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Nwolise C, Corrie P, Fitzpatrick R, Gupta A, Jenkinson C, Middleton M, Matin R. Burden of cancer trial participation: A qualitative sub-study of the INTERIM feasibility RCT. Chronic Illn 2023; 19:81-94. [PMID: 34787471 PMCID: PMC9841458 DOI: 10.1177/17423953211060253] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/23/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE A qualitative sub-study was carried out within a larger phase II feasibility trial, to identify and describe the burden experienced by advanced melanoma patients participating in a clinical trial and the factors affecting their capacity to cope with the burden. METHODS Semi-structured interviews were conducted with fourteen patients with advanced melanoma recruited from National Health Service hospitals in the United Kingdom. Qualitative analysis was undertaken using a framework analysis approach. Normalisation process theory was applied to the concept of research participation burden in order to interpret and categorise findings. RESULTS Burdens of participation were identified as arising from making sense of the trial and treatment; arranging transport, appointment and prescriptions; enacting management strategies and enduring side effects; reflecting on trial documents and treatment efficacy, and emotional and mental effects of randomisation and treatment side effects. Factors reported as influencing capacity include personal attributes and skills, physical and cognitive abilities and support network. DISCUSSION This is the first study to highlight the substantial burden faced by patients with advanced melanoma in a clinical trial and factors that may lessen or worsen the burden. Consideration of identified burdens during trial design and execution will reduce the burden experienced by research participants.
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Affiliation(s)
- Chidiebere Nwolise
- Health Services Research Unit, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Applied Research
Collaboration Oxford, Oxford, UK
| | - Pippa Corrie
- Cambridge Cancer Centre, Cambridge University Hospitals NHS
Foundation Trust (Addenbrooke's Hospital), Cambridge, UK
| | - Ray Fitzpatrick
- Health Services Research Unit, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Applied Research
Collaboration Oxford, Oxford, UK
| | | | - Crispin Jenkinson
- Health Services Research Unit, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
| | - Mark Middleton
- University of Oxford Department of
Oncology, Cancer Research UK Oxford
Centre, Oxford, UK
| | - Rubeta Matin
- Dermatology Department, Churchill Hospital, Oxford, UK
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2
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The importance of using placebo controls in nonpharmacological randomised trials. Pain 2022; 164:921-925. [PMID: 36472324 PMCID: PMC10108587 DOI: 10.1097/j.pain.0000000000002839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
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Corn BW, Feldman DB. It's hard to extinguish hope. Cancer 2021; 128:1168-1170. [PMID: 34787895 DOI: 10.1002/cncr.34032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Benjamin W Corn
- Faculty of Medicine, Hebrew University, Jerusalem, Israel.,Department of Radiation Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - David B Feldman
- Department of Counseling Psychology, Santa Clara University, Santa Clara, California
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Decisional involvement and information preferences of patients with hematologic malignancies. Blood Adv 2020; 4:5492-5500. [PMID: 33166406 DOI: 10.1182/bloodadvances.2020003044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/13/2020] [Indexed: 11/20/2022] Open
Abstract
Understanding decisional involvement and information preferences in patients with hematologic malignancies may help to optimize physician-patient communication about treatment decisions and align the decision-making processes with patients' preferences. We described and examined factors associated with preferences of patients with hematologic malignancies for decisional involvement, information sources, and presentation of information. In a multicenter observational study, we recruited 216 patients with hematologic malignancies of any stage from September 2003 to June 2007. Patients were asked about their decisional involvement preferences (Control Preferences Scale), information sources (including most useful source of information), and preferences for their oncologists' presentation of treatment success information. We used multivariate logistic regressions to identify factors associated with decisional involvement preferences and usefulness of information sources (physicians vs nonphysicians). Patient-directed, shared, and physician-directed approaches were preferred in 34%, 38%, and 28% of patients, respectively. Physicians and computer/Internet were the most common information sources; 42% perceived physicians as the most useful source. On multivariate analysis, patients with less than a college education (vs postgraduate education) were less likely to perceive their physician as the most useful source (adjusted odds ratio [AOR], 0.46; 95% confidence interval (CI), 0.21-1.00), whereas patients with acute leukemia (vs other blood cancers) were more likely to perceive their physician as the most useful source (AOR, 2.49; 95% CI, 1.07-5.80). In terms of communicating treatment success rates, 70% preferred ≥1 method(s), and 88% preferred presentation in percentages. Our study suggests that decisional involvement and information preferences vary and should be assessed explicitly as part of each decision-making encounter.
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The research burden of randomized controlled trial participation: a systematic thematic synthesis of qualitative evidence. BMC Med 2020; 18:6. [PMID: 31955710 PMCID: PMC6970283 DOI: 10.1186/s12916-019-1476-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 11/29/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Participation in randomized controlled trials (RCTs) may be quite demanding and could represent an important burden for patients. We aimed to explore this research burden (i.e., the psychological, physical, and financial burdens) experienced by patients through their participation in a RCT. METHODS We conducted a systematic review of qualitative studies exploring adult patients' experiences with RCT participation. We searched MEDLINE (PubMed), CINAHL, PSYCHINFO, and Embase (search date March 2018) for eligible reports. Qualitative data coding and indexing were assisted by NVivo. The quality of reports was assessed by using the Critical Appraisal Skills Program (CASP) tool. RESULTS We included 45 qualitative studies that involved 1732 RCT participants. Important psychological burdens were identified at every stage of the trial process. Participants reported feeling anxiety and being afraid of "being a 'guinea pig'" and described undergoing randomization and allocation to a placebo as particularly difficult resulting in disappointment, anger, and depression. Patients' follow-up and trial closure were also responsible for a wide range of psychological, physical, and financial burdens. Furthermore, factors related to burdensome impacts and consequences were discerned. These factors involved trial information, poorly organized and too-demanding follow-up, and lack of appropriate management when the patient's participation ended. Trial participation was also associated with beneficial effects such as the satisfaction of feeling "useful," gaining "a sense of control," and receiving special attention. CONCLUSIONS Our finding provides a detailed description of research burden across the whole RCT process. Many of the burdens described could be anticipated, and some avoided in a movement toward minimally disruptive clinical research. Such an approach could improve trial recruitment and retention. REVIEW REGISTRATION PROSPERO CRD42018098994.
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Nakahira J, Sawai T, Ishio J, Nakano S, Minami T. Factors Associated with Poor Satisfaction with Anesthesia in Patients Who Had Previous Surgery: A Retrospective Study. Anesth Pain Med 2020; 9:e90915. [PMID: 31903326 PMCID: PMC6935288 DOI: 10.5812/aapm.90915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 09/26/2019] [Accepted: 10/07/2019] [Indexed: 11/16/2022] Open
Abstract
Background As most studies investigating patient satisfaction with anesthesia have some bias, previous results may underrepresent the true level of dissatisfaction with anesthesia. Objectives This study aimed to identify factors associated with patient satisfaction with anesthesia. Methods Data from patients aged ≥ 20 years who had previous surgery and were scheduled for additional surgery were obtained retrospectively through preoperative interviews conducted. Informed consent for anesthesia was obtained by an anesthesiologist prior to the additional surgery. The patients were assigned to one of four anesthesia satisfaction levels, then were categorized into two groups; a high satisfaction group and a low satisfaction group. After comparing parameters between the two groups, logistic regression analysis was performed to identify factors that were negatively associated with satisfaction with anesthesia. Results Of 478 patients interviewed subjects, 469 patients were analyzed. Five individuals were excluded because they were unable to provide informed consent, and four subjects were excluded because they were aged < 10 years at the time of their previous surgery. Age < 65 years, previous surgery for malignancy, female sex, estimated operation duration < 3 hours, and American Society of Anesthesiologists Physical Status score 1 or 2 were included in a logistic regression analysis. Age < 65 years, previous surgery for malignancy, and female sex were predictive of poor patient satisfaction with anesthesia. Reasons for poor satisfaction with anesthesia included postoperative shivering and chills, fear of surgery, ineffective spinal anesthesia, and postoperative surgery-related pain. Of the patients awaiting surgery for malignancy, 57.3% had previous surgery for malignancy. Conclusions Age < 65 years, previous surgery for malignancy, and female sex were negatively associated with patient satisfaction with anesthesia. These factors should be considered when preparing patients for future procedures to improve postoperative patient satisfaction.
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Affiliation(s)
- Junko Nakahira
- Department of Anesthesiology, Osaka Medical College, Takatsuki, Japan
- Corresponding Author: Department of Anesthesiology, Osaka Medical College, Takatsuki, Japan. Tel: +81-9098748678,
| | - Toshiyuki Sawai
- Department of Anesthesiology, Osaka Medical College, Takatsuki, Japan
| | - Junichi Ishio
- Department of Anesthesiology, Osaka Medical College, Takatsuki, Japan
| | - Shoko Nakano
- Department of Anesthesiology, Osaka Medical College, Takatsuki, Japan
| | - Toshiaki Minami
- Department of Anesthesiology, Osaka Medical College, Takatsuki, Japan
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Deutsch GB, Deneve JL, Al-Kasspooles MF, Nfonsam VN, Gunderson CC, Secord AA, Rodgers P, Hendren S, Silberfein EJ, Grant M, Sloan J, Sun V, Arnold KB, Anderson GL, Krouse RS. Intellectual Equipoise and Challenges: Accruing Patients With Advanced Cancer to a Trial Randomizing to Surgical or Nonsurgical Management (SWOG S1316). Am J Hosp Palliat Care 2019; 37:12-18. [PMID: 31122027 DOI: 10.1177/1049909119851471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Prospective, randomized trials are needed to determine optimal treatment approaches for palliative care problems such as malignant bowel obstruction (MBO). Randomization poses unique issues for such studies, especially with divergent treatment approaches and varying levels of equipoise. We report our experience accruing randomized patients to the Prospective Comparative Effectiveness Trial for Malignant Bowel Obstruction (SWOG S1316) study, comparing surgical and nonsurgical management of MBO. METHODS Patients with MBO who were surgical candidates and had treatment equipoise were accrued and offered randomization to surgical or nonsurgical management. Patients choosing nonrandomization were offered prospective observation. Trial details are listed on www.clinicaltrials.gov (NCT #02270450). An accrual algorithm was developed to enhance enrollment. RESULTS Accrual is ongoing with 176 patients enrolled. Most (89%) patients chose nonrandomization, opting for nonsurgical management. Of 25 sites that have accrued to this study, 6 enrolled patients on the randomization arm. Approximately 59% (20/34) of the randomization accrual goal has been achieved. Patient-related factors and clinician bias have been the most prevalent reasons for lack of randomization. An algorithm was developed from clinician experience to aid randomization. Using principles in this tool, repeated physician conversations discussing treatment options and goals of care, and a supportive team-approach has helped increase accrual. CONCLUSIONS Experience gained from the S1316 study can aid future palliative care trials. Although difficult, it is possible to randomize patients to palliative studies by giving clinicians clear recommendations utilizing an algorithm of conversation, allotment of necessary time to discuss the trial, and encouragement to overcome internal bias.
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Affiliation(s)
- Gary B Deutsch
- Department of Surgery, Northwell Health, Lake Success, NY, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Camille C Gunderson
- Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke Cancer Institute, Durham, NC, USA
| | - Phillip Rodgers
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samantha Hendren
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Marcia Grant
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Jeff Sloan
- Mayo Clinic Rochester, Rochester, MN, USA
| | - Virginia Sun
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Kathryn B Arnold
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Garnet L Anderson
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Robert S Krouse
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Policy, Philadelphia, PA, USA
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Affiliation(s)
| | - Stewart M. Dunn
- Director, Medical Psychology Unit, Royal Prince Alfred Hospital, University of Sydney
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Abstract
Formal teaching in ethics is neglected in psychiatric training. This paper takes a practical approach in outlining ethical issues relevant to different stages of a research project. It is suggested that whatever the scale of the research, it is important to examine the ethical issues which surround the development of a project, as well as those which are integral to the protocol.
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Abstract
Anesthesia for lung transplantation is both a demand ing and rewarding experience. Success requires team- work, experience, knowledge of cardiorespiratory patho physiology and its anesthetic implications, appropriate use of noninvasive and invasive monitoring, and the ability to respond quickly and effectively to life- threatening perioperative events. Specific issues in clude management of a patient with end-stage lung and heart disease, lung isolation and one-lung ventilation, perioperative respiratory failure, pulmonary hyperten sion, and acute right ventricular failure. Recent ad vances include greater understanding of dynamic hyper inflation ("gas-trapping") during mechanical ventilation, perioperative use of inhaled nitric oxide and treatment of acute right ventricular failure. Successful anesthetic management leads to greater hemodynamic stability, improvement in gas exchange and a reduction in need for cardiopulmonary bypass, all of which should lead to improved patient outcome.
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Affiliation(s)
- Paul S. Myles
- Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Australia
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11
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Vain NE, Musante GA, Mariani GL. Meconium Stained Newborns: Ethics for Evidence in Resuscitation. J Pediatr 2015; 166:1109-12. [PMID: 25720365 DOI: 10.1016/j.jpeds.2015.01.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 01/28/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Nestor E Vain
- Department of Pediatrics, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina; FUNDASAMIN (Fundación para la Salud Materno Infantil), Buenos Aires, Argentina; Department of Neonatology, Hospitals Sanatorio de la Trinidad Palermo and San Isidro, Buenos Aires, Argentina.
| | - Gabriel A Musante
- Department of Pediatrics, Facultad de Ciencias Biomédicas, Universidad Austral, Argentina; Department of Maternal and Child Health, Hospital Universitario Austral, Pilar, Argentina
| | - Gonzalo L Mariani
- Department of Pediatrics, School of Medicine, University Institute, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Neonatology Division, Hospital Italiano, Buenos Aires, Argentina
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Mack JW, Joffe S. Communicating about prognosis: ethical responsibilities of pediatricians and parents. Pediatrics 2014; 133 Suppl 1:S24-30. [PMID: 24488537 DOI: 10.1542/peds.2013-3608e] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Clinicians are sometimes reluctant to discuss prognosis with parents of children with life-threatening illness, usually because they worry about the emotional impact of this information. However, parents often want this prognostic information because it underpins informed decision-making, especially near the end of life. In addition, despite understandable clinician concerns about its emotional impact, prognostic disclosure can actually support hope and peace of mind among parents struggling to live with a child's illness. Children, too, may need to understand what is ahead to manage uncertainty and make plans for the ways their remaining life will be lived. In this article, we describe the ethical issues involved in disclosure of prognostic information to parents and children with life-threatening illness and offer practical guidance for these conversations.
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Affiliation(s)
- Jennifer W Mack
- Department of Pediatric Oncology and the Center for Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
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13
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Stein RA, Sharpe L, Bell ML, Boyle FM, Dunn SM, Clarke SJ. Randomized Controlled Trial of a Structured Intervention to Facilitate End-of-Life Decision Making in Patients With Advanced Cancer. J Clin Oncol 2013; 31:3403-10. [DOI: 10.1200/jco.2011.40.8872] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose This study tested the efficacy of an intervention on end-of-life decision making for patients with advanced cancer. Patients and Methods One hundred twenty patients with metastatic cancer who were no longer being treated with curative intent (and 87 caregivers) were randomly assigned to the intervention (n = 55) or treatment as usual (n = 65). Primary outcome measures were the proportion of patients with do-not-resuscitate (DNR) orders, timing of DNR orders, and place of death. Secondary outcome measures were completed at study enrollment, 3 weeks later, and 3 months later, including patients' knowledge, mood, and caregiver burden. Results High, but equivalent, rates of DNR orders were observed in both groups. In per-protocol analyses, DNR orders were placed earlier for patients who received the intervention (median, 27 v 12.5 days; 95% CI, 1.1 to 5.9; P = .03) and they were more likely to avoid a hospital death (19% v 50% (95% CI, 11% to 50%; P = .004). Differences between the groups over time were evident for estimates of cardiopulmonary rehabilitation (CPR) success rates (P = .01) but not knowledge of CPR (P = .2). There was no evidence that the intervention resulted in more anxious or depressive symptoms. Caregivers experienced less burden in terms of disruption to schedule if the patient received the intervention (P = .05). Conclusion An intervention, consisting of an informational pamphlet and discussion, was associated with earlier placement of DNR orders relative to death and less likelihood of death in hospital. There was no negative impact of the intervention on secondary outcomes, although the sample may have been too small to detect differences.
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Affiliation(s)
- Rhea A. Stein
- All authors: University of Sydney, Sydney, New South Wales, Australia
| | - Louise Sharpe
- All authors: University of Sydney, Sydney, New South Wales, Australia
| | - Melanie L. Bell
- All authors: University of Sydney, Sydney, New South Wales, Australia
| | - Fran M. Boyle
- All authors: University of Sydney, Sydney, New South Wales, Australia
| | - Stewart M. Dunn
- All authors: University of Sydney, Sydney, New South Wales, Australia
| | - Stephen J. Clarke
- All authors: University of Sydney, Sydney, New South Wales, Australia
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Daniels G, Vogel S. Consent in osteopathy: A cross sectional survey of patients' information and process preferences. INT J OSTEOPATH MED 2012. [DOI: 10.1016/j.ijosm.2012.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Jawaid M, Farhan M, Masood Z, Husnain SMN. Preoperative informed consent: is it truly informed? IRANIAN JOURNAL OF PUBLIC HEALTH 2012. [PMID: 23193502 PMCID: PMC3494211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pre-operative informed consent is an important aspect of surgery, yet there has been no formal training regarding it in Pakistan. This study was done to assess the preoperative informed consent practice. METHODS After taking informed permission, a questionnaire was filled in during an interview with 350 patients, who have undergone elective surgical procedures under routine practice conditions from July to October 2010. All the patients were asked a set of standard questions which related to the information they were provided before the operation as a part of standard informed consent practice. RESULTS Most i.e. 307 (87.7%) patients were informed about their condition but very few 12 (3.4%) were briefed regarding complications. Only 17 (4.9%) patients said they knew about the risks and complications of proposed anesthesia. One hundred thirty-eight (39.4%) patients said that they were allowed to ask questions while giving consent. Most of the time 196 (56%) consent was taken one day before surgery but in few 2 (0.6%) instances it was taken on the morning of surgery and on operation table in some cases 3 (0.9%) as reported by patients. The consent form was signed by the patients themselves in only 204 (58.3%) cases and by their relatives in the rest. About half the number of patients 171 (48.9%) interviewed were satisfied from the information they received as informed consent process. CONCLUSION This study highlights the poor quality of patient knowledge about surgical procedures and the inadequate information provided.
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Affiliation(s)
- M Jawaid
- Section of Surgery, Dow University of Health Sciences, Karachi, Pakistan,Corresponding Author: Tel: +92-0300-9279786
| | - M Farhan
- Cardiac Surgery, Dow University of Health Sciences, Karachi, Pakistan
| | - Z Masood
- Section of Surgery, Civil Hospital Karachi, Pakistan
| | - SMN Husnain
- Surgical Unit III, Civil Hospital Karachi, Pakistan
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Attitudes towards palliative care in primary metastatic cancer: a survey among oncologists. Wien Klin Wochenschr 2010; 122:45-9. [PMID: 20177859 DOI: 10.1007/s00508-009-1295-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Accepted: 11/11/2009] [Indexed: 10/19/2022]
Abstract
Oncologists differ widely in their attitudes towards palliative care and services. These attitudes depend on a number of individual and society-based variables. It is recommended that palliative care be started early in the disease trajectory of patients with a life-threatening disease but in Austria we lack data on oncologists' adherence to this recommendation. We surveyed 785 oncologists in Austria by presenting the clinical course of a hypothetical patient with primary metastatic breast cancer from diagnosis until death. The majority of oncologists would involve palliative care services when the patient's Karnofsky index (KI) was < 50, and hospice services when the KI was < 40. Special training in palliative care was significantly associated with early use of hospice services. Reasons for not involving palliative care and hospice services earlier than indicated were systematically evaluated and included, among others, "fear of destroying the patient's hopes" (36% of respondents with regard to palliative services, 57% with regard to hospices). Overall, 67% of the oncologists would inform the patient about the malignant nature of her disease and the anticipated limitation of her life expectancy at the time of diagnosis. Issuing an advance directive would be discussed by only 25% at that time. Our data show that oncologists involve palliative care services at an advanced stage of disease in patients with primary metastatic cancer and that information about malignancy and the incurable nature of the disease is not uniformly provided at the time of diagnosis.
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Falagas ME, Akrivos PD, Alexiou VG, Saridakis V, Moutos T, Peppas G, Kondilis BK. Patients' perception of quality of pre-operative informed consent in athens, Greece: a pilot study. PLoS One 2009; 4:e8073. [PMID: 19956713 PMCID: PMC2777312 DOI: 10.1371/journal.pone.0008073] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 11/01/2009] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We sought to perform a study to record and evaluate patients' views of the way surgeons communicate informed consent (IC) in Greece. METHODOLOGY/PRINCIPAL FINDINGS A prospective pilot study was carried out in Athens from 9/2007 to 4/2008. The study sample was extracted from patients, operated by eight different surgeons, who volunteered to fill in a post-surgery self-report questionnaire on IC. A composite delivered information index and a patient-physician relationship index were constructed for the purposes of the analysis. In total, 77 patients (42 males) volunteered to respond to the questionnaire. The delivered information index scores ranged from 3 to 10, the mean score was 8, and the standard deviation (SD) was 1.9. All patients were aware of their underlying diagnosis and reason for surgery. However, a considerable proportion of the respondents (14.3%) achieved a score below or equal to 5. The patient-physician relationship scores ranged from 0 to 20, the mean score was 16 and the standard deviation (SD) was 4.3. The better the patient-physician relationship, the more information was finally delivered to the patient from the physician (Spearman's rank-order correlation coefficient was 0.4 and p<0.001). Delivered information index was significantly higher among participants who comprehended the right to informed consent, compared to participants who did not (p<0.001), and among participants who were given information regarding other possible therapeutic options (p = 0.001). 43% of the respondents answered that less than 10 minutes were spent on the consent process, 58.4% of patients stated that they had not been informed about other possible therapeutic choices and 28.6% did not really comprehend their legal rights to IC. CONCLUSIONS Despite the inherent limitations and the small sample size that do not permit to draw any firm conclusions, results indicate that a successful IC process may be associated with specific elements such as the patient-physician relationship, the time spent by the physician to inform the patient, a participant's comprehension of the right to IC and the provision of information regarding other possible therapeutic options.
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Abstract
Patients face difficult decisions about chemotherapy near the end of life. Such treatment might prolong survival or reduce symptoms but cause adverse effects, prevent the patient from engaging in meaningful life review and preparing for death, and preclude entry into hospice. Palliative care and oncology clinicians should be logical partners in caring for patients with serious cancers for which symptom control, medically appropriate goal setting, and communication are paramount, but some studies have shown limited cooperation. We illustrate how clinicians involved in palliative care and oncology can more effectively work together with the story of Mr L, a previously healthy 56-year-old man, who wanted to survive his lung cancer at all costs. He lived 14 months with 3 types of chemotherapy, received chemotherapy just 6 days before his death, and resisted entering hospice until his prognosis and options were explicitly communicated. Approaches to communication about prognosis and treatment options and questions that patients may want to ask are discussed.
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Affiliation(s)
- Sarah Elizabeth Harrington
- Department of Internal Medicine and the Thomas Palliative Care Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298, USA
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19
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Lecouturier J, Rodgers H, Ford GA, Rapley T, Stobbart L, Louw SJ, Murtagh MJ. Clinical research without consent in adults in the emergency setting: a review of patient and public views. BMC Med Ethics 2008; 9:9. [PMID: 18445261 PMCID: PMC2390563 DOI: 10.1186/1472-6939-9-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Accepted: 04/29/2008] [Indexed: 11/28/2022] Open
Abstract
Background In emergency research, obtaining informed consent can be problematic. Research to develop and improve treatments for patients admitted to hospital with life-threatening and debilitating conditions is much needed yet the issue of research without consent (RWC) raises concerns about unethical practices and the loss of individual autonomy. Consistent with the policy and practice turn towards greater patient and public involvement in health care decisions, in the US, Canada and EU, guidelines and legislation implemented to protect patients and facilitate acute research with adults who are unable to give consent have been developed with little involvement of the lay public. This paper reviews research examining public opinion regarding RWC for research in emergency situations, and whether the rules and regulations permitting research of this kind are in accordance with the views of those who ultimately may be the most affected. Methods Seven electronic databases were searched: Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, Philosopher's Index, Age Info, PsychInfo, Sociological Abstracts and Web of Science. Only those articles pertaining to the views of the public in the US, Canada and EU member states were included. Opinion pieces and those not published in English were excluded. Results Considering the wealth of literature on the perspectives of professionals, there was relatively little information about public attitudes. Twelve studies employing a range of research methods were identified. In five of the six questionnaire surveys around half the sample did not agree generally with RWC, though paradoxically, a higher percentage would personally take part in such a study. Unfortunately most of the studies were not designed to investigate individuals' views in any depth. There also appears to be a level of mistrust of medical research and some patients were more likely to accept an experimental treatment 'outside' of a research protocol. Conclusion There are too few data to evaluate whether the rules and regulations permitting RWC protects – or is acceptable to – the public. However, any attempts to engage the public should take place in the context of findings from further basic research to attend to the apparently paradoxical findings of some of the current surveys.
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Affiliation(s)
- Jan Lecouturier
- Institute of Health and Society, Newcastle University, The Medical School, Framlington Place, Newcastle upon Tyne, UK.
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Ivarsson B, Larsson S, Lührs C, Sjöberg T. Patients perceptions of information about risks at cardiac surgery. PATIENT EDUCATION AND COUNSELING 2007; 67:32-8. [PMID: 17350783 DOI: 10.1016/j.pec.2007.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Revised: 01/24/2007] [Accepted: 01/24/2007] [Indexed: 05/14/2023]
Abstract
OBJECTIVE The aim was to describe the patients' own experiences of risk information in connection with cardiac surgery and it's outcome. METHODS Questionnaires were answered prior to and 8 weeks after cardiac surgery. Data were analysed using qualitative content analysis. Patients in the intervention group (n=55) received standard information and a newly written extended information brochure about risks in connection with cardiac surgery. Patients in the control group (n=44) only received standard information. RESULTS Three categories emerged: attitude towards information, deficiencies and advantages of the information and concerns related to cardiac surgery. Patients in both groups pointed out the importance of information when they were put on the waiting list. Patients in the control group missed information about complications and some patients thought that their complications were caused by maltreatment. Patients having complications in the intervention group were more understanding about their situation. CONCLUSION Much can be done for the patients on their path from diagnosis and being accepted for cardiac surgery and throughout the treatment period regarding the provision of information. PRACTICE IMPLICATIONS If patients become carefully and thoroughly informed by the health care professionals, they are more satisfied and better prepared if complications occur.
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Affiliation(s)
- Bodil Ivarsson
- Department of Cardiothoracic Surgery, Lund University Hospital, SE-221 85 Lund, Sweden.
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Basta LL. End‐of‐Life and Other Ethical Issues Related to Pacemaker and Defibrillator Use in the Elderly. ACTA ACUST UNITED AC 2007; 15:114-7. [PMID: 16525225 DOI: 10.1111/j.1076-7460.2006.04818.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In the past decade, the rate of implantation of pacemakers and cardioverter-defibrillators in the elderly with cardiac impairment has soared. As patients near the end of life, interventions become more complicated and expensive, and less effective. In this context, "informed consent" requires consideration of issues different from those faced in more routine settings. Informed consent requires full disclosure, patient competence, and free exercise of will-but in practice, few patients or their families are in a position to make fully informed decisions about highly complex treatments at the end of life. Physicians continue to bear the responsibility of advising patients about sophisticated interventions or, alternatively, palliative care. Physician training, with its narrow focus on the treatment of disease with drugs and technology, has not prepared physicians to advise patients on issues arising from the availability of multiple interventions at the end of life. Professional societies can fill a gap by developing programs and materials to help physicians treat their dying patients in a high-technology era.
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Wood CG, Wei SJ, Hampshire MK, Devine PA, Metz JM. The Influence of Race on the Attitudes of Radiation Oncology Patients Towards Clinical Trial Enrollment. Am J Clin Oncol 2006; 29:593-9. [PMID: 17148997 DOI: 10.1097/01.coc.0000236213.61427.84] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Enrollment of adult cancer patients in clinical trials remains low, particularly in the minority population. Understanding patient attitudes towards clinical trials during the recruitment process may enhance accrual. Unfortunately, data describing patient attitudes towards clinical trials are limited, particularly in the radiation oncology clinic setting. METHODS A piloted questionnaire assessing basic demographics and attitudes toward clinical trials was offered in 2 radiation oncology clinics between April 2003 and October 2003. The questionnaire was completed by 166 patients. The mean age of the patients completing the questionnaire was 56 years (range, 15-84 years). Of the 166 patients included in the analysis, 108 (65%) were White. The most common cancer diagnoses included prostate (19%), head and neck (16%), and breast (14%). RESULTS There was no statistical difference between Whites and non-Whites regarding their interest in learning about clinical trials (84.3% versus 84.9%, P = 0.92); nor was there a significant difference in the rate of previous or current trial enrollment (21.3% versus 34.0%, P = 0.08). White patients were more likely to gather information about clinical trials from the Internet (30.6% versus 11.3%, P = 0.007), and they were more likely to use physicians as a source of this information (50.0% versus 34.0%, P = 0.05). Non-White patients were more likely to obtain information about clinical trials from other patients (24.5% versus 12.0%, P = 0.04). In addition, more non-White patients believed they had been treated on clinical trials without their knowledge (21.6% versus 9.3%, P = 0.032). Patients differed somewhat in their expectations of clinical trials. More non-Whites indicated that they would need a >50% chance of benefiting from a trial (64.4% versus 45.0%, P = 0.03) to enroll on that trial, though there were no statistical differences in outlook towards potential toxicities associated with treatment on a clinical trial. CONCLUSIONS Minority patients historically enroll in clinical trials at a significantly lower rate. Our study of radiation oncology patients documents significant differences in attitudes towards clinical trials between Whites and non-Whites. Understanding the differences in attitudes may allow physicians to overcome barriers that would otherwise hinder the enrollment of non-White patients into clinical trials.
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Affiliation(s)
- Charles G Wood
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Abstract
Now that partial face transplantation has been performed, attention is focused on likely functional, aesthetic and immunological outcomes, and full facial transplantation is the likely next step. Facial transplantation has been the source of ethical debate, a key part of which focuses on valid informed consent. We review the process of informed consent in health settings, assessing how applicable the current standards are for facial transplantation. The factors which need to be assessed during the screening programme are outlined. We conclude that both individual and process factors are important in obtaining consent for radical new procedures, and outline our own gold standard for ensuring informed consent in facial transplantation.
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Affiliation(s)
- Anthony Renshaw
- Department of Plastic Surgery, Royal Free Hospital, London, UK.
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Mishra PK, Ozalp F, Gardner RS, Arangannal A, Murday A. Informed consent in cardiac surgery: is it truly informed? J Cardiovasc Med (Hagerstown) 2006; 7:675-81. [PMID: 16932081 DOI: 10.2459/01.jcm.0000243001.59675.bf] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To develop a validated questionnaire to measure how informed patients are when giving consent for elective coronary artery bypass grafting. METHODS We developed a questionnaire covering the domains described in the consent guidelines published by the General Medical Council. The questionnaire was developed for use in face-to-face interviews as opposed to a self-administered questionnaire. Interviews were conducted after the patients had given consent for surgery. A total of 41 patients were interviewed. To validate the questionnaire we tested the interobserver reliability by using four different interviewers and the construct validity by comparing it with area deprivation index and with predicted intelligence quotient scores obtained from the National Adult Reading Test. RESULTS The correlation of the ranking of the questions between the interviewers was satisfactory (Spearman's rank correlation coefficient, rs = 0.84-0.89). The total questionnaire scores correlated well with predicted intelligence quotient scores (rs = 0.48) but not with area deprivation index (rs = 0.01). Questions with the worst scores were those related to mortality, morbidity, alternative treatment options and their relative success rates and risks. CONCLUSIONS We have developed a validated questionnaire which tests patient's level of knowledge with respect to surgical myocardial revascularisation. Our study identified areas of informed consent where the minimal level of knowledge is below the recommended level. The questionnaire could be used in audits and clinical trials in patients undergoing coronary artery bypass grafting. It could be used as a tool to measure the effectiveness of patient education programmes. With appropriate changes, this instrument could also be applied in other fields of medical intervention, which require patients to give informed consent.
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Garcia J, Elbourne D, Snowdon C. Equipoise: a case study of the views of clinicians involved in two neonatal trials. Clin Trials 2006; 1:170-8. [PMID: 16281889 DOI: 10.1191/1740774504cn020xx] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND It is considered to be a fundamental ethical premise of human experimentation, that it should be carried out only where the effects of an intervention are unclear. The point at which it is considered that there is insufficient scientific and medical evidence to clearly state the superiority of an intervention has been termed equipoise. This concept has been the subject of much recent impassioned debate but little empirical research about the views of people involved in recruitment to randomized controlled trials (RCTs), and none in the particularly emotive area of neonatal intensive care. METHODS Thirty neonatologists recruiting into one or both of two neonatal RCTs in five centres in England were interviewed using a semi-structured schedule to explore their involvement in randomised trials. The interviews were tape-recorded and transcribed. Equipoise was one among a range of topics covered. Concepts relating to equipoise were identified by close reading of the entire interviews. Themes emerging from the data were noted in their contexts then discussed between the co-authors. Interviewees also completed a brief questionnaire about their demographic background, and their experience of research and RCTs. RESULTS Almost all the neonatologists used the concept of equipoise [using words and phrases such as uncertainty, lack of knowledge (or ignorance), strengths of views, and balancing of pros and cons] in their interview and, for most of them, equipoise seemed to be a useful term. They explored ideas about equipoise at the individual and community levels, and some linked equipoise with notions of the responsibility that should be exercised by the scientific and professional communities. They differed in the importance they gave to individual equipoise, and in how they reacted to threats to equipoise. Feelings of doubt about a trial and disturbed equipoise were more often expressed by more junior doctors. CONCLUSIONS Our findings suggest that the concept of equipoise goes beyond the idea of uncertainty. In part this is because it includes the balancing of benefit and harm; this balancing is part of a professional obligation and requires engagement with 'expert' knowledge. Equipoise could therefore be seen as 'active' or 'responsible' uncertainty. Elucidation of this difficult concept may help to facilitate recruitment for both clinicians and parents in future trials and thereby help to find answers to important clinical questions.
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Affiliation(s)
- Jo Garcia
- Medical Statistics Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Kiesler DJ, Auerbach SM. Optimal matches of patient preferences for information, decision-making and interpersonal behavior: evidence, models and interventions. PATIENT EDUCATION AND COUNSELING 2006; 61:319-41. [PMID: 16368220 DOI: 10.1016/j.pec.2005.08.002] [Citation(s) in RCA: 253] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Revised: 08/04/2005] [Accepted: 08/05/2005] [Indexed: 05/03/2023]
Abstract
OBJECTIVE A comprehensive review was conducted of the theoretical and empirical work that addresses the preference-match strategy in physician-patient communication. METHODS Searches were conducted on Medline, PsychINFO, InFoTrac One File Plus, Sociological Abstracts, and Dissertation Abstracts through 2004. The following keywords were used: patient preferred and received information; patient preferred and actualized treatment decision-making; patient-physician beliefs in shared decision-making; patient-physician match, fit, or concordance; reciprocal relationship or mutuality; doctor-patient affiliation, control, relationship; match/fit between patient and physician in affiliation, control, or relationship. RESULTS Findings revealed varying degrees of support for the positive effects of matching patients' preferred levels of information, decisional control, and consultative interpersonal behavior. CONCLUSIONS Findings justify not only continued but expanded research efforts in this area that would incorporate recommended changes in research design and implementation. PRACTICE AND RESEARCH IMPLICATIONS: Assessment strategies and match interventions are discussed that, if evidence continues to be supportive, might routinely optimize patient-physician encounters toward more positive outcomes. Methodological guidelines are suggested that can improve future preference-match studies of the patient-physician interaction. Practitioners need to consider adoption of patient-match assessment and intervention strategies in addition to recent exclusive concentrations on patient-centered and shared decision-making approaches.
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Affiliation(s)
- Donald J Kiesler
- Virginia Commonwealth University, Department of Psychology, 808 W. Franklin Street, Box 842018, Richmond, VA 23284, USA
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Chew-Graham C, Mole E, Evans LJ, Rogers A. Informed consent? How do primary care professionals prepare women for cervical smears: a qualitative study. PATIENT EDUCATION AND COUNSELING 2006; 61:381-8. [PMID: 15964735 DOI: 10.1016/j.pec.2005.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Revised: 04/20/2005] [Accepted: 04/23/2005] [Indexed: 05/03/2023]
Abstract
BACKGROUND Cervical screening is a procedure that is mainly carried out in primary care, predominantly by general practitioners (GPs) and practice nurses (PNs). Much has been published about the effects on women of receiving an abnormal smear result but little has been done to investigate the preparation of women by primary care professionals for this. OBJECTIVE To explore the self-reported behaviours of GPs and PNs in preparing a woman for a cervical smear test and possible abnormal result. METHODS Letters inviting respondents to participate were sent to selected GPs and PNs at medical student teaching practices in Manchester, England. Twelve GPs and 15 PNs were interviewed. Interviews were audiotaped and covered aspects of the cervical screening programme, practice protocols and explored views about consenting a woman for a smear test and the information giving about the possibility of an abnormal test result. Interviews were analysed by constant comparison and the interview schedule modified. Recruitment for interviews ceased when category saturation was achieved. CONCLUSION PNs and GPs differed widely in their descriptions of how they prepare a women for a smear. PNs reported following routines which they felt incorporated women's questions and anxieties; GPs reported that the discussion with the woman depended on the reason for doing the smear but also the amount of time available within the consultation. Few respondents reported raising issues of reliability or sensitivity of the test with women, neither did they report discussing with women the possibility of an abnormal smear result or what further investigation and treatment may be required. The degree of persuasion reported by practitioners used to encourage women to attend for smears varied and was related to their attitudes to the national cervical screening programme. PRACTICE IMPLICATIONS The current system for recall being separate from practice activity, whilst ensuring accuracy of the data-base, may limit the opportunity for information-giving which is sensitive to the needs to the local population. There is a need to include consent issues in the training of PNs, rather than just practical aspects of smear-taking, and to formalise training updates for GPs. In addition, the taking of opportunistic smears and the constraints placed upon time and information-giving need addressing. The role of other primary care staff in encouraging women to attend for smears raises training needs for these staff which practices or primary care trusts must address.
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Affiliation(s)
- Carolyn Chew-Graham
- Division of Primary Care, Faculty of Medicine, University of Manchester, Rusholme Academic Unit, Walmer Street, Rusholme, Manchester M14 5NP, UK.
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Maslin-Prothero S. The role of the multidisciplinary team in recruiting to cancer clinical trials. Eur J Cancer Care (Engl) 2006; 15:146-54. [PMID: 16643262 DOI: 10.1111/j.1365-2354.2005.00625.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This research analyses factors affecting the accrual of women to two breast cancer trials, the British Association of Surgical Oncology (BASO) II trial (a treatment trial) and the International Breast cancer Intervention Study (IBIS) (a prevention trial). The research sought to identify the factors affecting the recruitment of women to breast cancer clinical trials from the multidisciplinary teams' and women's perspectives using multiple methods. This paper reports on the findings from research undertaken with multidisciplinary teams across the United Kingdom and highlights their role in recruiting people to cancer clinical trials. The findings contribute to the debate and knowledge on recruitment in a number of ways by including the views of key stakeholders concerned with these trials, by highlighting the factors affecting recruitment to these two trials, and finally, by making recommendations on methods to enhance recruitment.
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Affiliation(s)
- S Maslin-Prothero
- Keele University School of Nursing and Midwifery, Clinical Education Centre, University Hospital of North Staffordshire NHS Trust, City General, Stoke on Trent, UK.
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Grunfeld EA, Maher EJ, Browne S, Ward P, Young T, Vivat B, Walker G, Wilson C, Potts HW, Westcombe AM, Richards MA, Ramirez AJ. Advanced Breast Cancer Patients' Perceptions of Decision Making for Palliative Chemotherapy. J Clin Oncol 2006; 24:1090-8. [PMID: 16505428 DOI: 10.1200/jco.2005.01.9208] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To examine advanced breast cancer patients' perceptions of the key decision-making consultation for palliative chemotherapy. Patients and Methods One hundred two women with advanced breast cancer, who were offered palliative chemotherapy, participated in a study-specific semistructured interview examining perceptions of the information they had received and their involvement in the decision-making process. One hundred seventeen interviews included 70 in relation to first-line chemotherapy and 47 in relation to second-line chemotherapy (15 patients were interviewed in relation to both first- and second-line chemotherapy). Results Eighty-six percent of patient interviews (n = 101) reported patient satisfaction with the information they received, and 91% (n = 106) reported satisfaction with the decision-making process. Factors most influential in decisions to accept chemotherapy were the possibility of controlling the tumor (45%, n = 53 of patient interviews) and providing hope (33%, n = 28 of patient interviews; 19%, n = 13 being offered first-line chemotherapy v 43%, n = 20 being offered second-line chemotherapy; P = .006). Thirty-eight percent of patient interviews (n = 44) reported the patient as taking an active role in the decision-making process (33%, n = 23 at first-line chemotherapy v 43%, n = 20 at second-line chemotherapy; P = .06). Conclusion Women offered second-line chemotherapy were more likely to undergo chemotherapy because of the hope it offers and were more likely to take an active role in that decision compared with women who were offered first-line chemotherapy. Compassionate and honest communication about prognosis and likelihood of benefit from treatment may help to close the gap between hope and expectation and enable patients to make fully informed decisions about palliative chemotherapy.
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Affiliation(s)
- Elizabeth A Grunfeld
- Department of Psychology and Cancer Research, United Kingdom London Psychosocial Group, Institute of Psychiatry, King's College, London, United Kingdom.
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Howlader MH, Dhanji AR, Uppal R, Magee P, Wood AJ, Anyanwu AC. Patients' views of the consent process for adult cardiac surgery: questionnaire survey. SCAND CARDIOVASC J 2005; 38:363-8. [PMID: 15804804 DOI: 10.1080/14017430410023811] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Consent for surgical procedures has assumed increasing importance in surgical practice in recent days especially following the public inquiry into paediatric cardiac surgery deaths at Bristol in the UK. This study examines patient perceptions and recollections following surgical consent as currently practised in a UK cardiac unit. METHODS One hundred consecutive patients who underwent cardiac surgery in a London teaching hospital from January to February 2003 were studied. Patients completed questionnaires a day before their discharge from the hospital. RESULTS The majority of patients (89/100) responded that the information given at consent had been adequate or more than adequate. The time spent on the consent process was thought to be adequate by 91 patients. Eleven patients felt the consent had been insensitive. Several patients (38/100) felt use of booklets in preference to verbal explanations would be less intimidating. For most patients (94/100) the operation and postoperative course met their expectations; although 12 patients experienced untold complications, only five felt that they should have been informed of the possibility of the complication. Although most patients were informed of the risk of death during consent, at time of discharge 43 had forgotten the figure that had been quoted. Regarding the influence of media and publicity, 19 patients said that media had influenced their expectations of the consent process, 59 would have liked to see hospital league tables while 26 would have liked to know the mortality figures for their surgeon prior to giving consent. CONCLUSIONS Our study shows that patients undergoing cardiac surgery are largely satisfied with our improved consent procedures in the post-Bristol era. Use of booklets may be a useful adjunct to verbal consent as currently practised.
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Affiliation(s)
- Mohammad H Howlader
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, Bart's and The London NHS Trust, Bartholomew Close, London EC1A 7BE, UK.
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Dreyfuss D. Is it better to consent to an RCT or to care? Muetadeltaepsilonnu alphagammaalphanu ("nothing in excess"). Intensive Care Med 2005; 31:345-55. [PMID: 15605232 PMCID: PMC7095248 DOI: 10.1007/s00134-004-2493-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2004] [Accepted: 10/21/2004] [Indexed: 01/03/2023]
Affiliation(s)
- Didier Dreyfuss
- Intensive Care Medicine Department, Hôpital Louis Mourier, Colombes, Assistance Publique-Hôpitaux de Paris, France.
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Trevisani L, Sartori S, Gaudenzi P, Gilli G, Matarese G, Gullini S, Abbasciano V. Upper gastrointestinal endoscopy: Are preparatory interventions or conscious sedation effective? A randomized trial. World J Gastroenterol 2004; 10:3313-7. [PMID: 15484307 PMCID: PMC4572302 DOI: 10.3748/wjg.v10.i22.3313] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: The fears and concerns are associated with gastroscopy (EGD) decrease patient compliance. Conscious sedation (CS) and non-pharmacological interventions have been proposed to reduce anxiety and allow better execution of EGD. The aim of this study was to assess whether CS, supplementary information with a videotape, or presence of a relative during the examination could improve the tolerance to EGD.
METHODS: Two hundred and twenty-six outpatients (pts), scheduled for a first-time non-emergency EGD were randomly assigned to 4 groups: Co-group (62 pts): throat anaesthesia only; Mi-group (52 pts): CS with i.v. midazolam; Re-group (58 pts): presence of a relative throughout the procedure; Vi-group (54 pts): additional information with a videotape. Anxiety was measured using the "Spielberger State and Trait Anxiety Scales". The patients assessed the overall discomfort during the procedure on an 100-mm visual analogue scale, and their tolerance to EGD answering a questionnaire. The endoscopist evaluated the technical difficulty of the examination and the tolerance of the patients on an 100-mm visual analogue scale and answering a questionnaire.
RESULTS: Pre-endoscopy anxiety levels were higher in the Mi-group than in the other groups (P < 0.001). On the basis of the patients' evaluation, EGD was well tolerated by 80.7% of patients in Mi-group, 43.5% in Co-group, 58.6% in Re-group, and 50% in Vi-group (P < 0.01). The discomfort caused by EGD, evaluated by either the endoscopist or the patients, was lower in Mi-group than in the other groups. The discomfort was correlated with "age" (P < 0.001) and "groups of patients" (P < 0.05) in the patients' evaluation, and with "gender" (females tolerated better than males, P < 0.001) and "groups of patients" (P < 0.05) in the endoscopist's evaluation.
CONCLUSION: Conscious sedation can improve the tolerance to EGD. Male gender and young age are predictive factors of bad tolerance to the procedure.
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Affiliation(s)
- Lucio Trevisani
- Digestive Endoscopy Service, Department of Internal Medicine, S. Anna Hospital, Ferrara, Italy.
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Basta LL. Ethical issues in the management of geriatric cardiac patients. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2004; 13:327-8. [PMID: 15538071 DOI: 10.1111/j.1076-7460.2004.02731.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Krag A, Nielsen HS, Norup M, Madsen SM, Rossel P. Research report: do general practitioners tell their patients about side effects to common treatments? Soc Sci Med 2004; 59:1677-83. [PMID: 15279924 DOI: 10.1016/j.socscimed.2004.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The principle of respect for patients' autonomy, or right to self-determination, has gained increasing importance in health care legislation during the last decade. To respect this principle the patients' informed consent to a proposed treatment is required. In relation to ordinary treatments in general practice, where several reasonable alternatives may be available and where non-treatment may be an acceptable alternative, this requirement is at least as strong as in other parts of the health care system. In this context, information about side effects may be crucial for the patient's decision to accept a proposed treatment or not. The aims of this study were to investigate the extent to which general practitioners in Denmark inform their patients about possible side effects without being asked when a common treatment is proposed. We also wished to examine the relation between physicians' estimation of the severity and frequency of these side effects, and their willingness to inform patients spontaneously as well as their preferred reasons for choosing to inform or not inform the patients. A questionnaire was sent to a random sample of 450 Danish general practitioners. The respondents differed considerably with regard to their willingness to inform patients about side effects but they were significantly more likely to give the information spontaneously if they considered the side effects frequent than when side effects were considered rare. In contrast, estimations of severity did not seem to be of any importance. The majority of the respondents informed their patients primarily to enable them to react appropriately to the side effects in question or to make sure that the patient would comply with the treatment. These findings indicate that the information given to patients about side effects by Danish general practitioners is not in accordance with the principle of respect for the patients' autonomy and not in accordance with the requirements of Danish legislation.
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Affiliation(s)
- Aleksander Krag
- Department of Medical Philosophy and Clinical Theory, University of Copenhagen, Blegdamsvej 3 bldg. 22.3., Copenhagen N 2200, Denmark
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Abstract
User involvement is central to the UK government's modernization agenda for the National Health Service (NHS). This paper represents work undertaken for the NHS National Cancer Research and Development Programme and NHS Executive Trent. It includes reflection on the experience of user involvement in health care research drawing on current UK health policy documents and an examination of the factors affecting recruitment to breast cancer clinical trials, and contributes to the debate on recruitment to clinical trials. Reference to UK policy documents is made throughout as well as real life experience of involving users in research. It summarizes key issues that nurses and midwives must consider to ensure effective user participation in research and practice.
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Affiliation(s)
- Sian Maslin-Prothero
- School of Nursing and Midwifery, University of Southampton, Highfield, Southampton, UK.
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Kite S, Wilkinson S. Beyond futility: to what extent is the concept of futility useful in clinical decision-making about CPR? Lancet Oncol 2002; 3:638-42. [PMID: 12372726 DOI: 10.1016/s1470-2045(02)00878-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The concept of futility has often been invoked to justify abstention from treatment and decisions such as 'do not attempt resuscitation' (DNAR). In this capacity, futility has played an important part in the development of several sets of official clinical guidelines. In this paper, we examine the nature of futility and question whether it is a sufficiently robust concept to meet the ethical and clinical demands placed upon it. Although the concept of futility promises simplicity, it cannot stand alone as a satisfactory framework for clinical decision-making. Practitioners and policy makers should be cautious about their use of the concept.
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Affiliation(s)
- Suzanne Kite
- Palliative Medicine at the Leeds General Infirmary and Cookridge Hospitals, Yorkshire, Leeds, UK.
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Farnell SM. Medical research: why trouble the patient for informed consent? MEDICAL AND PEDIATRIC ONCOLOGY 2002; 39:207-9; discussion 210-1. [PMID: 12210453 DOI: 10.1002/mpo.10109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sheila M Farnell
- The Garden House, 32 Mallorie Park Drive, Ripon, HG4 2QF, England
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A Staff Dialogue on Phase I Trials: Psychosocial Issues Faced by Patients, Their Families, and Caregivers. Oncologist 2002. [DOI: 10.1634/theoncologist.7-suppl_2-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
BACKGROUND The use of the randomized consent design (commonly known as the Zelen design) is a controversial issue in randomized controlled trials. In the Zelen design, participants are randomly allocated prior to seeking consent. Those participants allocated to the intervention group are then approached and offered the intervention, which they can decline or accept. Zelen first proposed the design in 1979. It has been used infrequently since this time, although there are some notable exceptions in nursing, midwifery and some medical specialities. AIM This paper describes the Zelen design, including the two forms used (the single and double consent versions) and discusses the advantages and disadvantages of using such a design. METHODS An explanation of the differences between the Zelen design and a conventional randomized controlled trial is presented. In a conventional design, detailed knowledge of the alternative interventions is given to the prospective participant. The participant gives consent and is allocated to one of the groups. In a Zelen design, participants are randomly allocated and then approached and offered the group to which they were allocated. The Zelen design is used firstly, to reduce disappointment bias in the conventional consent-randomization process, and secondly, to remove subjective bias in the recruitment process. There are concerns relating to the use of the Zelen design, including ethical concerns relating to the timing of random allocation and consent and the collection of clinical data. CONCLUSION It is hoped that by presenting issues pertaining to the Zelen design, other nursing and midwifery researchers may be prompted to consider its use when designing clinical research. The Zelen design is controversial, and debate about its merits and shortcomings is useful. This paper contributes to the ongoing debate.
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Affiliation(s)
- Caroline S E Homer
- Midwifery Practice and Research Centre, Division of Women's and Children's Health, St George Hospital, Kogarah, New South Wales, Australia.
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Abstract
Power is an inescapable aspect of all social relationships, and inherently is neither good nor evil. Doctors need power to fulfil their professional obligations to multiple constituencies including patients, the community and themselves. Patients need power to formulate their values, articulate and achieve health needs, and fulfil their responsibilities. However, both parties can use or misuse power. The ethical effectiveness of a health system is maximised by empowering doctors and patients to develop 'adult-adult' rather than 'adult-child' relationships that respect and enable autonomy, accountability, fidelity and humanity. Even in adult-adult relationships, conflicts and complexities arise. Lack of concordance between doctors and patients can encourage paternalism but may be best resolved through negotiated care. A further area of conflict involves the 'double agency' of doctors for both patients and the community. Empowerment of all players is not always possible but is most likely where each party considers and acknowledges power issues.
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Affiliation(s)
- F Goodyear-Smith
- Division of General Practice & Primary, Health Care, Faculty of Medical & Health Sciences, University of Auckland, New Zealand.
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41
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GERAGHTY J, ZBAR A, COSTA A. Informing the public about advances in cancer therapy. Eur J Cancer Care (Engl) 2002. [DOI: 10.1046/j.1365-2354.2002.00285.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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42
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GERAGHTY J, ZBAR A, COSTA A. Informing the public about advances in cancer therapy. Eur J Cancer Care (Engl) 2002. [DOI: 10.1111/j.1365-2354.2002.00285.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gattellari M, Voigt KJ, Butow PN, Tattersall MHN. When the treatment goal is not cure: are cancer patients equipped to make informed decisions? J Clin Oncol 2002; 20:503-13. [PMID: 11786580 DOI: 10.1200/jco.2002.20.2.503] [Citation(s) in RCA: 167] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Informed decision making now is considered the underpinning of ethical medical practice. We aimed to determine the extent to which patients with incurable cancer are adequately informed of their prognosis and treatment options and encouraged to participate in treatment decisions. PATIENTS AND METHODS One hundred eighteen cancer patients with incurable disease presenting for an initial consultation with one of nine oncologists at two Sydney tertiary referral hospitals participated in the study. Consultations were recorded on audiotape to permit a content analysis of doctor-patient interactions. We devised a coding system to assess disclosure of information and to evaluate doctor encouragement of patient participation in treatment decision making. Patient recall, satisfaction, anxiety, and perceptions of the decision-making process were assessed to determine the effects of informed decision making on patient outcomes. RESULTS Most patients were informed about the aim of anticancer treatment (84.7%), that their disease was incurable (74.6%), and about life expectancy (57.6%). An alternative to anticancer treatments was presented to 44.1%, 36.4% were informed about how anticancer treatment would affect quality of life, and 29.7% were offered a management choice. Oncologists checked patient understanding in only 10.2% of consultations. Although greater information disclosure did not seem to elevate anxiety levels, greater patient participation in the decision-making process was associated with increased anxiety levels (P =.0005), which persisted over a 2-week time span. CONCLUSION Most patients were well informed, but important gaps remain, especially concerning information about prognosis and alternatives to anticancer treatment. These gaps invite the question concerning whether patients are led toward anticancer treatment.
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Affiliation(s)
- Melina Gattellari
- Medical Psychology Unit and Department of Cancer, University of Sydney, and Royal North Shore Hospital, Sydney, New South Wales, Australia.
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¿Debe ANALES ESPAÑOLES DE PEDIATRÍA publicar estudios que no incluyan consentimiento informado? An Pediatr (Barc) 2002. [DOI: 10.1016/s1695-4033(02)78707-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Cox K. Informed consent and decision-making: patients' experiences of the process of recruitment to phases I and II anti-cancer drug trials. PATIENT EDUCATION AND COUNSELING 2002; 46:31-38. [PMID: 11804767 DOI: 10.1016/s0738-3991(01)00147-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
This paper presents an examination of the process of recruitment in cancer clinical trials. This research was undertaken as part of a larger study which sought to assess the psychosocial impact of participation in phases I and II anti-cancer drug trials from the patient's perspective. Through a combination of in-depth interviews with 55 patients who were offered participation in a clinical trial, and reading ease assessments of the written information they were given, patients' experiences of recruitment to the trial and their perceptions of the informed consent process were obtained. The results indicate that patients decisions may be influenced by the way information was presented to them verbally and that the written information was difficult for them to understand. This aspect of the research identified the powerful influence of the verbal consultation when seeking consent for trial involvement, the lack of understanding patients had of what they were taking part in and the need to address the readability of the written information with which they are provided.
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Affiliation(s)
- Karen Cox
- Post-Graduate Division, Faculty of Medicine and Health Sciences, School of Nursing, University of Nottingham, Nottingham, UK
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Abstract
BACKGROUND With the emphasis on the need for clinical governance and evidence-based practice in the healthcare industry there is increasing pressure on researchers to provide tangible research evidence of the effectiveness of new treatments, interventions and services. Recruiting an adequate size of sample is an important factor in the success or otherwise of a study to answer the research question. Difficulty in the recruitment of older people to research is widely acknowledged. However, much can be achieved to maximize the success of this process. AIMS OF THE PAPER This paper describes and explores our experience of recruiting frail, older people to research, with particular emphasis on ensuring quality in the process of research related to ethical practice. CONCLUSIONS Recruitment of frail older people to research can be a complex process in which the awareness and integrity of the researcher is key in upholding the principle of nonexploitation. It is important not to underestimate this difficulty and to ensure that the data collection period is sufficient to recruit adequate numbers. There is a need to continue to develop and refine recruitment skills and strategies to maximize the involvement of frail older people to research while protecting their right to refuse.
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Affiliation(s)
- R Harris
- Florence Nightingale School of Nursing and Midwifery, King's College, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK.
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Abstract
In order to ensure that further developments and improvements are made in palliative care, research is essential. Palliative care is no different from other specialities in that it needs a scientific foundation on which to base its practice. Research in palliative care is particularly difficult, however, because of the population under study. Research in palliative care presents a 'minefield' of ethical issues. One of the major issues is how to obtain informed consent from patients. This article discusses the practical and ethical issues surrounding consent for quantitative research in palliative care, and offers some guidance to health professionals considering the issue with patients.
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Affiliation(s)
- E Rees
- The Palliative Care Unit, The Royal Marsden Hospital, Sutton, UK
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Abstract
Background: The aim of this study was to explore the experiences of relatives of seriously ill patients with do-not-resuscitate (DNR) orders. Methods: The relatives of 21 patients who died with a DNR order were invited 3-6 months later to talk about their experiences before, at the time of, and after the death of the patient. Results: Although many of the relatives complained about the patients being moved around a lot in the hospital, most were satisfied with the medical therapy, the care, and the communication with the physicians and nurses. Almost all of them seemed to be well informed about the bad prognosis of the patient, and many mentioned that life support was no option. However, only one relative spontaneously mentioned that DNR was ordered. Conclusions: It is important to include patients' relatives in DNR decisions after careful planning and timing of the conversation. It is also best to avoid moving patients around too much in order to provide continuity for patients, relatives, physicians, and nurses.
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Affiliation(s)
- R Löfmark
- Department of Medicine, Länssjukhuset, SE-801 87, Gävle, Sweden
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van der Steen JT, Ooms ME, Ribbe MW, van der Wal G. Decisions to treat or not to treat pneumonia in demented psychogeriatric nursing home patients: evaluation of a guideline. Alzheimer Dis Assoc Disord 2001; 15:119-28. [PMID: 11522929 DOI: 10.1097/00002093-200107000-00003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We evaluated a new guideline, in the form of a "checklist of considerations," to support end-of-life decision making in the treatment of demented patients with pneumonia. Questionnaires were sent to nursing home physicians (NHPs) in The Netherlands at three times: before implementation of the checklist (concerning 91 individual patients), during use of the checklist (concerning another 107 individual patients), and after data collection (concerning the targeted patient category of demented nursing home patients with pneumonia as a whole). In the last questionnaire, one NHP from each nursing home (n = 55 NHPs) gave his or her general opinion about the checklist. We measured the usefulness of the checklist in supporting decision making and its frequency of actual use. The NHPs accepted the contents of the checklist for use in the targeted patient category. It was used in 46% of the incident cases of pneumonia. The checklist was considered more useful in supporting decision making for the targeted patient category (85% of the NHPs) than for the individual patient (47%). Possible explanations for this discrepancy in "usefulness" include the difference in the nature of the outcome measures and the fact that the checklist was used more frequently for the "easier cases." Information on individual patient level, patient category level, and nursing home and NHP characteristics is used to suggest checklist improvements.
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Affiliation(s)
- J T van der Steen
- Institute for Research in Extramural Medicine (EMGO), Department of Nursing Home Medicine, Vrije Universiteit Medical Center Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
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