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Shlobin NA, Regenhardt RW, Young MJ. Ethical Considerations in Endovascular Thrombectomy for Stroke. World Neurosurg 2024; 185:126-134. [PMID: 38364896 DOI: 10.1016/j.wneu.2024.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Stroke is a leading cause of morbidity and mortality globally. Endovascular mechanical thrombectomy is considered for patients with large vessel occlusion stroke presenting up to 24 hours from onset and is being increasingly utilized across diverse clinical contexts. Proactive consideration of distinctive ethical dimensions of endovascular thrombectomy (EVT) can enable stroke care teams to deliver goal-concordant care to appropriately selected patients with stroke but have been underexplored. METHODS A narrative review with case examples was conducted. RESULTS We explain and critically evaluate the application of foundational bioethical principles and narrative ethics to the practice of EVT, highlight key ethical issues that may emerge in neuroendovascular practice and develop an ethical framework to aid in the responsible use of EVT for people with large-vessel occlusive ischemic stroke. CONCLUSIONS EVT for stroke introduces important ethical considerations. Salient challenges include decision-making capacity and informed consent, the telos of EVT, uncertainty, access to care, and resource allocation. An ethical framework focusing on combining patient values and preferences with the best available evidence in the context of a multidisciplinary care team is essential to ensure that the benefits of EVT are responsibly achieved and sustained.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Robert W Regenhardt
- Departments of Neurosurgery and Neurology, Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Faris H, Dewar B, Fedyk M, Dowlatshahi D, Menon B, Swartz RH, Hill MD, Shamy M. Protocol for Deferral of Consent in Acute Stroke Trials. Neurology 2023; 100:292-300. [PMID: 36414423 PMCID: PMC9946194 DOI: 10.1212/wnl.0000000000201533] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022] Open
Abstract
The challenges of conducting hyperacute stroke research and obtaining informed consent have been increasingly recognized within the stroke research community in recent years. Deferral of consent, in which a patient is enrolled in a trial and then provides consent at some point thereafter, is increasingly used to enroll patients into hyperacute stroke trials in Canada and Europe, although it is not permitted in the United States. Deferral of consent offers several potential advantages-quicker door-to-randomization, increased enrolment, decreased selection bias-but these must be balanced against the risk of enrolling patients against their wishes. We seek to minimize the attendant risks of deferral of consent by offering practical guidance regarding how to conduct acute stroke trials using deferral of consent. Building on existing guidelines and recent experiences with deferral of consent in acute stroke trials, we have developed a protocol for the use of deferral of consent that aims to maximize patient involvement while minimizing ethical and scientific risks.
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Affiliation(s)
| | | | | | | | | | | | | | - Michel Shamy
- From the Ottawa Hospital Research Institute (H.F., B.D., D.D., M.S.), Ottawa, Ontario, Canada; School of Medicine (M.F.), University of California, Davis; Department of Medicine (D.D., M.S.), University of Ottawa & the Ottawa Hospital, Ontario; Department of Clinical Neurosciences (B.M., M.D.H.), University of Calgary and Calgary Stroke Program, Alberta; and Department of Medicine (R.H.S.), University of Toronto & Sunnybrook Health Sciences Centre, Ontario, Canada.
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Liang X, Yu Y. Effect of Optimized Emergency Care on Treatment Rate and Prognosis of Elderly Patients with Acute Stroke in Emergency Department: A Systematic Review and Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5841978. [PMID: 35928978 PMCID: PMC9345692 DOI: 10.1155/2022/5841978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/05/2022] [Accepted: 07/08/2022] [Indexed: 12/27/2022]
Abstract
Objective This research was to detect the treatment rate and prognosis of elderly patients with acute stroke in emergency department by the optimization of emergency care applying meta-analysis. Methods The online databases including PubMed, EMBASE, ScienceDirect, Cochrane Library, China knowledge Network Database (CNKI), China VIP Database, Wanfang Database, and China Biomedical Literature Database (CBM) were searched. The retrieval time limit was set from the establishment of the database to the present. The data were extracted independently by two investigators. The bias of per publication was assessed following Cochrane manual 5.1.0 standard. RevMan5.4 statistical software was used to analyze the collected data by meta. Results The 8 randomized controlled trials included in this meta-analysis all reported patients' baseline status. The meta-analysis of the rescue time of the study group and the control group (CH2 = 1507.80, df = 4, P ≤ 0.001, and I2 = 100%) showed that the emergency nursing with optimized emergency procedures can shorten the rescue of elderly acute stroke patients in the emergency department time. There are 6 literatures reporting the case fatality rate (Chi2 = 1.12, df = 5, P = 0.95 > 0.05, and I2 = 0%), and the death rate of the study group was not higher than that of the control group (Z = 4.4 and P < 0.0001). The use of optimized first aid can reduce mortality in elderly patients with acute stroke. Six articles on disability rate reported the heterogeneity of disability rate (CH2 = 2.88, df = 5, P = 0.72 > 0.05, and I2 = 0%), indicating that the disability rate in the study group was lower than that in the control group (Z = 3.91 and P < 0.0001), indicating that emergency nursing by optimizing emergency procedures can reduce the disability rate of elderly stroke patients in emergency department. Conclusion Optimizing the emergency care process can effectively improve the emergency rate and prognosis of elderly patients with acute stroke in emergency department; however, further research with higher methodological quality and longer intervention time are needed to verify later.
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Affiliation(s)
- Xia Liang
- Zhejiang Hospital Sandun Branch, The Emergency Department, Zhejiang, Hangzhou 310030, China
| | - Yanhong Yu
- Zhejiang Hospital Sandun Branch, Geriatrics Department, Zhejiang, Hangzhou 310030, China
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Bellomo T, Fokas J, Tsao N, Anderson C, Becker C, Gioscia-Ryan R, Meurer W. Ethical Considerations during the Informed Consent Process for Acute Ischemic Stroke in International Clinical Trials. Ethics Hum Res 2022; 44:14-25. [PMID: 35802793 DOI: 10.1002/eahr.500133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
We sought to investigate the experiences of researchers in existing active-control trials in acute ischemic stroke comparing investigational therapy to tissue plasminogen activator (tPA) in order to identify the approaches and challenges in obtaining informed consent. Out of 401 articles evaluated, 14 trials met inclusion criteria. Trial representatives were contacted to complete a survey concerning the consent process. None of the 14 trials published materials related to the informed consent process. Trials with 75% to 100% of patients directly consented had shorter door-to-treatment (DTT) times than trials that directly consented less than 50% of patients. Trials that had translators available (for recruiting participants who were not native speakers in the local language) and translated consent documents had longer DTT times. The study findings suggest that differences in the standards of informed consent internationally may allow more patients with moderate strokes to provide direct consent without delaying DTT time. Future trials should emphasize transparency to the public and scientific community in the informed consent process.
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Affiliation(s)
- Tiffany Bellomo
- Vascular surgery resident at the Massachusetts General Hospital
| | - Jennifer Fokas
- Neurology resident at McGaw Medical Center of Northwestern University
| | - Noah Tsao
- Medical student at the University of Rochester
| | | | | | | | - William Meurer
- Associate professor of emergency medicine at the University of Michigan
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Decision-making psychological state and characteristic of proxies of thrombolytic patients: a pilot study. Sci Rep 2022; 12:10345. [PMID: 35725751 PMCID: PMC9209408 DOI: 10.1038/s41598-022-14124-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/01/2022] [Indexed: 11/16/2022] Open
Abstract
Intravenous thrombolysis is the preferred treatment modality for acute ischemic stroke. In China, written informed consent from patients or proxies must be obtained before intravenous thrombolysis is performed, which always leads to in-hospital delay of thrombolysis. To explore the relationship between characteristics of thrombolysis decision-making and psychological states of proxies of AIS patients. This was a pilot study. 231 proxies of AIS patients were recruited, including 147 males and 84 females. STAI, WFPTS, CAOT, CPS, C-DCS and time-consuming of decision-making were collected by trained nurses during the period from signing informed consent to thrombolysis finished. The general information was collected within 24 h after admission. Pearson correlation analysis and the Ridge regression analysis were used to explore the correlation and causality between psychological indicators (STAI, WFPTS, CAOT, CPS) and decision-making characteristics (C-DCS, Time consuming). Structural equation modeling was used to explore the direct and indirect effect of psychological factors on decision-making characteristics. The mean of anxiety, trust in physicians, and decision conflict were 49.20 ± 9.50, 37.83 ± 6.63 and 30.60 ± 14.77, respectively. The CAOT was associated with C-DCS through the mediation of STAI and WFPTS (p < 0.001). The CAOT was associated with time-consuming through the mediation of STAI, WFPTS and CPS (p < 0.05). The CAOT, STAI and WFPTS were associated with C-DCS (p < 0.05), and STAI, WFPTS and CPS were associated with time-consuming (p < 0.01). The proxy of patients with acute ischemic stroke had severe decision conflict in thrombolysis decision-making. The psychological state was associated with decision conflict and the time-consuming. Medical staff should explore methods to release the anxiety and increase the trust in physicians to reduce the decision-making conflict and time-consuming, which could promote the smooth progress of the informed consent.
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Zonjee VJ, Slenders JPL, de Beer F, Visser MC, Ter Meulen BC, Van den Berg-Vos RM, van Schaik SM. Practice variation in the informed consent procedure for thrombolysis in acute ischemic stroke: a survey among neurologists and neurology residents. BMC Med Ethics 2021; 22:114. [PMID: 34433444 PMCID: PMC8390276 DOI: 10.1186/s12910-021-00684-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background Obtaining informed consent for intravenous thrombolysis in acute ischemic stroke can be challenging, and little is known about if and how the informed consent procedure is performed by neurologists in clinical practice. This study examines the procedure of informed consent for intravenous thrombolysis in acute ischemic stroke in high-volume stroke centers in the Netherlands. Methods In four high volume stroke centers, neurology residents and attending neurologists received an online questionnaire concerning informed consent for thrombolysis with tissue-type plasminogen activator (tPA). The respondents were asked to report their usual informed consent practice for tPA treatment and their considerations on whether informed consent should be obtained. Results From the 203 invited clinicians, 50% (n = 101) completed the questionnaire. One-third of the neurology residents (n = 21) and 21% of the neurologists (n = 8) reported that they always obtain informed consent for tPA treatment. If a patient is not capable of providing informed consent, 30% of the residents (n = 19) reported that they start tPA treatment without informed consent. In these circumstances, 53% of the neurologists (n = 20) reported that the resident under their supervision would start tPA treatment without informed consent. Most neurologists (n = 21; 55%) and neurology residents (n = 45; 72%) obtained informed consent within one minute. None of the respondents used more than five minutes for informed consent. Important themes regarding obtaining informed consent for treatment were patients’ capacity, and medical, ethical and legal considerations. Conclusion The current practice of informed consent for thrombolysis in acute ischemic stroke varies among neurologists and neurology residents. If informed consent is obtained, most clinicians stated to obtain informed consent within one minute. In the future, a shortened information provision process may be applied, making a shift from informed consent to informed refusal, while still considering the patient’s capacity, stroke severity, and possible treatment delays. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00684-6.
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Affiliation(s)
- Valentijn J Zonjee
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands.
| | - Jos P L Slenders
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
| | - Frank de Beer
- Department of Neurology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Marieke C Visser
- Department of Neurology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Bastiaan C Ter Meulen
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
| | - Renske M Van den Berg-Vos
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands.,Department of Neurology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Sander M van Schaik
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
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Bulmer T, Volders D, Kamal N. Analysis of Thrombolysis Process for Acute Ischemic Stroke in Urban and Rural Hospitals in Nova Scotia Canada. Front Neurol 2021; 12:645228. [PMID: 33790851 PMCID: PMC8005571 DOI: 10.3389/fneur.2021.645228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/12/2021] [Indexed: 11/27/2022] Open
Abstract
Background: Stroke is a devastating disease, but it is treatable with alteplase or tissue plasminogen activator (tPA). The effectiveness of tPA is highly time-dependent, meaning rapid treatment is critical. Fast treatment with tPA has been reported in many urban hospitals, but hospitals in rural locations struggle to reduce treatment times. This qualitative study examines current thrombolysis processes in one urban and two rural hospitals in Nova Scotia, Canada, by mapping and comparing the treatment process in these settings for acute ischemic stroke (AIS) patients, and by analyzing the healthcare professionals views on various treatment topics. Methods: Structured interviews were conducted with healthcare professionals involved in stroke treatment across the three sites. The interviews focused on the various activities in the thrombolysis treatment at each site. Additionally, participants were asked about the following 10 topics: comfort treating acute ischemic stroke patients; perceptions about tPA; appropriate tPA treatment window; stroke patient priority; tPA availability; patient consent; urban-rural treatment differences; efficiency of their treatment process; treatment delays; and suggested process improvements. Results were analyzed using the Framework Method, as well as through the development of process maps. Results: Twenty three healthcare professionals were interviewed at 2 rural hospitals and 1 urban hospital. Acute ischemic stroke patients are triaged as the highest or urgent priority at each included site. Physicians are more hesitant to treat with tPA in rural settings. A total of 11 urban-rural treatment differences were noted by the rural sites. Additionally, 11 patient-related and 29 system treatment delays were described. A process map was developed for each site, representing the arrival by ambulance and by private vehicle pathways. Conclusions: Guidelines and clear protocols are critical in reducing treatment times and ensuring consistent access to treatment. The majority of treatment delays encountered are system delays, which can be appropriately planned for to reduce delays within the care pathway. There is a general consensus that there is an urban-rural treatment gap for acute ischemic stroke patients in Nova Scotia, and that continuing education is key in rural hospitals to improve Emergency Department (ED) physician comfort with treating patients with tPA.
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Affiliation(s)
- Tessa Bulmer
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Interventional & Diagnostic Neuroradiology, QEII Health Sciences Centre, Nova Scotia Health, Halifax, NS, Canada.,Department of Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
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Meurer WJ, Skolarus L. Stroke Thrombolysis. Circ Cardiovasc Qual Outcomes 2019; 12:e005931. [PMID: 31412736 DOI: 10.1161/circoutcomes.119.005931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- William J Meurer
- Department of Emergency Medicine (W.J.M.), University of Michigan, Ann Arbor.,Department of Neurology, and Stroke Program (W.J.M., L.S.), University of Michigan, Ann Arbor
| | - Lesli Skolarus
- Department of Neurology, and Stroke Program (W.J.M., L.S.), University of Michigan, Ann Arbor
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