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Udoh U, Dewar B, Nicholls S, Fedyk M, Fahed R, Perry J, Hill MD, Menon B, Swartz RH, Poppe AY, Gocan S, Brehaut J, Dainty K, Shepherd V, Dowlatshahi D, Shamy M. Advance Consent in Acute Stroke Trials: Survey of Canadian Stroke Physicians. Can J Neurol Sci 2024; 51:122-125. [PMID: 36799025 DOI: 10.1017/cjn.2023.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Advance consent presents a potential solution to the challenge of obtaining informed consent for participation in acute stroke trials. Clinicians in stroke prevention clinics are uniquely positioned to identify and seek consent from potential stroke trial participants. To assess the acceptability of advance consent to Canadian stroke clinic physicians, we performed an online survey. We obtained 58 respondents (response rate 35%): the vast majority (82%) expressed comfort with obtaining advance consent and 92% felt that doing so would not be a significant disruption to clinic workflow. These results support further study of advance consent for acute stroke trials.
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Affiliation(s)
- Ubong Udoh
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stuart Nicholls
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Mark Fedyk
- School of Medicine, University of California, Davis, Davis, CA, USA
| | - Robert Fahed
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jeff Perry
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Emergency Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary and Calgary Stroke Program, Calgary, Alberta, Canada
| | - Bijoy Menon
- Department of Clinical Neurosciences, University of Calgary and Calgary Stroke Program, Calgary, Alberta, Canada
| | - Richard H Swartz
- Department of Medicine, University of Toronto & Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alexandre Y Poppe
- Department of Neurosciences, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Sophia Gocan
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jamie Brehaut
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Katie Dainty
- Department of Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Dar Dowlatshahi
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michel Shamy
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
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Perry J. Challenges of anticipation of future decisions in dementia and dementia research. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2022; 44:62. [PMID: 36376514 PMCID: PMC9663374 DOI: 10.1007/s40656-022-00541-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
Anticipation of future decisions can be important for individuals at risk for diseases to maintain autonomy over time. For future treatment and care decisions, advance care planning is accepted as a useful anticipation tool. As research with persons with dementia seems imperative to develop disease-modifying interventions, and with changing regulations regarding research participation in Germany, advance research directives (ARDs) are considered a solution to include persons with dementia in research in an ethically sound manner. However, little is known about what affected people deem anticipatable.This contribution provides a critical reflection of the literature on anticipation and of a qualitative study on the assessment of ARDs with persons with cognitive impairment in Germany. It combines theoretical and empirical reflections to inform the ethical-legal discourse.Anticipation involves the conceptual separation of the past, the present, and the future. Including dimensions such as preparedness, injunction, and optimization helps in establishing a framework for anticipatory decision-making. While dementia may offer a window of time to consider future decisions, individual beliefs about dementia including fears about stigma, loss of personhood, and solitude strongly impact anticipating sentiments. Concepts of anticipation can be useful for the examination of uncertainty, changing values, needs, and preferences interconnected with the dementia trajectory and can serve as a means to make an uncertain future more concrete. However, fears of losing one's autonomy in the process of dementia also apply to possibilities of anticipation as these require cognitive assessment and reassessment of an imagined future with dementia.
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Affiliation(s)
- Julia Perry
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Humboldtallee 36, 37073, Göttingen, Germany.
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Advance Care Planning for Seniors Diagnosed with Dementia: A Scoping Review of the Canadian Literature. Can J Aging 2022; 41:377-403. [PMID: 35282848 DOI: 10.1017/s0714980821000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Advance care planning (ACP) is commonly recommended for persons living with dementia. Increasing age and uncertain disease trajectory add complexity to this process. A scoping review of the Canadian literature was completed to assess the feasibility and acceptability of ACP for seniors (≥ 65 years of age) diagnosed with dementia and to provide practice, policy, and research recommendations towards ACP as a critical aspect of care. Twenty-nine articles were grouped into five themes: (1) feasibility of patient engagement in ACP; (2) opinions regarding medical assistance in dying (MAiD) for incompetent patients; (3) knowledge translation to support persons living with dementia, professionals, and caregivers; (4) barriers to and facilitators of the delivery of holistic dementia care; and (5) Indigenous health considerations. Additional research should consider socio-demographic and social/cultural factors associated with older persons living with dementia's engagement in ACP. Future policies warrant a multidisciplinary approach when reviewing legalities. Finally, ACP knowledge translation should become a routine aspect of dementia care.
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Heinrichs B. Advance research directives: avoiding double standards. BMC Med Ethics 2021; 22:137. [PMID: 34627232 PMCID: PMC8502375 DOI: 10.1186/s12910-021-00704-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 09/23/2021] [Indexed: 11/26/2022] Open
Abstract
Background Advance research directives (ARD) have been suggested as a means by which to facilitate research with incapacitated subjects, in particular in the context of dementia research. However, established disclosure requirements for study participation raise an ethical problem for the application of ARDs: While regular consent procedures call for detailed information on a specific study (“token disclosure”), ARDs can typically only include generic information (“type disclosure”). The introduction of ARDs could thus establish a double standard in the sense that within the context of ARDs, type disclosure would be considered sufficient, while beyond this context, token disclosure would remain necessary. Main body This paper provides an ethical analysis of ARDs, taking into account the results of numerous empirical studies that have been performed so far. It will be argued that a revised understanding of informed consent can allow for context-sensitive disclosure standards. As a consequence, ARDs that include type disclosure can be acceptable under suitable circumstances. Such an approach raises a number of objections. A thorough examination shows, however, that they are not sufficient to justify a rejection of the approach. Conclusion The approach presented in this paper avoids introducing a double standard. It is, therefore, more suitable for the implementation of ARDs than established approaches.
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Affiliation(s)
- Bert Heinrichs
- Institute of Neurosciences and Medicine: Ethics in the Neurosciences (INM-8), Forschungszentrum Jülich, 52425, Jülich, Germany. .,Institute of Science and Ethics (IWE), Rheinische Friedrich-Wilhelms-Universität Bonn, Bonner Talweg 57, 53113, Bonn, Germany.
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Forero Villalobos JJ, Vargas Celis I, Bernales Silva M. Voluntades anticipadas: desafíos éticos en el cuidado del paciente. PERSONA Y BIOÉTICA 2019. [DOI: 10.5294/pebi.2019.23.2.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Las voluntades anticipadas en salud tienen como finalidad que la persona manifieste de manera anticipada su voluntad sobre los cuidados y el tratamiento de su salud, lo cual le permite expresar personalmente y de forma previa sus preferencias. Esta revisión de la literatura tiene por objetivo describir el concepto y la estructura de las voluntades anticipadas, así como los aspectos éticos involucrados durante el cuidado del paciente. Con las palabras clave “Advanced Health Care Directive” AND “Ethical Implication” y sus símiles en español (voluntades anticipadas, implicaciones éticas), se revisaron cinco bases de datos: ProQuest, Philosophy (JSTOR), PubMed, Web of Science y SciELO; las publicaciones se agruparon entre los años 2010 y 2018. Se obtuvieron 31 artículos de los cuales se realizó una lectura crítica. Los resultados de esta revisión fueron agrupados en las siguientes categorías: concepto, estructura, situaciones clínicas donde se aplican las voluntades anticipadas, fortalezas y limitaciones; así como los aspectos éticos involucrados. Actualmente, son más comunes las vivencias relacionadas con las situaciones al final de la vida, donde la persona pierde su capacidad de decidir y no puede manifestar sus deseos, por lo que es imposible conocer su voluntad. Gran parte de los profesionales de la salud no tienen capacitación adecuada sobre el desarrollo y la aplicación de las voluntades anticipadas, escenario que se convierte en una oportunidad para la investigación y profundización sobre el tema. Las voluntades anticipadas son una herramienta que proporciona al equipo de salud información fidedigna de los valores y deseos del paciente, por lo que es importante capacitar a estos profesionales para brindar una atención respetuosa y de calidad.
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Digout C, Lawson B, MacKenzie A, Burge F. Prevalence of Having Advance Directives and a Signed Power of Attorney in Nova Scotia. J Palliat Care 2019; 34:189-196. [DOI: 10.1177/0825859719831312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christian Digout
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Beverley Lawson
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Adrian MacKenzie
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Hérault É, Bravo G, Trottier L. Advance Directives for Research: How Do They Compare with Surrogates’ Predictions of Older Adults’ Preferences? ACTA ACUST UNITED AC 2018. [DOI: 10.1002/eahr.405002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Élodie Hérault
- University Institute of Geriatrics of Sherbrooke; Research Center on Aging
| | - Gina Bravo
- Research Center on Aging; Université de Sherbrooke; Department of Community Health Sciences, Faculty of Medicine and Health Sciences
| | - Lise Trottier
- University Institute of Geriatrics of Sherbrooke; Research Center on Aging
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Armas A, Meyer SB, Corbett KK, Pearce AR. Face-to-face communication between patients and family physicians in Canada: A scoping review. PATIENT EDUCATION AND COUNSELING 2018; 101:789-803. [PMID: 29173960 DOI: 10.1016/j.pec.2017.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/07/2017] [Accepted: 11/16/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Patient-provider communication is critical in primary care. Canada's unique health system, population distribution, and cultural context suggest there is value in addressing the topic in the Canadian context. We conducted a scoping review to synthesize recent Canadian literature to inform practice in primary care settings and identify research agendas for patient-provider communication in Canada. METHODS Using Arksey and O'Malley's framework we searched four literature databases: Medline, Web of Science, CINAHL and EMBASE. We extracted 21,932 articles published between 2010 and 2017. A total of 108 articles met the inclusion criteria. The articles were analyzed qualitatively using thematic analysis to identify major themes. RESULTS Four major themes were identified: information sharing, relationships, health system challenges, and development and use of communication tools. CONCLUSION Our review identified a need for Canadian research regarding: communication in primary care with Aboriginal, immigrant, and rural populations; the impact of medical tourism on primary care; and how to improve communication to facilitate continuity of care. PRACTICE IMPLICATIONS Challenges providers face in primary care in Canada include: communicating with linguistically and culturally diverse populations; addressing issues that emerge with the rise of medical tourism; a need for decision aids to improve communication with patients.
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Affiliation(s)
- Alana Armas
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada.
| | - Samantha B Meyer
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Kitty K Corbett
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Alex R Pearce
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
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Werner P, Schicktanz S. Practical and Ethical Aspects of Advance Research Directives for Research on Healthy Aging: German and Israeli Professionals' Perspectives. Front Med (Lausanne) 2018; 5:81. [PMID: 29675415 PMCID: PMC5895655 DOI: 10.3389/fmed.2018.00081] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/12/2018] [Indexed: 11/16/2022] Open
Abstract
Background Healthy aging is the development and maintenance of optimal cognitive, social and physical well-being, and function in older adults. Preventing or minimizing disease is one of the main ways of achieving healthy aging. Dementia is one of the most prevalent and life-changing diseases of old age. Thus, dementia prevention research is defined as one of the main priorities worldwide. However, conducting research with persons who lack the capacity to give consent is a major ethical issue. Objective Our study attempts to explore if and how advance research directives (ARDs) may be used as a future tool to deal with the ethical and practical issues in dementia research. Method We conducted focus groups and in-depth interviews with German and Israeli professional stakeholders from the fields of gerontology, ethics, medical law, psychiatry, neurology and policy advice (n = 16), and analyzed the main topics discussed regarding cross-national similarities and controversies within the groups, as well as across the two national contexts. Results While both countries are in the midst of a developmental process and have recognized the importance and need for ARD as a tool for expanding healthy aging, Germany is in a more advanced stage than Israel because of the EU regulation process, which indicates the influence of international harmonization on these research-related ethical issues. Consensual themes within the qualitative material were identified: the need for a broader debate on ARD, the ethical importance of autonomy and risk–benefit assessment for ARD implementation, the role of the proxy and the need for the differentiation of types of dementia research. Controversies and dilemmas aroused around themes such as the current role of IRBs in each country, the need for limits, and how to guaranty safeguarding and control. Discussion Implementing a new tool is a step-by-step procedure requiring a thorough understanding of the current state of knowledge as well as of the challenges and hurdles ahead. As long as improving quality of life and promoting autonomy continue to be core elements in the process of healthy aging, efforts to advance knowledge and solve dilemmas associated with the implementation of ARD is of the utmost importance.
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Affiliation(s)
- Perla Werner
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | - Silke Schicktanz
- Institute of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
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Gowda GS, Noorthoorn EO, Lepping P, Kumar CN, Nanjegowda RB, Math SB. Factors influencing advance directives among psychiatric inpatients in India. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2018; 56:17-26. [PMID: 29701595 DOI: 10.1016/j.ijlp.2017.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/30/2017] [Accepted: 10/10/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Advance directives are documents stating treatment preferences in case of future lack of decision making capacity. In India, as in many other countries, legislators advocate Psychiatric Advance Directives (PADs), while evidence on its use is limited. This study examined factors influencing PADs by gathering inpatients perspectives on PADs at discharge and investigating patient characteristics associated with the expression of treatment wishes in PADs. METHODS We conducted a hospital based descriptive study in Bangalore. 200 patients were included. The Mini International Neuropsychiatric Interview, CGI-S and CGI-I (Clinical Global Impression scales), the Insight Scale-2, and an Illness insight assessment were completed within 3days of admission. We used the Bangalore Advance Directive Interview (BADI) to assess attitudes towards PADs. 182 subjects were reassessed within 3days of discharge, along with an interview on their perspectives on PADs. RESULTS 67% welcomed the need for PADs in India. 95.6% made their own PADs. 80% followed their doctors' advice in their PAD. Subjects lacking insight or remaining symptomatic at discharge opted significantly more often against ECT, antipsychotics, and inpatient care. Linear regression showed that low socio-economic status, unwillingness to stay in hospital, and having received ECT before were inversely associated with the expression of treatment wishes in PADs. CONCLUSIONS This study's findings are relevant for India and Western countries alike while generating legislation including patients' perspectives. A majority of patients favoured PADs. Absent insight, severe psychopathology and incomplete recovery may negatively influence the way PADs are completed. Therefore, clinicians must assess patient's capacity to formulate PADs carefully, as capacity may significantly influence patients' views. The timing of when to formulate one's PAD within the illness process may be essential.
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Affiliation(s)
- Guru S Gowda
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029, India.
| | - Eric O Noorthoorn
- Dutch Information Centre on Containment Measures located Bilthoven Utrecht, The Netherlands; GGNet Community Mental Health Centre, PO Box 2003, 7230 GC Warnsveld, The Netherlands
| | - Peter Lepping
- BCUHB, Department of liaison psychiatry, Wrexham, UK, and Bangor University, Wales, UK; Department of Psychiatry, Mysore Medical College and Research Institute (MMCRI), Mysore, India; Centre for Mental Health and Society, Technology Park, Croesnewydd Road,Wrexham LL13 7TP, Wales, United Kingdom
| | | | - Raveesh Bevinahalli Nanjegowda
- Department of Psychiatry, Mysore Medical College and Research Institute (MMCRI), Mysore, India; Department of Psychiatry, Dharwad Institute of Mental Health and Neurosciences, (DIMHANS), Belgaum Road, Dharwad 580008, India
| | - Suresh Bada Math
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029, India
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Bravo G, Trottier L, Arcand M, Boire-Lavigne AM, Blanchette D, Dubois MF, Guay M, Lane J, Hottin P, Bellemare S. Promoting advance care planning among community-based older adults: A randomized controlled trial. PATIENT EDUCATION AND COUNSELING 2016; 99:1785-1795. [PMID: 27283764 DOI: 10.1016/j.pec.2016.05.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 05/01/2016] [Accepted: 05/08/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To test an intervention designed to motivate older adults in documenting their healthcare preferences in advance, and to guide proxies in making hypothetical decisions that match those of the older adult. METHODS The trial involved 235 older adults, of which half were assisted in communicating their wishes to their proxy. Hypothetical vignettes were used at baseline and twice after the intervention to elicit older adults' preferences and assess their proxy's ability to predict them. RESULTS By the end of the trial, 80% of older adults allocated to the experimental group had documented their wishes. Changes over time in mean accuracy scores did not differ between groups for any hypothetical situations, except when limiting the sample to dyads that were highly discordant at baseline. CONCLUSION The intervention motivated a large proportion of older adults to express their preferences but had little effect on proxies' ability to predict them. PRACTICE IMPLICATIONS Educational tools developed for this study will assist healthcare providers in helping older adults to record their wishes in advance. Clients must be informed of the challenge of making substitute decisions and of the need to discuss the amount of leeway the proxy should have in interpreting expressed wishes.
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Affiliation(s)
- Gina Bravo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada; Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Canada.
| | - Lise Trottier
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Canada
| | - Marcel Arcand
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Canada; Department of Family Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Anne-Marie Boire-Lavigne
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Danièle Blanchette
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Canada; Department of Accounting Sciences, Faculty of Business Administration, Université de Sherbrooke, Sherbrooke, Canada
| | - Marie-France Dubois
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada; Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Canada
| | - Maryse Guay
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada; Charles-LeMoyne Hospital Research Centre, Longueuil, Canada
| | - Julie Lane
- Department of Coordination and Academic Affairs, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Canada
| | - Paule Hottin
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Suzanne Bellemare
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Canada
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Substitute consent practices in the face of uncertainty: a survey of Canadian researchers in aging. Int Psychogeriatr 2013; 25:1821-30. [PMID: 23927951 DOI: 10.1017/s1041610213001336] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In Canada and elsewhere, research policies require researchers to secure consent from a legally authorized representative (LAR) for prospective participants unable to consent. Few jurisdictions, however, offer a clear legislative basis for LAR identification. We investigated Canadian researchers' practices regarding the involvement of decisionally incapacitated participants and tested whether reported practices were associated with (1) researchers' understanding of the law on third-party authorization of research and (2) their comfort with allowing a family member to consent on behalf of an incapacitated relative. METHODS We surveyed researchers in aging from four Canadian provinces about their practices with prospective participants deemed incapable of consent, their understanding of relevant law, and comfort with family consent for research purposes. Understanding and comfort were measured with research vignettes that briefly described hypothetical studies in which an adult who lacks the capacity to consent was invited to participate. RESULTS Many respondents reported soliciting consent from a family member (45.7% for low-risk studies and 10.7% for serious risks studies), even in jurisdictions where such authority is uncertain at law. Researchers' tendency to solicit family consent was associated with their comfort in doing so, but not with their understanding of the law on substitute consent for research. CONCLUSIONS Findings underscore the need to clarify who may authorize an incapacitated adult's participation in research. Meanwhile, people should inform their relatives of their desire to participate or not in research in the event of incapacity, given researchers' tendency to turn to family for consent, even where not supported by law.
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Wildeman S, Dunn LB, Onyemelukwe C. Incapacity in Canada: review of laws and policies on research involving decisionally impaired adults. Am J Geriatr Psychiatry 2013; 21:314-25. [PMID: 23498378 DOI: 10.1016/j.jagp.2013.01.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 04/12/2012] [Accepted: 06/04/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In Canada, as in the United States, the legal frameworks governing research involving adults incapable of providing informed consent are beset by gaps and ambiguities. In both countries, federal laws and policies relevant to the regulation of research involving decisionally incapable adults interact in complex ways with provincial or state laws. To alert researchers to these complexities and to urge law reform, this review provides a comprehensive account of the federal and provincial/ territorial legal frameworks relevant to research involving decisionally incapable adults in Canada. DESIGN We identified the federal and provincial/territorial laws and policies pertinent to this review by updating previous work on substitute decision-making about research in Canada and then performing keyword searches on a Canadian legal information database (CanLii) to identify further laws of relevance. Our analysis of identified laws focused on three questions: 1) What (if any) preconditions-including permissible risk and/or benefit thresholds-are imposed on research involving persons who lack capacity to consent? 2) What provisions (if any) are in place for identification of the legally authorized representative for research decision making? and 3) What factors, if any, are stipulated as mandatory relevant considerations for the legally authorized representative's decision-making process? RESULTS Across Canada, laws relating to substitute decision-making are highly variable, and often ambiguous or uncertain, on each of the matters targeted in our analysis. CONCLUSIONS Researchers and research institutions should be aware of federal and provincial/territorial legal requirements for research involving persons who lack capacity to consent in Canada. The relevant governments should undertake coordinated efforts at law reform to clarify, and potentially harmonize, these requirements.
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Affiliation(s)
- Sheila Wildeman
- Schulich School of Law, Dalhousie University, Halifax, Canada.
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Bravo G, Arcand M, Blanchette D, Boire-Lavigne AM, Dubois MF, Guay M, Hottin P, Lane J, Lauzon J, Bellemare S. Promoting advance planning for health care and research among older adults: a randomized controlled trial. BMC Med Ethics 2012; 13:1. [PMID: 22221980 PMCID: PMC3328256 DOI: 10.1186/1472-6939-13-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 01/05/2012] [Indexed: 01/25/2023] Open
Abstract
Background Family members are often required to act as substitute decision-makers when health care or research participation decisions must be made for an incapacitated relative. Yet most families are unable to accurately predict older adult preferences regarding future health care and willingness to engage in research studies. Discussion and documentation of preferences could improve proxies' abilities to decide for their loved ones. This trial assesses the efficacy of an advance planning intervention in improving the accuracy of substitute decision-making and increasing the frequency of documented preferences for health care and research. It also investigates the financial impact on the healthcare system of improving substitute decision-making. Methods/Design Dyads (n = 240) comprising an older adult and his/her self-selected proxy are randomly allocated to the experimental or control group, after stratification for type of designated proxy and self-report of prior documentation of healthcare preferences. At baseline, clinical and research vignettes are used to elicit older adult preferences and assess the ability of their proxy to predict those preferences. Responses are elicited under four health states, ranging from the subject's current health state to severe dementia. For each state, we estimated the public costs of the healthcare services that would typically be provided to a patient under these scenarios. Experimental dyads are visited at home, twice, by a specially trained facilitator who communicates the dyad-specific results of the concordance assessment, helps older adults convey their wishes to their proxies, and offers assistance in completing a guide entitled My Preferences that we designed specifically for that purpose. In between these meetings, experimental dyads attend a group information session about My Preferences. Control dyads attend three monthly workshops aimed at promoting healthy behaviors. Concordance assessments are repeated at the end of the intervention and 6 months later to assess improvement in predictive accuracy and cost savings, if any. Copies of completed guides are made at the time of these assessments. Discussion This study will determine whether the tested intervention guides proxies in making decisions that concur with those of older adults, motivates the latter to record their wishes in writing, and yields savings for the healthcare system. Trial Registration ISRCTN89993391
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Affiliation(s)
- Gina Bravo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada.
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