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Rolfes V, Hinz U, Fangerau H, Voßberg D, Haupt M. [MacCAT-T between Claim and Practice - Challenges of Assessing Capacity for Consent in Dementia]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2024; 92:413-422. [PMID: 38547903 DOI: 10.1055/a-2236-9338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2024]
Abstract
BACKGROUND Consent is a prerequisite for medical diagnostic and therapeutic action. There is no standardised procedure for assessing the ability to give consent. The most widely used tool for structured assessment is the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). OBJECTIVES People with dementia have impaired capacity to consent because of their disease. In order to answer the question to what extent structured assessment procedures can be usefully applied to people with dementia, we analyse the function, strengths and weaknesses of structured assessment procedures with a focus on the MacCAT-T and discuss suggestions for modification and further development of the tool. METHODS Using the PubMed literature database, a systematic literature search and analysis was conducted on papers published since 2010, following PRISMA guidelines.Results Although the MacCAT-T is a valid and reliable tool, it cannot comprehensively address memory problems in people with dementia. It primarily measures cognitive functions. However, Decisions based on emotions, intuitions and values, are not captured by the MacCAT-T. Communicative limitations in people with dementia are not taken into account. CONCLUSIONS It is recommended to provide information in simple language, written down and visualised for people with dementia. The development and elaboration of a graduated procedure for the examination of capacity to consent is indicated. The gradations of the scope and depth of the assessment to be determined should be based on the severity of the cognitive impairment, the benefit/risk ratio of the proposed medical intervention and the individual profile of affective functions and value-based imprints.
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Affiliation(s)
- Vasilija Rolfes
- Institut für Geschichte, Theorie und Ethik der Medizin, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Uta Hinz
- Institut für Geschichte, Theorie und Ethik der Medizin, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Heiner Fangerau
- Institut für Geschichte, Theorie und Ethik der Medizin, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Dilara Voßberg
- Institut für Geschichte, Theorie und Ethik der Medizin, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Martin Haupt
- Institut für Geschichte, Theorie und Ethik der Medizin, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Lehrpraxis der Klinik und Poliklinik für Psychiatrie und Psychotherapie der Heinrich-Heine-Universität Düsseldorf im Neuro Centrum Düsseldorf, Düsseldorf, Germany
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Poth A, Penger S, Knebel M, Müller T, Pantel J, Oswald F, Haberstroh J. Empowering patients with dementia to make legally effective decisions: a randomized controlled trial on enhancing capacity to consent to treatment. Aging Ment Health 2023; 27:292-300. [PMID: 34989288 DOI: 10.1080/13607863.2021.2024797] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Objectives: As our society ages, the incidence of age-related diseases increases and with it the number of medical treatments that require informed consent. Capacity to consent is often categorically questioned in persons with dementia (PwD) without appropriate assessment, depriving them of their right to autonomous decision-making. Supportive structures for PwD that comply with legal requirements are lacking. The EmMa project tried to overcome this shortcoming by developing and testing possible supportive measures to enhance the informed consent process for PwD.Method: These enhanced consent procedures (ECPs) were tested in a randomized controlled trial with 40 PwD. It was hypothesized that strengths-based ECPs could improve capacity to consent to a drug treatment in PwD as measured with a semi-structured interview.Results: Against the expectations, no effect of the ECPs on capacity to consent could be found, but the ECPs improved understanding of information in PwD.Conclusion: To empower PwD in clinical settings, however, all aspects of capacity to consent should be targeted with specific aids that are implemented carefully and selectively. More research on possible aids for ECPs is urgently needed in order to enable ethically and legally robust informed consent. In particular, effective ways to improve both reasoning and appreciation are yet to be found.
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Affiliation(s)
- Aoife Poth
- Psychological Ageing Research (PAR), University of Siegen, Siegen, Germany
| | - Susanne Penger
- Psychological Ageing Research (PAR), University of Siegen, Siegen, Germany
| | - Maren Knebel
- Interdisciplinary Ageing Research (IAW), Goethe University Frankfurt, Frankfurt, Germany
| | - Tanja Müller
- Psychological Ageing Research (PAR), University of Siegen, Siegen, Germany
| | - Johannes Pantel
- Institute of General Practice in Frankfurt am Main, Goethe University Frankfurt, Frankfurt, Germany
| | - Frank Oswald
- Interdisciplinary Ageing Research (IAW), Goethe University Frankfurt, Frankfurt, Germany
| | - Julia Haberstroh
- Psychological Ageing Research (PAR), University of Siegen, Siegen, Germany
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Solomon ED, Mozersky J, Goodman M, Parsons MV, Baldwin KA, Friedrich AB, Harris JK, DuBois JM. A randomized implementation trial to increase adoption of evidence-informed consent practices. J Clin Transl Sci 2022; 7:e28. [PMID: 36721403 PMCID: PMC9884547 DOI: 10.1017/cts.2022.520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Several evidence-informed consent practices (ECPs) have been shown to improve informed consent in clinical trials but are not routinely used. These include optimizing consent formatting, using plain language, using validated instruments to assess understanding, and involving legally authorized representatives when appropriate. We hypothesized that participants receiving an implementation science toolkit and a social media push would have increased adoption of ECPs and other outcomes. Methods We conducted a 1-year trial with clinical research professionals in the USA (n = 1284) who have trials open to older adults or focus on Alzheimer's disease. We randomized participants to receive information on ECPs via receiving a toolkit with a social media push (intervention) or receiving an online learning module (active control). Participants completed a baseline survey and a follow-up survey after 1 year. A subset of participants was interviewed (n = 43). Results Participants who engaged more with the toolkit were more likely to have tried to implement an ECP during the trial than participants less engaged with the toolkit or the active control group. However, there were no significant differences in the adoption of ECPs, intention to adopt, or positive attitudes. Participants reported the toolkit and social media push were satisfactory, and participating increased their awareness of ECPs. However, they reported lacking the time needed to engage with the toolkit more fully. Conclusions Using an implementation science approach to increase the use of ECPs was only modestly successful. Data suggest that having institutional review boards recommend or require ECPs may be an effective way to increase their use.
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Affiliation(s)
- Erin D. Solomon
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Jessica Mozersky
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Melody Goodman
- School of Global Public Health, New York University, New York, NY, USA
| | - Meredith V. Parsons
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Kari A. Baldwin
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Annie B. Friedrich
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Jenine K. Harris
- George Warren Brown School of Social Work, Washington University, St. Louis, MO, USA
| | - James M. DuBois
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
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4
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Zietlow K, Dubin L, Battles A, Vitale C. Guardianship: A medicolegal review for clinicians. J Am Geriatr Soc 2022; 70:3070-3079. [PMID: 35420158 PMCID: PMC9790446 DOI: 10.1111/jgs.17797] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/17/2022] [Accepted: 03/11/2022] [Indexed: 12/30/2022]
Abstract
Guardianship may pose an ethical dilemma for physicians, who must balance protecting vulnerable patients from potential safety concerns with respecting their autonomy. Older adults with dementia are particularly susceptible to loss of independence and the ability to participate in medical decision making. To have the capacity for medical decision making, individuals must understand relevant information, appreciate their circumstances, demonstrate reasoning, and express a consistent choice free from coercion. Although capacity assessments are usually task-specific, geriatricians and other specialists may be asked to comment on capacity more globally. These determinations may be used to support a Petition for the Appointment of a Guardian of a Legally Incapacitated Adult, the legal process of pursuing guardianship in probate court. Assigned guardians may be known to the incapacitated individual (e.g., a family member or friend) or may be professional guardians with no prior relationship to the ward. Guardians are encouraged to use substituted decision-making, taking into account the ward's previously expressed values and preferences. Although a number of viable alternatives to guardianship exist, numerous systemic barriers may prevent these from being fully explored. The ongoing need for guardianship should be periodically revisited and reassessed. Data about guardians and wards is shockingly sparse, as there are no centralized databases. Laws and regulations for guardianships vary significantly between states. Physicians can serve as important allies and advocates for patients with cognitive impairment at risk of incapacity, can help preserve their autonomy for as long as possible, and ensure appropriate protections are in place if the patient does lose their decision-making ability.
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Affiliation(s)
- Kahli Zietlow
- Division of Geriatric and Palliative Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA,Geriatric Research Education and Clinical CenterVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Leslie Dubin
- School of Social WorkUniversity of MichiganAnn ArborMichiganUSA
| | - Alethia Battles
- School of Social WorkUniversity of MichiganAnn ArborMichiganUSA,Office of the Vice President and General CounselUniversity of MichiganAnn ArborMichiganUSA
| | - Caroline Vitale
- Division of Geriatric and Palliative Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA,Geriatric Research Education and Clinical CenterVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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Decisional capacity to consent to treatment and research in patients affected by Mild Cognitive Impairment. A systematic review and meta-analysis. Int Psychogeriatr 2022; 34:529-542. [PMID: 33583459 DOI: 10.1017/s1041610220004056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To perform a meta-analysis of clinical studies on the differences in treatment or research decision-making capacity among patients with Mild Cognitive Impairment (MCI), Alzheimer's disease (AD), and healthy comparisons (HCs). DESIGN A systematic search was conducted on Medline/Pubmed, CINAHL, PsycINFO, Web of Science, and Scopus. Standardized mean differences and random-effects model were used in all cases. SETTING The United States, France, Japan, and China. PARTICIPANTS Four hundred and ten patients with MCI, 149 with AD, and 368 HCs were included. MEASUREMENTS The studies we included in the analysis assessed decisional capacity to consent by the MacArthur Competence Assessment Tool for Treatment (MAcCAT-T), MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), Capacity to Consent to Treatment Instrument (CCTI), and University of California Brief Assessment of Capacity to Consent (UBACC). RESULTS We identified 109 potentially eligible studies from 1672 records, and 7 papers were included in the meta-analysis. The meta-analysis showed that there was significant impairment in a decision-making capacity in MCI patients compared to the HCs group in terms of Understanding (SMD = -1.04, 95% CI: -1.31 to -0.77, P < 0.001; I2 = 52%, P = 0.07), Appreciation (SMD = -0.51, 95% CI: -0.66 to -0.36, P < 0.001; I2 = 0%, P = 0.97), and Reasoning (SMD = -0.62, 95% CI: -0.77, -0.47, P < 0.001; I2=0%, P =0.46). MCI patients scored significantly higher in Understanding (SMD = 1.50, 95% CI: 0.91, 2.09, P = 0.01, I2 = 78%, P = 0.00001) compared to patients affected by AD. CONCLUSIONS Patients affected by MCI are at higher risk of impaired capacity to consent to treatment and research compared to HCs, despite being at lower risk compared to patients affected by AD. Clinicians and researchers need to carefully evaluate decisional capacity in MCI patients providing informed consent.
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Cobb NL, Edwards DF, Chin EM, Lah JJ, Goldstein FC, Manzanares CM, Suver CM. From paper to screen: regulatory and operational considerations for modernizing the informed consent process. J Clin Transl Sci 2022; 6:e71. [PMID: 35836789 PMCID: PMC9257776 DOI: 10.1017/cts.2022.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/16/2022] [Accepted: 03/19/2022] [Indexed: 11/06/2022] Open
Abstract
Electronic platforms provide an opportunity to improve the informed consent (IC) process by permitting elements shown to increase research participant understanding and satisfaction, such as graphics, self-pacing, meaningful engagement, and access to additional information on demand. However, including these elements can pose operational and regulatory challenges for study teams and institutional review boards (IRBs) responsible for the ethical conduct and oversight of research. We examined the experience of two study teams at Alzheimer's Disease Research Centers who chose to move from a paper-based IC process to an electronic informed consent (eIC) process to highlight some of these complexities and explore how IRBs and study teams can navigate them. Here, we identify the key regulations that should be considered when developing and using an eIC process as well as some of the operational considerations eIC presents related to IRB review and how they can be addressed.
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Affiliation(s)
- Nichelle L. Cobb
- Association for the Accreditation of Human Research Protection Programs, Inc. (AAHRPP), Washington, DC, USA
| | - Dorothy F. Edwards
- University of Wisconsin-Madison School of Medicine and Public Health, Wisconsin Alzheimer’s Disease Research Center, Madison, WI, USA
| | - Erin M. Chin
- University of Wisconsin-Madison School of Medicine and Public Health, Wisconsin Alzheimer’s Disease Research Center, Madison, WI, USA
| | - James J. Lah
- Emory University, Goizueta Alzheimer’s Disease Research Center, Atlanta, GA, USA
| | - Felicia C. Goldstein
- Emory University, Goizueta Alzheimer’s Disease Research Center, Atlanta, GA, USA
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de Medeiros K, Girling LM, Berlinger N. Inclusion of people living with Alzheimer's disease or related dementias who lack a study partner in social research: Ethical considerations from a qualitative evidence synthesis. DEMENTIA 2022; 21:1200-1218. [PMID: 35232292 DOI: 10.1177/14713012211072501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Because use of a study partner (proxy decision-maker) to give informed consent on behalf of someone living with Alzheimer's disease or related dementias (ADRD) is common in nearly all clinical research, people living with ADRD who lack a study partner are regularly excluded from participation. Social research presents different opportunities and risks than clinical research. We argue that guidelines developed for the latter may be unduly restrictive for social research and, further, that the automatic exclusion of people living with ADRD presents separate ethical challenges by failing to support extant decision-making capacity and by contributing to underrepresentation in research. PURPOSE The study objective was to identify key components related to including cognitively vulnerable participants who lack a study partner in social research. RESEARCH DESIGN/STUDY SAMPLE We conducted an adaptive qualitative evidence synthesis (QES) and subsequent content analysis on 49 articles addressing capacity and research consent for potentially cognitively compromised individuals, to include people living with ADRD, who lack a study partner. RESULTS We identified four major topic areas: defining competency, capacity, and consent; aspects of informed consent; strategies to assess comprehension of risks associated with social research; and risks versus benefits. CONCLUSIONS Based on findings, we suggest new and ethically appropriate ways to determine capacity to consent to social research, make consent processes accessible to a population experiencing cognitive challenges, and consider the risks of excluding a growing population from research that could benefit millions.
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Affiliation(s)
- Kate de Medeiros
- Department of Sociology and Gerontology, 6403Miami University, Oxford, OH, USA
| | - Laura M Girling
- Center for Aging Studies, 14701The University of Maryland, Baltimore County, Baltimore, MD, USA
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Solomon ED, Mozersky J, Wroblewski M, Baldwin K, Parsons M, Goodman M, DuBois JM. Understanding the Use of Optimal Formatting and Plain Language When Presenting Key Information in Clinical Trials. J Empir Res Hum Res Ethics 2022; 17:177-192. [PMID: 34410175 PMCID: PMC8712347 DOI: 10.1177/15562646211037546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent revisions to the Common Rule require that consent documents begin with a focused presentation of the study's key information that is organized to facilitate understanding. We surveyed 1,284 researchers working with older adults or individuals with Alzheimer's disease, supplemented with 60 qualitative interviews, to understand current use and barriers to using evidence-based formatting and plain language in key information. Researchers reported using formatting in 42% of their key information sections, and plain language in 63% of their key information sections. Perceived barriers included lack of knowledge, Institutional Review Board, other members of their team, and the burden associated with implementation. Education and training are required to increase adoption of the practices.
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Affiliation(s)
| | | | | | - Kari Baldwin
- Washington University School of Medicine in St. Louis (USA)
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Sun W, Matsuoka T, Narumoto J. Decision-Making Support for People With Alzheimer's Disease: A Narrative Review. Front Psychol 2021; 12:750803. [PMID: 34867639 PMCID: PMC8633444 DOI: 10.3389/fpsyg.2021.750803] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/25/2021] [Indexed: 01/01/2023] Open
Abstract
The proportion of people with dementia has been increasing yearly, and the decision-making capacity of these people has become a major concern in fields such as the financial industry and in medical settings. In this narrative review, we discuss decision-making in people with Alzheimer’s disease (AD), and we propose the support for decision-making in people with AD, especially financial and medical decision-making. We summarize several hypotheses and theories on the decision-making capacity of people with AD. These include the frontal lobe hypothesis, physiological theory, dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis, and the Person-Task-Fit (PTF) framework. Both internal and external factors can affect decision-making by people with AD. Internal factors are affected by changes in the brain and neurotransmitters, as well as alterations in cognitive ability and emotion. External factors include task characters, task contents, and situation influence. Since feedback has a significant effect on decision-making capacity, a series of suggestions may be helpful to improve this capacity, such as explicit advice, simple options, pleasant rewards, the Talking Mats approach, memory and organizational aid, support by caregivers, cognitive training and feedback. Thus, in providing decision-making support for people with AD, it is important to identify the internal and external factors that impair this process and to deal with these factors.
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Affiliation(s)
- Weiyi Sun
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teruyuki Matsuoka
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Jin Narumoto
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Decision-Making in People With Dementia or Mild Cognitive Impairment: A Narrative Review of Decision-Making Tools. J Am Med Dir Assoc 2021; 22:2056-2062.e4. [PMID: 34314703 DOI: 10.1016/j.jamda.2021.06.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This review summarized the applicability of various decision-making tools for helping people with dementia or mild cognitive impairment (MCI) and their families make decisions. DESIGN This study was a narrative literature review. The protocol of this review was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42020182259). SETTING AND PARTICIPANTS People with dementia or MCI and their families were included in this study. METHODS This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We searched the Cochrane Library, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Chinese Electronic Periodical Services databases from inception to May 2021. The Joanna Briggs Institute Critical Appraisal Checklists for a variety of study designs were used. RESULTS Topics related to decision-making were categorized as everyday activity decisions or medical treatment decisions. Various types of decision-making tools were identified, and we observed that decision aids can be modified and used for both everyday activity decisions and medical treatment decisions. In addition to highlighting decision aids for specific decisional issues and topics, we also elucidated other validated tools that can be used to facilitate the decision-making process. CONCLUSIONS AND IMPLICATIONS This study highlighted the topics involved in decision-making and using decision-making tools. The current review provides information that can help individuals and health care professionals choose optimal decision-making tools. On the basis of our findings, future studies can determine the most appropriate tools for intervention or outcome measures.
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Kato Y, Matsuoka T, Eguchi Y, Iiboshi K, Koumi H, Nakamura K, Okabe K, Nakaaki S, Furukawa TA, Mimura M, Narumoto J. Anxiety Impacts Consent Capacity to Treatment in Alzheimer's Disease. Front Psychol 2021; 12:685430. [PMID: 34194376 PMCID: PMC8236526 DOI: 10.3389/fpsyg.2021.685430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Abstract
This study aimed to clarify how behavioral and psychological symptoms of dementia (BPSD) and cognitive function affect the decision-making capacity of persons with Alzheimer's disease (AD) in a real informed consent situation about anti-dementia drug prescriptions. The participants were 76 patients with AD. We used the MacArthur Competence Assessment Tool to assess the capacity for consent to treatment (MacCAT-T). We simultaneously used the Mini-Mental State Examination, Executive Interview, Executive Clock Drawing Task, Logical Memory I of the Wechsler Memory Scale-Revised (LM I), LM II, and Neuropsychiatric Inventory (NPI) to assess cognitive function and psychiatric symptoms. We calculated the correlations between the MacCAT-T scores and the demographic, neuropsychological, and psychiatric variables. Once the univariable correlations were determined, we performed simple linear regression analyses to examine if the regression equations were significant. In the final analyses, we incorporated significant variables into stepwise multiple linear regression analyses to determine the most significant predictors of mental capacity. Age (β = −0.34), anxiety (β = −0.27), and LM I (β = 0.26) were significant predictors of “understanding” (adjusted R2 = 0.29). LM II (β = 0.39), anxiety (β = −0.29), and education (β = 0.21) were significant predictors of “understanding of alternative treatments” (adjusted R2 = 0.30). Anxiety (β = −0.36) and age (β = −0.22) were significant predictors of “appreciation” (adjusted R2 = 0.18). Age (β = −0.31) and anxiety (β = −0.28) were significant predictors of explained variance in “reasoning” (adjusted R2 = 0.17). Patients with anxiety had lower scores on all five MacCAT-T subscales: “understanding,” without 3.8 [SD = 1.2] vs. with 2.6 [SD = 1.1]; “understanding of alternative treatments,” without 2.9 [SD = 2.2] vs. with 1.3 [SD = 1.8]; “appreciation,” without 2.9 [SD = 1.1] vs. with 1.9 [SD = 1.2]; “reasoning,” without 4.0 [SD = 2.0] vs. with 2.7 [SD = 1.7]; and “expressing a choice,” without 1.9 [SD = 0.4] vs. with 1.5 [SD = 0.6]. Considering the effects of BPSD, cognitive function, and age/education when assessing consent capacity in persons with AD is important. Reducing anxiety may contribute to improved capacity in persons with AD.
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Affiliation(s)
- Yuka Kato
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teruyuki Matsuoka
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoko Eguchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Kiyoko Iiboshi
- Department of Clinical Psychology, Faculty of Human Relations, Shigakukan University, Kagoshima, Japan
| | - Hiroyuki Koumi
- Department of Clinical Psychology, Faculty of Social Welfare, Hanazono University, Kyoto, Japan
| | - Kaeko Nakamura
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kayoko Okabe
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shutaro Nakaaki
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Toshiaki A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Jin Narumoto
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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12
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Wiebe E, Kelly M, McMorrow T, Tremblay-Huet S, Hennawy M. Assessment of capacity to give informed consent for medical assistance in dying: a qualitative study of clinicians' experience. CMAJ Open 2021; 9:E358-E363. [PMID: 33849985 PMCID: PMC8084565 DOI: 10.9778/cmajo.20200136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Under the Canadian Criminal Code, medical assistance in dying (MAiD) requires that patients give informed consent and that their ability to consent is assessed by 2 clinicians. In this study, we intended to understand how Canadian clinicians assessed capacity in people requesting MAiD. METHODS This qualitative study used interviews conducted between August 2019 and February 2020, by phone, video and email, to explore how clinicians assessed capacity in people requesting MAiD, what challenges they had encountered and what tools they used. The participants were recruited from provider mailing listserves of the Canadian Association of MAiD Assessors and Providers and Aide médicale à mourir. Interviews were audio-recorded and transcribed verbatim. The research team met to review transcripts and explore themes as they emerged in an iterative manner. We used abductive reasoning for thematic analysis and coding, and continued to discuss until we reached consensus. RESULTS The 20 participants worked in 5 of 10 provinces across Canada, represented different specialties and had experience assessing a total of 2410 patients requesting MAiD. The main theme was that, for most assessments, the participants used the conversation about how the patient had come to choose MAiD to get the information they needed. When the participants used formal capacity assessment tools, this was mostly for meticulous documentation, and they rarely asked for psychiatric consults. The participants described how they approached assessing cases of nonverbal patients and other challenging cases, using techniques such as ensuring a quiet environment and adequate hearing aids, and using questions requiring only "yes" or "no" as an answer. INTERPRETATION The participants were comfortable doing MAiD assessments and used their clinical judgment and experience to assess capacity in ways similar to other clinical practices. The findings of this study suggest that experienced MAiD assessors do not routinely require formal capacity assessments or tools to assess capacity in patients requesting MAiD.
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MESH Headings
- Attitude of Health Personnel
- Canada
- Clinical Decision-Making/ethics
- Clinical Decision-Making/methods
- Codes of Ethics
- Euthanasia, Active, Voluntary/ethics
- Euthanasia, Active, Voluntary/legislation & jurisprudence
- Euthanasia, Active, Voluntary/psychology
- Guidelines as Topic
- Humans
- Informed Consent/standards
- Mental Competency
- Nurses
- Physicians
- Practice Patterns, Physicians'/ethics
- Practice Patterns, Physicians'/standards
- Professional Practice/statistics & numerical data
- Qualitative Research
- Right to Die/ethics
- Right to Die/legislation & jurisprudence
- Social Control, Formal/methods
- Suicide, Assisted/ethics
- Suicide, Assisted/legislation & jurisprudence
- Suicide, Assisted/psychology
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Affiliation(s)
- Ellen Wiebe
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Michaela Kelly
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Thomas McMorrow
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Sabrina Tremblay-Huet
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Mirna Hennawy
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
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13
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Wied TS, Haberstroh J, Gather J, Karakaya T, Oswald F, Qubad M, Scholten M, Vollmann J, Pantel J. Supported Decision-Making in Persons With Dementia: Development of an Enhanced Consent Procedure for Lumbar Puncture. Front Psychiatry 2021; 12:780276. [PMID: 34867561 PMCID: PMC8635234 DOI: 10.3389/fpsyt.2021.780276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
The right to make autonomous decisions is enshrined in law. However, the question how persons with cognitive deficits can be enabled to make autonomous decisions has not been satisfactorily addressed. In particular, the concept of supported decision-making and its implementation into practice has been poorly explored for persons with dementia (PwD).This article describes the empirical development and implementation of support tools to enhance informed consent processes (so called enhanced consent procedures/ECP) for PwD on whether to undergo lumbar puncture. In the end of the process of pilot testing and further development of the tools, the following tools were defined: (1) Standardized Interview Structure, (2) Elaborated Plain Language, (3) Ambience and Room Design, (4) Keyword Lists, (5) Priority Cards, (6) Visualization, and (7) Simplified Written Informed Consent (Patient Information), as well as the general attitude (8) Person-Centered Attitude of the facilitator. As the development, implementation and evaluation of ECP tools is one objective of the transnational ENSURE project, we also include an overview of future empirical procedures. So far, our findings can serve as a selection of possibilities to support PwD in decision-making and help practitioners achieve an appropriate balance between the autonomy and protection of PwD in complex decision-making situation. Future studies should address the question if the proposed set of tools is effective to enhance informed consent processes in PwD.
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Affiliation(s)
- Theresa S Wied
- Geriatric Medicine, Institute of General Practice, Goethe University Frankfurt, Frankfurt, Germany
| | - Julia Haberstroh
- Psychological Aging Research, Institute of Psychology, University of Siegen, Siegen, Germany
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany.,Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Tarik Karakaya
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital, Goethe University, Frankfurt, Germany
| | - Frank Oswald
- Interdisciplinary Ageing Research, Faculty of Educational Sciences, Goethe University Frankfurt, Frankfurt, Germany
| | - Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital, Goethe University, Frankfurt, Germany
| | - Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Johannes Pantel
- Geriatric Medicine, Institute of General Practice, Goethe University Frankfurt, Frankfurt, Germany
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14
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Evans CJ, Yorganci E, Lewis P, Koffman J, Stone K, Tunnard I, Wee B, Bernal W, Hotopf M, Higginson IJ. Processes of consent in research for adults with impaired mental capacity nearing the end of life: systematic review and transparent expert consultation (MORECare_Capacity statement). BMC Med 2020; 18:221. [PMID: 32693800 PMCID: PMC7374835 DOI: 10.1186/s12916-020-01654-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/03/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Involving adults lacking capacity (ALC) in research on end of life care (EoLC) or serious illness is important, but often omitted. We aimed to develop evidence-based guidance on how best to include individuals with impaired capacity nearing the end of life in research, by identifying the challenges and solutions for processes of consent across the capacity spectrum. METHODS Methods Of Researching End of Life Care_Capacity (MORECare_C) furthers the MORECare statement on research evaluating EoLC. We used simultaneous methods of systematic review and transparent expert consultation (TEC). The systematic review involved four electronic databases searches. The eligibility criteria identified studies involving adults with serious illness and impaired capacity, and methods for recruitment in research, implementing the research methods, and exploring public attitudes. The TEC involved stakeholder consultation to discuss and generate recommendations, and a Delphi survey and an expert 'think-tank' to explore consensus. We narratively synthesised the literature mapping processes of consent with recruitment outcomes, solutions, and challenges. We explored recommendation consensus using descriptive statistics. Synthesis of all the findings informed the guidance statement. RESULTS Of the 5539 articles identified, 91 met eligibility. The studies encompassed people with dementia (27%) and in palliative care (18%). Seventy-five percent used observational designs. Studies on research methods (37 studies) focused on processes of proxy decision-making, advance consent, and deferred consent. Studies implementing research methods (30 studies) demonstrated the role of family members as both proxy decision-makers and supporting decision-making for the person with impaired capacity. The TEC involved 43 participants who generated 29 recommendations, with consensus that indicated. Key areas were the timeliness of the consent process and maximising an individual's decisional capacity. The think-tank (n = 19) refined equivocal recommendations including supporting proxy decision-makers, training practitioners, and incorporating legislative frameworks. CONCLUSIONS The MORECare_C statement details 20 solutions to recruit ALC nearing the EoL in research. The statement provides much needed guidance to enrol individuals with serious illness in research. Key is involving family members early and designing study procedures to accommodate variable and changeable levels of capacity. The statement demonstrates the ethical imperative and processes of recruiting adults across the capacity spectrum in varying populations and settings.
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Affiliation(s)
- C J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK.
- Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK.
| | - E Yorganci
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - P Lewis
- Centre of Medical Law and Ethics, The Dickson Poon School of Law, King's College London, London, UK
| | - J Koffman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - K Stone
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - I Tunnard
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - B Wee
- Oxford University Hospitals NHS Foundation Trust and Harris Manchester College, University of Oxford, Oxford, UK
| | - W Bernal
- King's College Hospital, London, UK
| | - M Hotopf
- Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - I J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
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15
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Pace A, Koekkoek JAF, van den Bent MJ, Bulbeck HJ, Fleming J, Grant R, Golla H, Henriksson R, Kerrigan S, Marosi C, Oberg I, Oberndorfer S, Oliver K, Pasman HRW, Le Rhun E, Rooney AG, Rudà R, Veronese S, Walbert T, Weller M, Wick W, Taphoorn MJB, Dirven L. Determining medical decision-making capacity in brain tumor patients: why and how? Neurooncol Pract 2020; 7:599-612. [PMID: 33312674 DOI: 10.1093/nop/npaa040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Brain tumor patients are at high risk of impaired medical decision-making capacity (MDC), which can be ethically challenging because it limits their ability to give informed consent to medical treatments or participation in research. The European Association of Neuro-Oncology Palliative Care Multidisciplinary Task Force performed a systematic review to identify relevant evidence with respect to MDC that could be used to give recommendations on how to cope with reduced MDC in brain tumor patients. Methods A literature search in several electronic databases was conducted up to September 2019, including studies with brain tumor and other neurological patients. Information related to the following topics was extracted: tools to measure MDC, consent to treatment or research, predictive patient- and treatment-related factors, surrogate decision making, and interventions to improve MDC. Results A total of 138 articles were deemed eligible. Several structured capacity-assessment instruments are available to aid clinical decision making. These instruments revealed a high incidence of impaired MDC both in brain tumors and other neurological diseases for treatment- and research-related decisions. Incapacity appeared to be mostly determined by the level of cognitive impairment. Surrogate decision making should be considered in case a patient lacks capacity, ensuring that the patient's "best interests" and wishes are guaranteed. Several methods are available that may help to enhance patients' consent capacity. Conclusions Clinical recommendations on how to detect and manage reduced MDC in brain tumor patients were formulated, reflecting among others the timing of MDC assessments, methods to enhance patients' consent capacity, and alternative procedures, including surrogate consent.
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Affiliation(s)
- Andrea Pace
- Neuro-Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Martin J van den Bent
- Department of Neurology, The Brain Tumor Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Helen J Bulbeck
- Brainstrust (The Brain Cancer People), Cowes, Isle of Wight, UK
| | - Jane Fleming
- Department of Palliative Medicine, University Hospital Waterford, Waterford, Ireland
| | - Robin Grant
- Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland, UK
| | - Heidrun Golla
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany
| | - Roger Henriksson
- Department of Radiation Sciences and Oncology, Umeå University, Umeå, Sweden
| | | | - Christine Marosi
- Department of Internal Medicine I, Clinical Division of Medical Oncology, Medical University of Vienna, Vienna, Austria
| | - Ingela Oberg
- Department of Neuroscience, Cambridge University Hospitals, Cambridge, UK
| | - Stefan Oberndorfer
- Department Neurology, University Clinic St Pölten, KLPU and KLI-Neurology and Neuropsychology, St Pölten, Austria
| | - Kathy Oliver
- International Brain Tumour Alliance, Tadworth, UK
| | - H Roeline W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Emilie Le Rhun
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Alasdair G Rooney
- Division of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, Edinburgh, Scotland, UK
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Simone Veronese
- Department of Palliative Care, Fondazione FARO, Turin, Italy
| | - Tobias Walbert
- Department of Neurology and Neurosurgery, Henry Ford Health System, Detroit, Michigan, US
| | - Michael Weller
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Wolfgang Wick
- Neurology Clinic and National Centre for Tumour Diseases, University Hospital Heidelberg, Heidelberg, Germany.,German Consortium of Translational Cancer Research (DKTK), Clinical Cooperation Unit Neurooncology, German Cancer Research Center, Heidelberg, Germany
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
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16
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Sisk BA, Mozersky J, Antes AL, DuBois JM. The "Ought-Is" Problem: An Implementation Science Framework for Translating Ethical Norms Into Practice. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:62-70. [PMID: 32208070 PMCID: PMC7164659 DOI: 10.1080/15265161.2020.1730483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
We argue that once a normative claim is developed, there is an imperative to effect changes based on this norm. As such, ethicists should adopt an "implementation mindset" when formulating norms, and collaborate with others who have the expertise needed to implement policies and practices. To guide this translation of norms into practice, we propose a framework that incorporates implementation science into ethics. Implementation science is a discipline dedicated to supporting the sustained enactment of interventions. We further argue that implementation principles should be integrated into the development of specific normative claims as well as the enactment of these norms. Ethicists formulating a specific norm should consider whether that norm can feasibly be enacted because the resultant specific norm will directly affect the types of interventions subsequently developed. To inform this argument, we will describe the fundamental principles of implementation science, using informed consent to research participation as an illustration.
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17
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Ries NM, Mansfield E, Sanson-Fisher R. Ethical and legal aspects of research involving older people with cognitive impairment: A survey of dementia researchers in Australia. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 68:101534. [PMID: 32033698 DOI: 10.1016/j.ijlp.2019.101534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 12/03/2019] [Indexed: 06/10/2023]
Abstract
People with dementia are under-represented in clinical research, in part due to the ethical and legal complexities of involving people in studies who may lack capacity to consent. Excluding this population from research limits the evidence to inform care. The attitudes and practices of researchers are key to the inclusion of people with dementia in research, however, there are few empirical studies on researchers' perspectives in this area. A cross-sectional study involved researchers in Australia who had experience in the ethical aspects of conducting dementia-related studies with human participants (n = 70). Data were collected via an online survey from November 2017 to January 2018. Most respondents (97%) agreed with the importance of including people at all stages of dementia in research, yet around three-quarters of respondents perceived ethical and legal rules and processes as unduly restrictive or time-consuming. Researchers reported variable practices in assessing prospective participants' capacity to consent to their studies. Various tools are used for this purpose, ranging from tools designed for research (eg, MacArthur Competence Assessment Tool for Clinical Research) to more general cognitive function screens (eg, Mini Mental State Exam). Few respondents (14%) routinely exclude people from studies who are unable to give their own consent, but instead seek permission from proxy decision-makers, such as legally appointed guardians or family carers. Respondents reported positive and negative outcomes of ethics review processes. Positive outcomes included strengthening the protections for participants with cognitive impairment while negative outcomes included delays and inconsistent decisions from different ethics committees. The findings suggest a need for improved strategies in the research context to assess and enhance the decision-making capacity of people with dementia to support appropriate opportunities for inclusion. Education for ethics committees, proxy decision-makers and other gatekeepers is also needed to reduce barriers to participation in research.
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Affiliation(s)
- Nola M Ries
- Faculty of Law, University of Technology Sydney, PO Box 123, Broadway, NSW 2007, Australia.
| | - Elise Mansfield
- Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.
| | - Rob Sanson-Fisher
- Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.
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18
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Carpenter CR, McFarland F, Avidan M, Berger M, Inouye SK, Karlawish J, Lin FR, Marcantonio E, Morris J, Reuben D, Shah R, Whitson H, Asthana S, Verghese J. Impact of Cognitive Impairment Across Specialties: Summary of a Report From the U13 Conference Series. J Am Geriatr Soc 2019; 67:2011-2017. [PMID: 31436318 PMCID: PMC6800784 DOI: 10.1111/jgs.16093] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/27/2019] [Accepted: 06/30/2019] [Indexed: 11/28/2022]
Abstract
Although declines in cognitive capacity are assumed to be a characteristic of aging, increasing evidence shows that it is age-related disease, rather than age itself, that causes cognitive impairment. Even so, older age is a primary risk factor for cognitive decline, and with individuals living longer as a result of medical advances, cognitive impairment and dementia are increasing in prevalence. On March 26 to 27, 2018, the American Geriatrics Society convened a conference in Bethesda, MD, to explore cognitive impairment across the subspecialties. Bringing together representatives from several subspecialties, this was the third of three conferences, supported by a U13 grant from the National Institute on Aging, to aid recipients of Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) in integrating geriatrics into their subspecialties. Scientific sessions focused on the impact of cognitive impairment, sensory contributors, comorbidities, links between delirium and dementia, and issues of informed consent in cognitively impaired populations. Discussions highlighted the complexity not only of cognitive health itself, but also of the bidirectional relationship between cognitive health and the health of other organ systems. Thus, conference participants noted the importance of multidisciplinary team science in future aging research. This article summarizes the full conference report, "The Impact of Cognitive Impairment Across Specialties," and notes areas where GEMSSTAR scholars can contribute to progress as they embark on their careers in aging research. J Am Geriatr Soc 67:2011-2017, 2019.
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Affiliation(s)
| | | | | | | | | | | | | | | | - John Morris
- Washington University School of Medicine, St. Louis, MO
| | | | - Raj Shah
- Rush University Medical Center, Chicago, IL
| | - Heather Whitson
- Duke University School of Medicine, Durham, NC and Geriatrics Research Education and Clinical Center, Durham VA, Durham, NC
| | - Sanjay Asthana
- University of Wisconsin, Madison, WI
- Albert Einstein College of Medicine, Bronx, NY
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19
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Mejia AM, Smith GE, Wicklund M, Armstrong MJ. Shared decision making in mild cognitive impairment. Neurol Clin Pract 2018; 9:160-164. [PMID: 31041132 DOI: 10.1212/cpj.0000000000000576] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/05/2018] [Indexed: 11/15/2022]
Abstract
Shared decision making (SDM) occurs when patients and clinicians consider patients' values and preferences while discussing medical evidence to inform healthcare decisions. SDM enables patients with mild cognitive impairment (MCI) to express values and preferences when making current healthcare decisions and presents a unique opportunity to inform future decision making in the case of further cognitive decline. However, clinicians often fail to facilitate SDM with patients with MCI. This review describes research pertaining to value solicitation, weighing of the medical evidence, and medical decision making for individuals with MCI, explores the role of caregivers, identifies barriers to and facilitators of SDM in MCI, and suggests strategies to optimize SDM for persons with MCI in neurology clinical practice. Further research is needed to identify more strategies for decision support for individuals affected by cognitive impairment.
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Affiliation(s)
- Andrea M Mejia
- Department of Clinical and Health Psychology (AMM, GES), University of Florida College of Public Health and Health Professions; and Department of Neurology (MW, MJA), University of Florida College of Medicine, Gainesville, FL
| | - Glenn E Smith
- Department of Clinical and Health Psychology (AMM, GES), University of Florida College of Public Health and Health Professions; and Department of Neurology (MW, MJA), University of Florida College of Medicine, Gainesville, FL
| | - Meredith Wicklund
- Department of Clinical and Health Psychology (AMM, GES), University of Florida College of Public Health and Health Professions; and Department of Neurology (MW, MJA), University of Florida College of Medicine, Gainesville, FL
| | - Melissa J Armstrong
- Department of Clinical and Health Psychology (AMM, GES), University of Florida College of Public Health and Health Professions; and Department of Neurology (MW, MJA), University of Florida College of Medicine, Gainesville, FL
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20
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van Duinkerken E, Farme J, Landeira-Fernandez J, Dourado MC, Laks J, Mograbi DC. Medical and Research Consent Decision-Making Capacity in Patients with Alzheimer’s Disease: A Systematic Review. J Alzheimers Dis 2018; 65:917-930. [DOI: 10.3233/jad-180311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Eelco van Duinkerken
- Center for Epilepsy, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Department of Medical Psychology, Amsterdam University Medical Centers, Free University, Amsterdam, the Netherlands
- Amsterdam Diabetes Center / Department of Internal Medicine, Amsterdam University Medical Centers, Free University, Amsterdam, the Netherlands
| | - Juliana Farme
- Department of Psychology, Pontifícia Universidade Católica Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jesus Landeira-Fernandez
- Department of Psychology, Pontifícia Universidade Católica Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcia C. Dourado
- Alzheimer’s Disease Center / Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jerson Laks
- Alzheimer’s Disease Center / Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Post Graduation Program in Translational Biomedicine- Universidade do Grande Rio, Duque de Caxias, Rio de Janeiro, Brazil
| | - Daniel C. Mograbi
- Department of Psychology, Pontifícia Universidade Católica Rio de Janeiro, Rio de Janeiro, Brazil
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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21
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Patira R, Zhao H, Azizi A. A retrospective analysis of care in patients with dementia hospitalized at a tertiary medical center. Aging Ment Health 2018; 22:773-777. [PMID: 28326805 DOI: 10.1080/13607863.2017.1304525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hospitalization is an opportunity to address various aspects related to management of dementia, including the goals of care to avoid futile care. We studied the prevalence of these factors when patients with dementia are hospitalized. DESIGN One hundred and thirty-one charts of patients with dementia admitted to a single university-based hospital were retrospectively reviewed. Data were collected and analyzed for age, gender, the severity of dementia, co-morbidities, co-existing vascular dementia, reversible causes of dementia, mental status scores, medications, consultations, procedures, complications, availability of advance directives, decision-maker, code status, and goals of care discussion. RESULTS In patients with dementia, co-morbidities and vascular disease burden were frequent. When these patients were hospitalized, use of psychotropic medications, invasive procedures, and multi-specialty consultations was common. Tests of mental status, screening for reversible causes, and use of FDA-approved medications for dementia is less common. Despite the lack of advance directives, goals of care were infrequently discussed. When goals of care were discussed, proxy decision-maker preferred palliative care and long-term institutionalization on discharge. CONCLUSION Goals of care and other aspects of management are not fully addressed in hospitalized patients with dementia.
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Affiliation(s)
- Riddhi Patira
- a Department of Neurology, Temple University Hospital , Philadelphia , PA , USA
| | - Huaqing Zhao
- b Department of Biostatistics, Temple University Hospital , Philadelphia , PA , USA
| | - Ausim Azizi
- a Department of Neurology, Temple University Hospital , Philadelphia , PA , USA
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22
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Palmer BW, Harmell AL, Dunn LB, Kim SY, Pinto LL, Golshan S, Jeste DV. Multimedia Aided Consent for Alzheimer's Disease Research. Clin Gerontol 2018; 41:20-32. [PMID: 29182458 PMCID: PMC6085078 DOI: 10.1080/07317115.2017.1373177] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Optimizing the research consent process simultaneously fosters respect for autonomy and protection of those with diminished capacity for autonomy. This study evaluated the effectiveness of an enhanced research consent procedure, employing multimedia disclosure and corrective feedback, in improving decisional capacity among 114 people with mild-to-moderate Alzheimer's disease (AD) and 134 non-psychiatric comparison (NC) subjects. METHODS Participants were randomized to consent type (routine versus enhanced) and protocol type (lower versus higher risk). Outcomes included a 5-item questionnaire assessing immediate comprehension, MacArthur Competence Assessment Tool for Clinical Research assessing four components of decision-making capacity, and categorical decisional capacity (based on a cut-score established in reference to expert judgments for a subset of participants). RESULTS There was no significant effect of the enhanced consent procedure, relative to routine consent, on immediate comprehension or decisional capacity. CONCLUSIONS Multimedia tools do not appear to be the solution to better consent for AD research. CLINICAL IMPLICATIONS Given the ethical primacy of informed consent and issues of justice for impaired populations who might be harmed by an absence of research-based treatment advances, continued search for ways to more meaningfully engage people with AD in the consent or assent process is warranted.
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Affiliation(s)
- Barton W Palmer
- a Veterans Affairs San Diego Healthcare System , San Diego , California , USA.,b Veterans Medical Research Foundation , San Diego , California , USA.,c Department of Psychiatry , University of California, San Diego , La Jolla , California , USA.,d Center for Healthy Aging/Stein Institute for Research on Aging , University of California, San Diego , La Jolla , California , USA
| | - Alexandrea L Harmell
- c Department of Psychiatry , University of California, San Diego , La Jolla , California , USA.,d Center for Healthy Aging/Stein Institute for Research on Aging , University of California, San Diego , La Jolla , California , USA.,e San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology , San Diego , California , USA.,f Mental Health Service , San Francisco VA Healthcare System , San Francisco , California , USA
| | - Laura B Dunn
- g Department of Psychiatry and Behavioral Sciences , Stanford University , Stanford , California , USA
| | - Scott Y Kim
- h Department of Bioethics , National Institute of Health , Bethesda , Maryland , USA
| | - Luz L Pinto
- b Veterans Medical Research Foundation , San Diego , California , USA.,c Department of Psychiatry , University of California, San Diego , La Jolla , California , USA.,d Center for Healthy Aging/Stein Institute for Research on Aging , University of California, San Diego , La Jolla , California , USA
| | - Shahrokh Golshan
- b Veterans Medical Research Foundation , San Diego , California , USA.,c Department of Psychiatry , University of California, San Diego , La Jolla , California , USA
| | - Dilip V Jeste
- c Department of Psychiatry , University of California, San Diego , La Jolla , California , USA.,d Center for Healthy Aging/Stein Institute for Research on Aging , University of California, San Diego , La Jolla , California , USA
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Gilbert T, Bosquet A, Thomas-Antérion C, Bonnefoy M, Le Saux O. Assessing capacity to consent for research in cognitively impaired older patients. Clin Interv Aging 2017; 12:1553-1563. [PMID: 29026293 PMCID: PMC5627738 DOI: 10.2147/cia.s141905] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The number of clinical trials including older patients, and particularly patients with cognitive impairment, is increasing. While statutory provisions exist to make sure that the capacity to consent is assessed systematically for each patient, many gray areas remain with regard to how this assessment is made or should be made in the routine practice of clinical research. Objectives The aim of this review was to draw up an inventory of assessment tools evaluating older patients’ capacity to consent specifically applicable to clinical research, which could be used in routine practice. Methods Two authors independently searched PubMed, Cochrane, and Google Scholar data-bases between November 2015 and January 2016. The search was actualized in April 2017. We used keywords (MeSH terms and text words) referring to informed consent, capacity to consent, consent for research, research ethics, cognitive impairment, vulnerable older patients, and assessment tools. Existing reviews were also considered. Results Among the numerous existing tools for assessing capacity to consent, 14 seemed potentially suited for clinical research and six were evaluated in older patients. The MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) was the most frequently cited. Conclusion The MacCAT-CR is currently the most used and the best validated questionnaire. However, it appears difficult to use and time-consuming. A more recent tool, the University of California Brief Assessment of Capacity to Consent (UBACC), seems interesting for routine practice because of its simplicity, relevance, and applicability in older patients.
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Affiliation(s)
- Thomas Gilbert
- Geriatric Department, Hospices Civils de Lyon, Lyon Sud Hospital, Pierre-Bénite, France
| | - Antoine Bosquet
- Internal Medicine Unit, AP-HP - Louis Mourier Hospital, Colombes, France
| | - Catherine Thomas-Antérion
- Plein Ciel, Lyon, France.,Laboratory for the Study of Cognitive Mechanisms, Lyon 2 University, Lyon, France
| | - Marc Bonnefoy
- Geriatric Department, Hospices Civils de Lyon, Lyon Sud Hospital, Pierre-Bénite, France
| | - Olivia Le Saux
- Geriatric Department, Hospices Civils de Lyon, Lyon Sud Hospital, Pierre-Bénite, France
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Palmer BW, Harmell AL, Pinto LL, Dunn LB, Kim SYH, Golshan S, Jeste DV. Determinants of Capacity to Consent to Research on Alzheimer's disease. Clin Gerontol 2016; 40:24-34. [PMID: 28154452 PMCID: PMC5279898 DOI: 10.1080/07317115.2016.1197352] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Investigators conducting Alzheimer's disease (AD) research need to consider participants' capacity to consent. Cognitive functioning is a significant predictor of decisional capacity, but there is a dearth of information on the influence of neuropsychiatric symptoms in AD on decisional capacity. We examined the rates of decisional capacity associated with two types of research protocols, and the association of capacity with neuropsychiatric symptoms and other participant characteristics. METHODS We comprehensively evaluated decisional capacity among 64 patients with mild-to-moderate AD and 70 healthy comparison (HC) subjects randomized to consider either a medium risk or higher risk hypothetical research protocol. Additional measures included sociodemographics, cognitive deficits, and neuropsychiatric symptoms. RESULTS Twenty AD patients (31.3%) and 67 HCs (95.7%) were deemed capable; 44 AD patients (68.8%) and 3 HCs (4.3%) incapable of consent. Age, education, and severity of cognitive deficits were associated with incapable status; there were no significant associations with severity of neuropsychiatric symptoms or protocol risk level. CONCLUSIONS Findings highlight the importance of understanding of capacity and its assessment among people with AD, rather than treating AD diagnosis as synonymous with impaired capacity. As novel treatments move from bench to bedside, methods of assessing and addressing capacity impairment must similarly advance. CLINICAL IMPLICATIONS In assessing research consent capacity, use structured assessments with population specific cut scores interpreted in the context of the person's background including education, culture, and language. Individuals should be encouraged to execute research proxy documents when able.
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Affiliation(s)
- Barton W. Palmer
- Department of Psychiatry, University of California, San Diego
- Veterans Medical Research Foundation, San Diego, CA
- Veterans Affairs San Diego Healthcare System
- Center for Healthy Aging/Stein Institute for Research on Aging, University of California, San Diego
| | - Alexandrea L. Harmell
- Department of Psychiatry, University of California, San Diego
- Center for Healthy Aging/Stein Institute for Research on Aging, University of California, San Diego
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA
| | - Luz L. Pinto
- Department of Psychiatry, University of California, San Diego
- Center for Healthy Aging/Stein Institute for Research on Aging, University of California, San Diego
| | - Laura B. Dunn
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA
| | - Scott Y. H. Kim
- Department of Bioethics, National Institute of Health, Bethesda, MD
| | - Shahrokh Golshan
- Department of Psychiatry, University of California, San Diego
- Veterans Affairs San Diego Healthcare System
| | - Dilip V. Jeste
- Department of Psychiatry, University of California, San Diego
- Center for Healthy Aging/Stein Institute for Research on Aging, University of California, San Diego
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Zeng L, Liang W, Pan J, Cao Y, Liu J, Wang Q, Wang L, Zou Y, Wang K, Kong L, Xie H, Xu W, Li W, Zhao W, Mi S, Chen Y, Cheng S, Li X, Cao Q, Zeng X, Wang N. Do Chinese Researchers Conduct Ethical Research and Use Ethics Committee Review in Clinical Trials of Anti-Dementia Drugs? An Analysis of Biomedical Publications Originating from China. J Alzheimers Dis 2016; 52:813-23. [PMID: 27031471 DOI: 10.3233/jad-150858] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Lingfeng Zeng
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, China
- Ethics Committee, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Weixiong Liang
- Drug Clinical Trial Institute, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Jianke Pan
- The 2nd School of Clinic Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ye Cao
- Clinical Trials Center, Cancer Center, Sun Yat-sen University/National Drug Clinical Trial Institute, Guangzhou, China
| | - Jun Liu
- Ethics Committee, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Qi Wang
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, China
- Drug Clinical Trial Institute, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Lu Wang
- Ethics Review Committee, World Federation of Chinese Medicine Societies, Beijing, China
| | - Yuanping Zou
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Kezhu Wang
- Institute of Medicinal Plant Development of Chinese Academy of Medical Sciences, Beijing, China
| | - Lingshuo Kong
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hui Xie
- The 2nd School of Clinic Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Weihua Xu
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Weirong Li
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wei Zhao
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Suiqing Mi
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yunbo Chen
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shuyi Cheng
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaoyan Li
- Ethics Committee, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Qian Cao
- Ethics Committee, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Xing Zeng
- Ethics Committee, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Ningsheng Wang
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangzhou University of Chinese Medicine, Guangzhou, China
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Moelter ST, Weintraub D, Mace L, Cary M, Sullo E, Xie SX, Karlawish J. Research consent capacity varies with executive function and memory in Parkinson's disease. Mov Disord 2016; 31:414-7. [PMID: 26861463 DOI: 10.1002/mds.26469] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 10/01/2015] [Accepted: 10/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We examined the association between cognitive domains and research consent capacity in PD. Our hypothesis was that research consent capacity is best predicted by executive function. METHODS A cohort of 90 PD patients and 30 healthy older adults were administered the MacArthur Competence Assessment Tool for Clinical Research, Dementia Rating Scale-2, and the MoCA. Experts classified patients as either "capable" or "not capable" of providing informed consent to participate in two clinical trials. RESULTS MacArthur Competence Assessment Tool for Clinical Research Reasoning scores for both clinical trial types were most associated with executive functions and delayed recall. As scores on these domains improved, the odds of an expert rating of "capable of consent" increased. CONCLUSIONS These results extend our previous findings by demonstrating that memory and executive abilities appear closely associated with capacity when evaluated using either a structured interview or expert judgment of that interview.
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Affiliation(s)
- Stephen T Moelter
- Department of Behavioral and Social Sciences, University of the Sciences, Philadelphia, Pennsylvania, USA
| | - Daniel Weintraub
- Parkinson's Disease Research, Education and Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Mental Illness Research, Education and Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Department of Psychiatry, Geriatric Psychiatry Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lauren Mace
- Department of Behavioral and Social Sciences, University of the Sciences, Philadelphia, Pennsylvania, USA
| | - Mark Cary
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth Sullo
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sharon X Xie
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Karlawish
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Alzheimer's Disease Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Wang X, Yu X, Appelbaum PS, Tang H, Yao G, Si T, Ma Y, Li T, Yu L, Shi C, Ma Y, Li L. Longitudinal informed consent competency in stable community patients with schizophrenia: A one-week training and one-year follow-up study. Schizophr Res 2016; 170:162-7. [PMID: 26678983 DOI: 10.1016/j.schres.2015.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 11/17/2015] [Accepted: 11/20/2015] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This study explores the efficacy of a one-week informed consent information training process for improving competence to provide consent in stable community patients with schizophrenia over a one-year follow-up period. METHOD A one-week training session designed to enhance competence to provide informed consent for research was conducted. The training was guided by a research protocol that provided detailed explanations of each major conceptual unit. Participants were followed for one year, and comprised 50 stable community outpatients with schizophrenia who were randomly assigned to either an intervention group (IG, n=33) or a control group (CG, n=17) that did not receive any training. The Chinese Mandarin MacArthur Competence Assessment Tool-Clinical Research (MacCAT-CR) was used to assess competence for informed consent pre-training (baseline), post-training (one week later), and at the end of one year. RESULTS A repeated measures analysis comparing the IG and CG at pre-training, post-training and the one-year follow-up revealed significant improvements in the Understanding and Appreciation subscale following the one-week training. However, by the end of one year, scores returned to baseline levels, with the exception of the Appreciation subscale, which was below baseline. There were significant main effects across time on the Appreciation and Reasoning subscales, indicating considerable changes over time. The CG showed no significant changes from pre-training to one week later or at one-year follow-up for all subscales. CONCLUSIONS The capacities of understanding and appreciation can be improved in stable community patients with schizophrenia after one week of training; however, this training effect is not sustained one year later. The results suggest that more intensive or periodic trainings may be needed to maintain long-term competence levels in patients with schizophrenia, particularly with regard to their capacity to appreciate the nature and consequences of study participation.
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Affiliation(s)
- Xueqin Wang
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Xin Yu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China.
| | - Paul S Appelbaum
- Columbia University College of Physicians & Surgeons, Department of Psychiatry, USA
| | - Hongyu Tang
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Guizhong Yao
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Tianmei Si
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Yating Ma
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Tao Li
- Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ling Yu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Chuan Shi
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Yibin Ma
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Lingli Li
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
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Informierte Einwilligung in der Demenzforschung. Eine qualitative Studie zum Informationsverständnis von Probanden. Ethik Med 2015. [DOI: 10.1007/s00481-015-0359-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Boland J, Currow DC, Wilcock A, Tieman J, Hussain JA, Pitsillides C, Abernethy AP, Johnson MJ. A systematic review of strategies used to increase recruitment of people with cancer or organ failure into clinical trials: implications for palliative care research. J Pain Symptom Manage 2015; 49:762-772.e5. [PMID: 25546286 DOI: 10.1016/j.jpainsymman.2014.09.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 08/31/2014] [Accepted: 09/22/2014] [Indexed: 11/27/2022]
Abstract
CONTEXT The challenges of palliative care clinical trial recruitment are well documented. OBJECTIVES The aim of the study was to review tested strategies to improve recruitment to trials of people with a range of conditions who may access palliative care services but are not explicitly stated to be "palliative." METHODS This was a systematic review with narrative description. The Cochrane, Embase, PubMed, PsycINFO, and CINAHL electronic databases were searched (English; January 2002 to February 2014) for quasi-experimental and randomized controlled trials (RCTs) testing the effect of recruitment strategies on accrual to clinical trials of people with organ failure and cancer. Titles, abstracts, and retrieved articles were screened by two researchers and categorized by recruitment challenge: 1) patients with reduced cognition, 2) those requiring emergency treatment, and 3) willingness of patients and clinical staff to contribute to trials. RESULTS Of 549 articles identified, 15 were included. Thirteen reported RCTs and two papers reported three quasi-experimental studies. Five were cluster RCTs of recruiting sites/institutions. One was a randomized cluster, crossover, feasibility study. Seven studies recruited patients with cancer. Others included patients with dementia, stroke, cardiovascular disease, diabetes, frail elderly, and bereaved carers. Some interventions improved recruitment: memory aid, contact before arrival, cluster consent, "opt out" consent. Others either reduced recruitment (formal mental capacity assessment) or made no difference (advance research directive; a variety of educational, supportive, and advertising interventions). CONCLUSION Successful strategies from other disciplines could be considered by palliative care researchers. Tailored, efficient, evidence-based strategies must be developed, acknowledging that strategies with face validity are not necessarily the most effective.
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Affiliation(s)
- Jason Boland
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia
| | | | - Jennifer Tieman
- Discipline, Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia
| | | | | | - Amy P Abernethy
- Discipline, Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia; Division of Medical Oncology, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
| | - Miriam J Johnson
- Hull York Medical School, University of Hull, Hull, United Kingdom.
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Karlawish J, Cary M, Moelter ST, Siderowf A, Sullo E, Xie S, Weintraub D. Cognitive impairment and PD patients' capacity to consent to research. Neurology 2013; 81:801-7. [PMID: 23892706 DOI: 10.1212/wnl.0b013e3182a05ba5] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine how cognitive impairment affects Parkinson disease (PD) patients' research consent capacity. METHODS A cross-sectional study of 90 patients with PD, divided using Mattis Dementia Rating Scale-2 scores into 3 groups of 30 (normal, borderline, and impaired), and 30 neurologically normal older adults completed 2 capacity interviews (an early-phase randomized and controlled drug trial and a sham-controlled surgical implantation of genetic tissue) using the MacArthur Competence Assessment Tool for Clinical Research. Expert clinicians used the interviews to classify the patients as either capable or not capable of providing their own informed consent. These judgments were compared with performance on the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE). RESULTS Cognitively normal PD patients typically scored well on the capacity measures. In contrast, patients with impaired cognition were not capable of providing their own informed consent: 17% (5/30) on the drug trial and 3% (1/30) on the surgery trial were judged capable. Patients with borderline impairment showed adequate performance on measures of appreciation and reasoning, but impaired performance on understanding the drug trial compared with normal controls and normal PD patients, and on understanding the surgery trial compared with normal controls. Sixty-seven percent (20/30) on the drug trial and 57% (17/30) on the surgery trial were judged capable of consent. Receiver operating characteristic analyses showed that the MMSE and MoCA could detect the likelihood of impaired capacity, with the MoCA demonstrating greater sensitivity. CONCLUSIONS PD patients with borderline cognitive impairment have impairments in their decisional capacity. The MoCA may be useful to identify the patients at risk of impaired capacity.
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Palmer BW, Ryan KA, Kim HM, Karlawish JH, Appelbaum PS, Kim SYH. Neuropsychological correlates of capacity determinations in Alzheimer disease: implications for assessment. Am J Geriatr Psychiatry 2013; 21:373-81. [PMID: 23498384 PMCID: PMC3382031 DOI: 10.1016/j.jagp.2012.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 10/06/2011] [Accepted: 10/20/2011] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To explore the neuropsychological correlates of the capacity to consent to research and to appoint a research proxy among persons with Alzheimer disease. DESIGN, SETTING, AND PARTICIPANTS Interview study of 77 persons with Alzheimer disease recruited through an Alzheimer disease research center and a memory disorder clinic. MEASUREMENTS The capacity to consent to two research scenarios (a drug randomized clinical trial and a neurosurgical clinical trial) and the capacity to appoint a research proxy were determined by five experienced consultation psychiatrists who rendered categorical judgments based on videotaped interviews of the MacArthur Competence Assessment Tool-Clinical Research and the Capacity to Appoint a Proxy Assessment. Mattis Dementia Rating Scale-Second Edition was used to assess neuropsychological functioning. RESULTS The capacity to appoint a proxy and to consent to the drug randomized clinical trial, as determined by a majority or greater opinion of the five-psychiatrist panel, was predicted by Conceptualization and Initiation/Perseveration subscales, whereas the capacity to consent to a neurosurgical randomized clinical trial was predicted by the Memory subscale. Furthermore, the more lenient individual psychiatrists' judgments were predicted by the Conceptualization subscale, whereas the stricter psychiatrists' judgments were predicted by the Memory subscale. CONCLUSIONS How experienced psychiatrists view the capacity of patients with Alzheimer disease for consenting to research and for appointing a proxy may be related to the patients' conceptualization and memory functioning. More explicit and standardized guidance on the role of short-term memory in capacity determinations may be useful.
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Affiliation(s)
- Barton W. Palmer
- Department of Psychiatry, University of California, San Diego, CA
| | - Kerry A. Ryan
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | - H. Myra Kim
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI
| | - Jason H. Karlawish
- Departments of Medicine and Medical Ethics, Division of Geriatrics, Alzheimer’s Disease Center, Center for Bioethics, and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Paul S. Appelbaum
- Division of Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, NY
| | - Scott Y. H. Kim
- Center for Bioethics and Social Sciences in Medicine and Department of Psychiatry, University of Michigan, Ann Arbor, MI
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33
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Klein E, Karlawish J. Ethical issues in the neurology of aging and cognitive decline. HANDBOOK OF CLINICAL NEUROLOGY 2013; 118:233-42. [DOI: 10.1016/b978-0-444-53501-6.00020-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
The aging adult population is growing, as well as the incidence of chronic illness among older adults. Physical activity (PA) has been demonstrated in the literature to be a beneficial component of self-management for chronic illnesses commonly found in the older adult population. Health sciences research seeks to develop new knowledge, practices, and policies that may benefit older adults' management of chronic illness and quality of life. However, research with the older adult population, though beneficial, includes potential methodological challenges specific to this age group. This article discusses common methodological issues in research among older adults, with a focus on PA intervention studies. Awareness and understanding of these issues may facilitate future development of research studies devoted to the aging adult population, through appropriate modification and tailoring of sampling techniques, intervention development, and data measures and collection.
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Trojanowski JQ, Arnold SE, Karlawish JH, Naylor M, Brunden KR, Lee VMY. A model for improving the treatment and care of Alzheimer's disease patients through interdisciplinary research. Alzheimers Dement 2012; 8:564-73. [PMID: 23102127 PMCID: PMC3643202 DOI: 10.1016/j.jalz.2011.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 08/22/2011] [Accepted: 08/24/2011] [Indexed: 12/31/2022]
Abstract
The emerging global epidemic of Alzheimer's disease (AD) demands novel paradigms to address the two unmet needs of the field: (a) cost-effective health care delivery programs/services, and (b) clinical and basic research to accelerate therapy discovery/development. This report outlines a model demonstration project, the Marian S. Ware Alzheimer Program at the University of Pennsylvania, which was designed to achieve four specific aims: (1) improve the integration and continuity of AD care; (2) identify biomarkers that detect the earliest presence of AD and related neurodegenerative cognitive disorders; (3) enhance both the design and conduct of clinical trials as well as review their results to more effectively test new AD therapies and translate valuable therapies into clinical practice; and (4) discover and develop novel disease-modifying small molecule treatments for AD. The "Ware-UPenn" program has been presented in this report as a useful prototype for partnerships between private philanthropy and academia in planning and developing programs to address a major national public health problem.
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Taylor JS, DeMers SM, Vig EK, Borson S. The Disappearing Subject: Exclusion of People with Cognitive Impairment and Dementia from Geriatrics Research. J Am Geriatr Soc 2012; 60:413-9. [DOI: 10.1111/j.1532-5415.2011.03847.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Elizabeth K. Vig
- Department of Geriatrics University of Washington
- Geriatrics and Extended Care Veterans Affairs Puget Sound Health Care System Seattle Washington
| | - Soo Borson
- Department of Psychiatry and Behavioral Sciences
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Hamann J, Bronner K, Margull J, Mendel R, Diehl-Schmid J, Bühner M, Klein R, Schneider A, Kurz A, Perneczky R. Patient Participation in Medical and Social Decisions in Alzheimer's Disease. J Am Geriatr Soc 2011; 59:2045-52. [PMID: 22092150 DOI: 10.1111/j.1532-5415.2011.03661.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Johannes Hamann
- Department of Psychiatry; Technische Universität München; München; Germany
| | - Katharina Bronner
- Department of Psychiatry; Technische Universität München; München; Germany
| | - Julia Margull
- Department of Psychiatry; Technische Universität München; München; Germany
| | - Rosmarie Mendel
- Department of Psychiatry; Technische Universität München; München; Germany
| | | | - Markus Bühner
- Department of Psychology; Karl-Franzens-Universität Graz; Graz; Austria
| | - Reinhold Klein
- Institute of General Practice; Technische Universität München; München; Germany
| | - Antonius Schneider
- Institute of General Practice; Technische Universität München; München; Germany
| | - Alexander Kurz
- Department of Psychiatry; Technische Universität München; München; Germany
| | - Robert Perneczky
- Department of Psychiatry; Technische Universität München; München; Germany
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Dubois J, Bante H, Hadley WB. Ethics in Psychiatric Research: A Review of 25 Years of NIH-funded Empirical Research Projects. AJOB PRIMARY RESEARCH 2011; 2:5-17. [PMID: 23259152 PMCID: PMC3524581 DOI: 10.1080/21507716.2011.631514] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND: This paper reviews the past 25 years of empirical research funded by the National Institutes of Health (NIH) on matters of ethics in psychiatric research. METHODS: Using the NIH RePORTER and Medline databases, we identified 43 grants and 77 publications that involved the empirical study of a matter of ethics in research involving mental health service users. RESULTS: These articles provide original and useful information on important topics, most especially the capacity to consent and the voluntariness of consent. For example, participants who share a diagnosis vary widely in levels of cognitive impairment that correlate with decisional capacity, and capacity to consent can be enhanced easily using iterative consent processes. Few articles address matters of justice or benefits in research, particularly from the perspectives of participants. No articles address matters of privacy, confidentiality, or researcher professionalism. CONCLUSIONS: Despite the usefulness of data from the studies conducted to date, current research on research ethics in psychiatry does not adequately address the concerns of service users as expressed in recent publications.
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Affiliation(s)
- James Dubois
- Saint Louis University - Gnaegi Center for Health Care Ethics, 221 North Grand Blvd, St. Louis, Missouri 63103,
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