Disclosure of Huntington's disease to family members: the dilemma of known but unknowing parties

Beliefs about sharing illness experiences in chronic fatigue syndrome: the role of interpersonal trust and personality

Background

Disclosure of illness and illness experiences can be complicated for patients diagnosed with chronic fatigue syndrome due to the stigma associated with the illness. In this study, we evaluate the psychometric properties of the Beliefs about Sharing Illness Experiences (BASIE) scale in chronic fatigue patients. In addition, we inves-tigate whether interpersonal trust and personality characteristics predict self-disclosure in chronic fatigue pa-tients.

Participants and procedure

The research was carried out in Rasht City, Iran. Participants were patients with chronic fatigue syndrome (N = 280) who were referred to Rasht pain management clinics in 2019. The psychometric properties of the BASIE scale were evaluated using content validity (CVI and CVR), exploratory factor analysis (EFA), confirma-tory factor analysis (CFA), and Cronbach’s α. In addition, Pearson’s correlation and multiple regression were used to test the roles of interpersonal trust and personality in predicting willingness to share illness experiences in chronic fatigue syndrome patients.

Results

A CVI of .91 and CVR of .92 showed strong content validly for the BASIE scale. EFA and CFA supported a two-factor structure of the instrument. The Cronbach’s α of .94 confirmed strong reliability. Multiple regression anal-ysis revealed that positive beliefs about sharing illness experiences were predicted by higher interpersonal trust, higher extraversion, and lower neuroticism.

Conclusions

The BASIE scale appears to be an appropriate tool for measuring chronic fatigue syndrome patients’ beliefs about sharing illness experiences. Also, interpersonal trust, extraversion, and neuroticism play important roles in sharing illness experiences. These findings may be helpful in the management of chronic fatigue syndrome and other stigmatized illnesses.

Parents' views of genetic testing and treatment of familial hypercholesterolemia in children: a qualitative study

Familial hypercholesterolemia (FH) is a serious inherited disorder, which greatly increases individuals’ risk of cardiovascular disease (CVD) in adult life. However, medical treatment and lifestyle adjustments can fully restore life expectancy. Whilst European guidance advises that where there is a known family mutation genetic testing is undertaken in early childhood, the majority of the at-risk population remain untested and undiagnosed. To date, only a small number of studies have explored parents’ and children’s experiences of testing and treatment for FH, and little is known about interactions between health professionals, parents, and children in clinic settings. In this study, in-depth interviews were undertaken with parents who had attended a genetics and/or lipid clinic for FH with their children (n = 17). A thematic analysis revealed four main themes: undertaking early prevention, postponing treatment, parental concerns, and the importance of the wider family context. The majority of parents supported genetic testing for FH in childhood. However, although some were very supportive of following early treatment recommendations, others expressed reluctance. Importantly, some parents were concerned that inappropriate information had been shared with their children and wished that more time had been given to discuss how, when, and what to tell in advance. Future research is needed to explore the long-term outcomes for children who undertake genetic testing and early treatment for FH and to trial interventions to improve the engagement, follow-up, and support of children who are at risk, or diagnosed, with this disorder.

Genetic counseling and testing for Huntington's disease: A historical review

This manuscript describes the ways in which genetic counseling has evolved since John Pearson and Sheldon Reed first promoted "a genetic education" in the 1950s as a voluntary, non-directive clinical tool for permitting individual decision making. It reviews how the emergence of Huntington's disease (HD) registries and patient support organizations, genetic testing, and the discovery of a disease-causing CAG repeat expansion changed the contours of genetic counseling for families with HD. It also reviews the guidelines, outcomes, ethical and laboratory challenges, and uptake of predictive, prenatal, and preimplantation testing, and it casts a vision for how clinicians can better make use of genetic counseling to reach a broader pool of families that may be affected by HD and to ensure that genetic counseling is associated with the best levels of care. © 2016 Wiley Periodicals, Inc.

Critical Diagnoses in Forensic Pathology: Ethics of Disclosure

A complex set of systems exists in the United States to manage and regulate the practice of medicine, and forensic pathologists (FPs) are bound by the associated ethical guidelines and associated statutory obligations. Individual FPs, for example, are required to have and maintain a state medical license that requires continuing medical education and provides oversight of many aspects of the practice of medicine. The laboratories in which forensic pathology is practiced, however, generally do not have to be accredited. In contrast, the College of American Pathologists (CAP) is the recognized accrediting body that “regulates” the majority of anatomic pathology and laboratory medicine, including hospital (consented) autopsies. Unlike hospital-based pathology practices, few incentives are present that encourage or require forensic pathology practices to pursue accreditation. Since the preponderance of forensic pathology practices do not fall under the purview of CAP, this relatively small subset of pathologists are left to determine their own set of professional and ethical standards. The National Association of Medical Examiners (NAME) laboratory accreditation and published autopsy guidelines provides a foundation for development of a quality management program, but does not specifically address disclosure of test results. Defining “critical diagnoses” in forensic pathology is challenging, and communicating these important findings to the proper individual(s) or organizations may not fall under statutory or accrediting requirements, and thus may become an ethical issue for the medical examiner/coroner.

Ethical considerations in REM sleep behavior disorder

A patient diagnosed with REM behavior sleep disorder (RBD) has as much as a 65% risk of developing an α-synucleinopathy. Currently, it is not possible to predict whether an individual will develop a disease, or, if so, which disease.The neurologist treating the patient must consider (1) the difference between disclosing a diagnosis and disclosing the risk of a diagnosis; (2) whether to disclose this risk to patients; and (3) if deciding to disclose the risk, the appropriate timing of such a conversation.

Ethical considerations in psychiatric genetics

Ethical considerations in psychiatric genetics are highly complex and fluid. This review introduces the reader to the wide range of ethical considerations in this field by examining four characteristics of genetic information. First, genetic information may, to a greater or lesser extent, predict a person's future health. Second, learning about one's genotype may have profound psychosocial consequences. Third, genetic information pertains to a person's biological relatives and thus can affect family members, communities, and population groups. Finally, psychiatric genetics is a rapidly evolving field. None of these characteristics is necessarily "exceptional" or unique to genetics, but they provide a useful framework for teasing apart a complex set of ethical considerations. This article reviews conceptual and empirical data that speak to these four characteristics and then presents a set of conceptual frameworks that can be used to systematically analyze the ethics of psychiatric genetic research and clinical genotyping. Finally, directions for future study are described--including the urgent need to gather data on actual risks and benefits of psychiatric genetic research and clinical applications, so that their utility can be assessed and appropriate ethical safeguards identified.

Standard Operating Procedures, ethical and legal regulations in BTB (Brain/Tissue/Bio) banking: what is still missing?

The use of human biological specimens in scientific research is the focus of current international public and professional concern and a major issue in bioethics in general. Brain/Tissue/Bio banks (BTB-banks) are a rapid developing sector; each of these banks acts locally as a steering unit for the establishment of the local Standard Operating Procedures (SOPs) and the legal regulations and ethical guidelines to be followed in the procurement and dissemination of research specimens. An appropriat Code of Conduct is crucial to a successful operation of the banks and the research application they handle. What are we still missing ? (1) Adequate funding for research BTB-banks. (2) Standard evaluation protocls for audit of BTB-bank performance. (3) Internationally accepted SOP's which will facilitate exchange and sharing of specimens and data with the scientific community. (4) Internationally accepted Code of Conduct. In the present paper we review the most pressing organizational, methodological, medico-legal and ethical issues involved in BTB-banking; funding, auditing, procurement, management/handling, dissemination and sharing of specimens, confidentiality and data protection, genetic testing, "financial gain" and safety measures. Taking into consideration the huge variety of the specimens stored in different repositories and the enormous differences in medico-legal systems and ethics regulations in different countries it is strongly recommend that the health-care systems and institutions who host BTB-Banks will put more efforts in getting adequate funding for the infrastructure and daily activities. The BTB-banks should define evaluation protocols, SOPs and their Code of Conduct. This in turn will enable the banks to share the collected specimens and data with the largest possible number of researchers and aim at a maximal scientific spin-off and advance in public health research.

Huntington's disease. Part 1: essential background and management

Huntington's disease is a neurodegenerative disorder that manifests in motor, cognitive and behavioural symptoms, gradually progressing over a number of years, if not decades. The complexity and unpredictability of the disease poses challenges for health-and social-care professionals. This article provides an essential background to the understanding and management of care for people with Huntington's disease, presenting a discussion of the main stages to highlight the symptoms and challenges associated with the disease. The article then moves on to discuss potential management and therapy issues identifying some key considerations in the treatment of the disease. Finally, the combined role of the multidisciplinary team is highlighted in providing health and social care to people with Huntington's disease as it progresses and increasing professional support is required.

Standard Operating Procedures, ethical and legal regulations in BTB (Brain/Tissue/Bio) banking: what is still missing?

The use of human biological specimens in scientific research is the focus of current international public and professional concern and a major issue in bioethics in general. Brain/Tissue/Bio banks (BTB-banks) are a rapid developing sector; each of these banks acts locally as a steering unit for the establishment of the local Standard Operating Procedures (SOPs) and the legal regulations and ethical guidelines to be followed in the procurement and dissemination of research specimens. An appropriat Code of Conduct is crucial to a successful operation of the banks and the research application they handle. What are we still missing ? (1) Adequate funding for research BTB-banks. (2) Standard evaluation protocls for audit of BTB-bank performance. (3) Internationally accepted SOP's which will facilitate exchange and sharing of specimens and data with the scientific community. (4) Internationally accepted Code of Conduct. In the present paper we review the most pressing organizational, methodological, medico-legal and ethical issues involved in BTB-banking; funding, auditing, procurement, management/handling, dissemination and sharing of specimens, confidentiality and data protection, genetic testing, "financial gain" and safety measures. Taking into consideration the huge variety of the specimens stored in different repositories and the enormous differences in medico-legal systems and ethics regulations in different countries it is strongly recommend that the health-care systems and institutions who host BTB-Banks will put more efforts in getting adequate funding for the infrastructure and daily activities. The BTB-banks should define evaluation protocols, SOPs and their Code of Conduct. This in turn will enable the banks to share the collected specimens and data with the largest possible number of researchers and aim at a maximal scientific spin-off and advance in public health research.

Israeli nurses and genetic information disclosure

The debate continues about whether people have a duty to pass on the positive results of their genetic tests to relatives who are at risk from the same disease, and, should they refuse, whether physicians and genetic counselors then have the duty to do so. To date, the role and views of nurses in this debate have not been investigated. In our study, a sample of Israeli nurses, untrained in genetics, were asked for their theoretical opinions and what practical steps they would take in the case of patients' refusal to disclose. The nurses were very sure that patients should inform their families but were equally sure that nurses must respect their decision to disclose or not. Few said they would take practical steps to disclose information if the patient objected. The authors believe that the most useful and appropriate role for nurses in this field is in working to bring about co-operation between patients and family members.

Communicating genetic information in families--a review of guidelines and position papers

This article aims to review ethical and clinical guidelines and policies addressing the communication of genetic information in families. Websites of national and regional bioethics committees, national human genetics societies, international health organisations, genetic interest groups and legal recommendations committees were searched for guidelines and policies. The databases Medline, Web of Science and Google Scholar were also utilised to search for additional guidelines relating to the communication of genetic information in families. The guidelines and policies included in this review are limited to those available in English. The search resulted in guidelines from 18 international, regional and national organisations from six countries pertaining to family communication of genetic information. The following ideals were common in their guidelines: (1) individuals have a moral obligation to communicate genetic information to their family members; (2) genetic health professionals should encourage individuals to communicate this information to their family members; and (3) genetic health professionals should support individuals throughout the communication process. The difference between the organisations' guidelines was the inclusion of information about the role of the health professional in supporting clients during the process of communicating genetic information to their family members. Only two recommendations suggested that the health professional should support their clients by identifying at-risk family members, but more guidelines recommended that directive counselling should be undertaken to encourage clients to communicate genetic information to their family members. In conclusion, the guidelines provide an overview of the role that genetic health professionals may undertake; however, there are gaps that need to be addressed.

Informed consent and the misattributed paternity problem in genetic counseling

When misattributed paternity is discovered in the course of genetic testing, a genetic counselor is presented with a dilemma concerning whether to reveal this information to the clients. She is committed to treating the clients equally and enabling informed decision making, but disclosing the information may carry consequences for the woman that the counselor cannot judge in advance. A frequent suggestion aimed at avoiding this problem is to include the risk of discovering nonpaternity in the informed consent process for counseling. In this paper I argue that such a move does not resolve the problem, because the conflict hinges on the interpretation of equality on which the counselor operates. Given the principles of genetic counseling, neither construal of equality yields a satisfactory solution to the conflict. In fact, I conclude that including nonpaternity in informed consent is not endorsed by either view, and we are still left with the question of what to do should nonpaternity be discovered. I suggest a compromise position concerning disclosure, involving revealing relevant genetic information but withholding nonpaternity when possible.

Guidelines for disclosing genetic information to family members: from development to use

This paper presents the existing legal frameworks, professional guidelines and other documents related to the conditions and extent of the disclosure of genetic information by physicians to at-risk family members. Although the duty of a physician regarding disclosure of genetic information to a patient's relatives has only been addressed by few legal cases, courts have found such a duty under some circumstances. Generally, disclosure should not be permitted without the patient's consent. Yet, due to the nature of genetic information, exceptions are foreseen, where treatment and prevention are available. This duty to warn a patient's relative is also supported by some professional and policy organizations that have addressed the issue. Practice guidelines with a communication and intervention plan are emerging, providing physicians with tools that allow them to assist patients in their communication with relatives without jeopardizing their professional liability. Since guidelines aim to improve the appropriateness of medical practice and consequently to better serve the interests of patients, it is important to determine to what degree they document the 'best practice' standards. Such an analysis is an essential step to evaluate the different approaches permitting the disclosure of genetic information to family members.

Genetics as a tool to improve cancer outcomes: ethics and policy

Genetic research is rapidly increasing the opportunities for the detection of inherited cancer risk. Clinicians and policy makers must ensure the adequate evaluation of the benefits and harms of this new area of practice, address the challenges of family-based detection of individuals at risk and develop practice guidelines and educational strategies that are responsive to rapidly changing knowledge. When the benefits of testing are well established, efforts must also be made to ensure access to genetic services for all who can benefit.

The Effect of Preventability and Severity Levels of a Genetic Disorder on Desire to Communicate Genetic Testing Information to Family Members

This study examined the impact of severity and preventability of a genetic disorder on belief that genetic test results should be shared with family members, desire to be tested, and opinions about physician?s role in sharing information. Participants were 359 undergraduate students who received one of four descriptions of a fictitious genetic disorder called hemocythemia (i.e., factorial combination of high versus low disease preventability and high versus low disease severity). Logistic regression analyses indicated that disease severity and preventability did not influence agreement that genetic information should be shared with family members, interest in being tested for the disorder, or agreement that physicians should share genetic information without permission. Those who read about the disorder as preventable were more likely to agree that their family members should be tested for the disorder (odds ratio [OR] = 1.82, p < 0.05). Females, African Americans, and those of other races were more likely to agree that they would want their family members tested for hemocythemia than males or European Americans (p < 0.05). Describing the disorder as preventable minimized the effect of the severity manipulation on perception of disease severity (p < 0.05). Understanding a disorder to be preventable may increase encouragement of family members to be tested and affect perceived seriousness of the condition.

A review of international and UK-based ethical guidelines for researchers conducting nontherapeutic genetic studies in developing countries

Initiation and implementation of nontherapeutic genetic research projects, sponsored by developed countries and conducted in developing countries, requires careful consideration and awareness of procedures that ensure ethical research. This article reviews, and discusses controversies surrounding, the ethical principles established internationally and recommended by institutions in the UK for designing and implementing nontherapeutic genetic research studies. Before project commencement, the researcher should submit proposals to appropriate ethics committees and, wherever possible, seek guidance from experienced researchers. The researcher must also be aware of his/her responsibilities when conducting research with human participants. Responsibilities include respecting autonomy, privacy and confidentiality of participants, respecting social and cultural differences, providing appropriate information to participants, obtaining informed consent and offering appropriate compensation for participation. Finally, researchers involved in human genetics studies must also consider specific issues and public concerns when collecting biological samples. This includes using anonymised samples, considering future use of samples and ensuring confidentiality of results.

Caring for the carers: quality of life in Huntington's disease

Huntington's disease (HD) is a dementia that is genetically inherited as an autosomal-dominant trait with a complete lifetime penetrance. For individuals who develop HD, it is generally the immediate family that take on the responsibility of caring. However, there is a paucity of research into the impact of HD on the quality of life (QoL) of the spousal carer and the possible benefits of quantifying the HD carer's experience. Therefore, the purpose of this article is to describe the experiences of family carers of HD patients, specifically in relation to their QoL and to introduce the Huntington's Disease Quality of Life Battery for Carers (HDQoL-C). This is a valid and reliable QoL measure that has been developed to quantify the care-giving experience in HD in order to implement and assess therapeutic interventions.

Managing familial risk in genetic testing

Increasing numbers of people are seeking genetic testing and uncovering information that directly concerns their biological relatives as well as themselves. This familial quality of genetic information raises ethical quandaries for physicians, particularly related to their duty of confidentiality. In this article, the American Medical Association's Council on Ethical and Judicial Affairs examines the informed consent process in the specific context of genetic testing, giving particular consideration to the handling of information that has consequences for biological relatives. Furthermore, it addresses the question of whether physicians' obligation to warn biological relatives ever should override the obligation to protect patient confidentiality.

Genetic professionals' reports of nondisclosure of genetic risk information within families

Patients attending genetic clinics are often the main gatekeepers of information for other family members. There has been much debate about the circumstances under which professionals may have an obligation, or may be permitted, to pass on personal genetic information about their clients but without their consent to other family members. We report findings from the first prospective study investigating the frequency with which genetics professionals become concerned about the failure of clients to pass on such information to their relatives. In all, 12 UK and two Australian regional genetic services reported such cases over 12 months, including details of actions taken by professionals in response to the clients' failure to disclose information. A total of 65 cases of non-disclosure were reported, representing <1% of the genetic clinic consultations in the collaborating centres during the study period. These included 39 cases of the failure of parents not passing full information to their adult offspring, 22 cases where siblings or other relatives were not given information and four cases where information was withheld from partners -- including former and prospective partners. Professionals reported clients' reasons for withholding information as complex, more often citing concern and the desire to shield relatives from distress rather than poor family relationships. In most cases, the professionals took further steps to persuade their clients to make a disclosure but in no instance did the professional force a disclosure without the client's consent.

Family communication about genetic risk: the little that is known

Although family communication is important in clinical genetics only a small number of studies have specifically explored the passing on of genetic knowledge to family members. In addition, many of these present exploratory or tentative findings based upon small sample sizes, or data collected only a short time after testing. Nevertheless, if health professionals are to develop effective strategies to help patients' deal with communication issues, we need to know more about what actually happens in families. The aim of this commentary is to identify factors which appear to influence whether patients share information about genetic risk with relatives who are unaware of that risk, with whom they share it and how they go about it. The paper draws upon evidence and thinking from the disciplines of psychology (including family therapy), sociology, medicine and genetic counselling. It is presented under the following headings: disease factors, individual factors, family factors and sociocultural factors. It concludes by highlighting a number of key issues which are relevant for health professionals.

Genetic testing: practical, ethical, and counseling considerations

Genetic testing is becoming a much more common practice in medicine today. This presents a unique set of challenges for medical professionals in virtually all specialties. The practical aspects of determining which test to order, and in interpreting the result accurately in the context of the family history, can be difficult. Additionally, the ethical conundrums that frequently present themselves when genetic risk assessment and/or genetic testing is being considered can be daunting. These challenges present real concerns for medical professionals and patients alike. Included in this article is a review of some of the practical and ethical complexities associated with genetic testing. Pretest and posttest genetic counseling is also emphasized as an important and essential process in today's medical practice.

Early-Onset Alzheimer Disease

Alzheimer disease (AD) is a neurodegenerative disease that is currently not preventable or curable. Early-onset AD can be due to mutations in several autosomal dominant genes. Clinical testing is available for presenilin 1 (PS1), which is the most common of these genes. However, many practical and ethical issues must be considered before ordering this test for patients with early-onset AD. In this paper, we present a case that demonstrates the complexities of genetic testing for early-onset AD.

Predictive Genetic Testing for Breast Cancer and Huntington’s Disease: The Opinions of Midwives and Nurses in Flanders

OBJECTIVE

Investigate attitudes of midwives and nurses regarding predictive testing for hereditary breast cancer and Huntington's disease.

METHODS

Mail questionnaires were sent to 119 midwives and 881 nurses.

RESULTS

The response rate was 58% for midwives, but only 33% for nurses. The attitude toward predictive testing in an asymptomatic adult was more favourable in case of hereditary breast cancer than in case of Huntington's disease, mostly because prevention or therapy is unavailable for the latter condition. Prevention of breast cancer through prophylactic mastectomy elicited adverse reactions among 40% of the participants. Predictive testing for these diseases in an adolescent at the own request was also rated favourably while testing in children at the parents' request was less acceptable. For both diseases, concealing carrier status information from the employer or the insurance company was judged as acceptable by the majority.

CONCLUSION

Our findings contribute to the understanding of nurses' and especially midwives' attitudes to predictive testing, which may in turn serve as a basis for genetic education for these groups of health care professionals.

To tell or not to tell: barriers and facilitators in family communication about genetic risk

Communication about genetic risk in families is an important issue for genetic counsellors. The objective of this study was to explore the barriers and facilitators in family communication about genetic risk. Semi-structured interviews were undertaken with patients in the Northeast of Scotland who had attended genetic counselling for risk of hereditary breast and ovarian cancer and Huntington's disease, and with some spouses/partners. The interviews confirmed that the issue of disclosure was a problem for some, and that there were generic communication issues common to both groups. Telling family members about genetic risk was generally seen as a family responsibility and family structures, dynamics and 'rules' influenced disclosure decisions. A sense of responsibility towards younger generations was also important. The level of certainty felt by a person in relation to his or her own risk estimate also influenced what he or she could tell other family members. Communication within a family about genetic risk is a complex issue and is influenced by both pre-existing familial and cultural factors and individuals' responses to risk information. If genetic counsellors understood how these factors operate in individual families they might be able to identify effective strategies to promote considered decisions and prevent unnecessary emotional distress.

Professional opportunities and responsibilities in the provision of genetic information to children relinquished for adoption

We report a case involving the disclosure of BRCA1 mutation results to a woman who had placed a child for adoption 30 years prior to learning her mutation status. The disclosure of the mother's genetic test result to the son resulted in unexpected subsequent communications. This article briefly describes the experience and discusses the unique issues that arise in counseling a parent who has relinquished a child who is subsequently at risk to inherit a mutation for an adult onset genetic condition.