively. The areas which were found to have the poorest level of understanding included what explanations patients need from clinicians in order for them to give consent, how to fully judge if a patient is capable of giving consent, how to manage a patient deemed incapable of giving consent, the legal status of fathers consenting on behalf of their children, whether consent forms have to be re-signed if the start of treatment is delayed by six months or more, and that dentists referring a patient for treatment requiring a general anaesthetic have the same duty to receive consent for the anaesthesia as do the clinicians who will be performing the surgical procedure.

CONCLUSIONS

The results of this audit indicate certain key areas of deficiency in the knowledge and understanding of informed consent amongst consultant orthodontists. The findings provide an opportunity for all clinicians to improve their education and therefore their potential to comply with both the ethical obligation and the legal requirement of gaining valid consent before the start of any treatment.

Obtaining informed consent for children receiving dental care: a pilot study

AIM

To explore the outcome of the consent process with parents/carers of children of different ethnic minority backgrounds in a primary care salaried dental service setting.

MATERIALS AND METHODS

One hundred parents of children were recruited to the study. The sample was balanced by ethnicity (White and Pakistani) and type of care (routine and general anaesthesia [GA]). Subjects were interviewed using a questionnaire enquiring about the various aspects of the consent process.

RESULTS

For routine care, 53% of parents were unaware of the type of pain relief to be used. The majority (78%) knew of the benefits of treatment but few (7%) were aware of risks or alternative treatment options (5%). Significantly more White parents were able to recall the treatment their child was to receive compared with Pakistani parents (P <0.01). With respect to GA, there were no significant differences according to ethnicity. Most parents (95%) could recall risks of treatment and 72% of parents could report benefits; however, only 20% could recall discussion of alternative treatment options.

CONCLUSION

For procedures involving GA, consent is more likely to be informed. For routine care, a more structured approach is required and Pakistani parents in particular need more support. A third of all parents (routine and GA group) felt that they had not been involved in the final treatment decision.

The accompanying adult: authority to give consent in the UK

BACKGROUND

Children may be accompanied by various people when attending for dental treatment. Before treatment is started, there is a legal requirement that the operator obtain informed consent for the proposed procedure. In the case of minors, the person authorized to give consent (parental responsibility) is usually a parent.

AIM

To ascertain if accompanying persons of children attending the Department of Paediatric Dentistry at the Eastman Dental Hospital, London were empowered to give consent for the child's dental treatment.

DESIGN

A total of 250 accompanying persons of children attending were selected, over a 6-month period. A questionnaire was used to establish whether the accompanying person(s) were authorized to give consent.

RESULT

The study showed that 12% of accompanying persons had no legal authority to give consent for the child's dental treatment.

CONCLUSION

Clinicians need to be aware of the status of persons accompanying children to ensure valid consent is obtained.

A qualitative look at parents' experience of their child's dental general anaesthesia

OBJECTIVES

Caries relapse after treatment of early childhood caries (ECC) under general anaesthesia (GA) has been frequently reported. This research used a qualitative method of inquiry to explore parents' experience of their child's treatment under GA, and their perception of the impact of this treatment on their child.

METHODS

The participants were parents whose children had recently undergone dental rehabilitation under GA. Data was collected by semistructured, open-ended interviews scheduled at the postoperative appointment. Interviews were audio-taped, transcribed, checked and coded into a qualitative computer software program for analysis. Data collection and analysis were done simultaneously, and the interview guide was modified based on responses.

RESULTS

Parents were troubled that their child needed a GA and appeared aware of the complications. While some parents felt 'guilty' and struggled to accept this mode of treatment for their child, others felt 'blameless', and were convinced that the GA was 'preferable' for their child and superior to conventional treatment. Nonetheless, all parents reported some levels of anxiety during the GA; they expressed their emotions with 'fear', 'worry' and 'concern'. After the GA, improvement was reported by most parents in their child's amount of dental pain, sleeping pattern, eating habits and acceptance of parental toothbrushing. The most common changes in their child's behaviour mentioned by parents were increased toothbrushing and decreased consumption of sugary foods. Several children who had had primary teeth extracted were distressed as a result of this 'loss'.

CONCLUSION

The general anaesthetic experience was troubling in a variety of ways for both parents and children. However, an 'early' and positive outcome of the GA was a reported improvement in dental health practices. Parents were more positive about maintaining the health of primary teeth and now knew how to take care of their child's teeth. Future exploration is required to reveal if and how the GA experience will affect long-term preventive behaviours.

Informed consent for children

PURPOSE OF REVIEW

Consent has always been an essential element in the physician-child/parent relationship, more importantly as an ethical duty than as a legal requirement, and continues to represent the most important form of communication between children and parents and physicians.

RECENT FINDINGS

The main themes described in this review - the age of competence to give consent and the role of the parents in giving consent - constitute the complex situation of consent in paediatrics. Refusal by children and parents and consent by children for participation in clinical research studies are also discussed.

SUMMARY

This review supports the moral viewpoint that minors with decision-making capacity, regardless of their age, should be involved in their healthcare decisions, even if the law is to have consent from parents or legal guardians.