Evaluating Informed Consent for Colonoscopy

Aids to improve understanding of statistical risk in patients consenting for surgery and interventional procedures: A systematic review

BACKGROUND

Informed consent is an essential process in clinical decision-making, through which healthcare providers educate patients about benefits, risks, and alternatives of a procedure. Statistical risk information is difficult to communicate and the effectiveness of aids aimed at supporting this type of communication is uncertain. This systematic review aims to study the impact of risk communication adjuncts on patients' understanding of statistical risk in surgery and interventional procedures.

METHODS

A systematic search was performed across Medline, Embase, PsycINFO, Scopus, and Web of Science until July 2021 with a repeated search in September 2022. RCTs and observational studies examining risk communication tools (e.g., information leaflets and audio-video) in adult (age >16) patients undergoing a surgical or interventional procedure were included. Primary outcomes included the objective assessment of statistical risk recall. Secondary outcomes included patient attitudes with respect to statistical information. Due to the study heterogeneity, a narrative synthesis was performed.

RESULTS

A total of 4348 articles were identified, and following abstract and full-text screening 14 articles, including 9 RCTs, were included. The total number of adult patients was 1513. The most common risk communication tool used was written information (n = 7). Most RCTs (7/9, 77.8%) showed statistically significant improvements in patient understanding of statistical risk in the intervention group. Quality assessment found some concerns with all RCTs.

CONCLUSION

Risk communication tools appear to improve recall of statistical risk. Additional prospective trials comparing various aids simultaneously are warranted to determine the most effective method of improving understanding.

Improving risk communication: a proof-of-concept randomised control trial assessing the impact of visual aids for neurosurgical consent

Introduction

Informed consent is a fundamental component in the work-up for surgical procedures. Statistical risk information pertaining to a procedure is by nature probabilistic and challenging to communicate, especially to those with poor numerical literacy. Visual aids and audio/video tools have previously been shown to improve patients' understanding of statistical information. In this study, we aimed to explore the impact of different methods of risk communication in healthy participants randomized to either undergo the consent process with visual aids or the standard consent process for lumbar puncture.

Material and methods

Healthy individuals above 18 years old were eligible. The exclusion criteria were prior experience of the procedure or relevant medical knowledge, lack of capacity to consent, underlying cognitive impairment and hospitalised individuals. After randomisation, both groups received identical medical information about the procedure of a lumbar puncture in a hypothetical clinical scenario via different means of consent. The control group underwent the standard consent process in current clinical practice (Consent Form 1 without any illustrative examples), whereas the intervention group received additional anatomy diagrams, the Paling Palette and the Paling perspective scale. Anonymised questionnaires were received to evaluate their perception of the procedure and its associated risks.

Results

Fifty-two individuals were eligible without statistically significant differences in age, sex, professional status and the familiarity of the procedure. Visual aids were noted to improve the confidence of participants to describe the risks by themselves (p = 0.009) and participants in the intervention group felt significantly less overwhelmed with medical information (p = 0.028). The enhanced consent process was found to be significantly more acceptable by participants (p = 0.03). There was a trend towards greater appropriateness (p = 0.06) and it appeared to have "good" usability (median SUS = 76.4), although this also did not reach statistical significance (p = 0.06).

Conclusion

Visual aids could be an appropriate alternative method for medical consent without being inferior regarding the understanding of the procedure, its risks and its benefits. Future studies could possibly compare or incorporate multiple interventions to determine the most effective tools in a larger scale of population including patients as well as healthy individuals.

The Impact of Endoscopy Sedation Information Sheets on the Level of Concern Regarding Possible Awareness in Patients Undergoing Endoscopy Sedation

Sedation encompasses a continuum from complete unconsciousness to drowsiness and anxiolysis where some awareness might be expected. Most patients undergoing endoscopy sedation expect to be completely unconscious during the procedure and thus have unmet expectations regarding their state of consciousness. This study aimed to evaluate whether endoscopy sedation information sheets reduce the level of concern regarding possible awareness during endoscopy sedation at a major regional hospital. Our findings were that 28.8% of patients who received the endoscopy sedation information sheet (n = 82) were concerned about awareness during the procedure, compared to 36.5% of patients in the control group (n = 105). However, the difference was not statistically significant. We also found that the incidence of awareness was higher (13.9%) in the intervention group compared to 8.8% in the control group but, again, not statistically different. This study allowed us to elucidate the level of concern regarding possible awareness during sedation and the incidence of awareness during endoscopy sedation. This will enable future work investigating the role of endoscopy sedation information methods involving written and video material in assisting pre-procedure patient counselling.

Effect of Consent and Educational Adjuncts to Consent on Patient Perceptions About Colonoscopy

BACKGROUND AND AIMS

Informed consent is a vital preprocedural step for endoscopy but there are substantial variations in its delivery. We therefore sought to assess a multifaceted intervention to improve the consent process.

METHODS

Gastroenterologists at a tertiary center were educated on the recommended components of informed consent. Following this, 3 cohorts of patients undergoing colonoscopy were surveyed before and after consent. In one cohort, the effect of optimized verbal consent alone was assessed. In the second and third groups, the effects of the addition of either a handout or a video describing colonoscopy and its risks were evaluated. The primary outcomes were the changes between preconsent and postconsent survey responses regarding confidence in understanding the procedure's purpose, likelihood of adverse events, and levels of anxiety.

RESULTS

In total, 240 patients were included with 79 to 81 patients per group. There were no significant differences among the groups' survey responses. Compared with patients receiving verbal consent alone, fewer patients in the handout and video groups increased their perceived risk of adverse events following consent, but this difference did not reach significance (P=0.08). Examining all groups together, anxiety levels changed significantly after consent (P=0.003), with 31% of patients reducing their anxiety level, 8% increasing it, and 62% having no change.

CONCLUSIONS

The consent process appears to decrease patient anxiety about colonoscopy. When used in conjunction with a high-quality verbal consent, written or video educational adjuncts provided on the day of colonoscopy likely have no effect on patient perceptions.

"It is just another test they want to do": Patient and caregiver understanding of the colonoscopy procedure

OBJECTIVE

Colonoscopy is a complex procedure that requires bowel preparation, sedation, and has the potential for substantial risk. Given this, we investigated colonoscopy patients' perceived and actual understanding of the procedure.

METHODS

Consecutive colonoscopy patients were enrolled and surveyed, with their caregivers, immediately prior to their procedure. Demographics, health literacy, socioeconomic status and perceived risks/benefits were assessed. Thematic analysis was conducted on open-ended responses and a 3-level outcome variable was created to categorize correctness of patients' and caregivers' understanding. Multinomial logistic regression was used to determine predictors of response level.

RESULTS

Patients (N=1821) were 77% White, 60% female, and averaged 54 years old; caregivers were demographically similar. Among patients, bivariate analysis revealed that younger age, minority race, and low income, education, and health literacy were associated with incomplete understanding. Multinomial regression revealed that age, education, health literacy, first-time colonoscopy, and perceived risk-benefit difference discriminated among groups. Bivariate and multinomial results for caregivers were similar.

CONCLUSION

Patients and caregivers varied on information, understanding and misconceptions about colonoscopy. Implications are discussed for inadequate: 1. informed consent, 2. bowel preparation, and 3. emotional preparation for cancer detection or adverse events.

PRACTICE IMPLICATIONS

Attention should be paid to patients' understanding of the purpose, anatomy, and logistics of colonoscopy, preferably prior to bowel preparation.