Ethical challenges of obtaining informed consent from surgical patients

Varicose Vein Education and Informed coNsent (VVEIN) Study: A Randomized Controlled Pilot Feasibility Study

BACKGROUND

The primary aim of this study was to assess the feasibility of introducing a digital health education tool (dHET) for varicose vein surgery.

METHODS

This randomized, feasibility study allocated 40 patients, into dHET (n = 20) or standard consent (SC) (n = 20) groups. Primary outcomes were related to feasibility. Secondary outcomes were knowledge recall, anxiety, and satisfaction.

RESULTS

Recruitment and retention rates were 100% and 97.5%, respectively. Acceptability was also rated high, confirming feasibility. There was also no evidence of a difference between groups for early knowledge recall (14 [12-17] vs. 14 [11-16]; P = 0.72) or delayed (at 2 weeks) knowledge recall (15 [13-16] vs. 15 [13-16]; P = 0.89). The dHET module took significantly longer to complete compared to SC (13 min [12-18] vs. 9 min [8-12]; P < 0.01). However, the control group asked significantly more questions about the intended procedure (P = 0.03). There was no evidence of a difference between groups for patient anxiety or satisfaction.

CONCLUSIONS

This trial shows that the addition of a dHET is feasible and noninferior to SC. Digital consent provides a unique opportunity to promote patient education and autonomy for better shared decision making. It also offers better documentation of the consent process.

Digital technology in informed consent for surgery: systematic review

BACKGROUND

Informed consent is an ethical and legal requirement in healthcare and supports patient autonomy to make informed choices about their own care. This review explores the impact of digital technology for informed consent in surgery.

METHODS

A systematic search of EBSCOhost (MEDLINE/CINAHL), Embase, Cochrane Central Register of Controlled Trials and Web of Science was performed in November 2021. All RCTs comparing outcomes of both digital and non-digital (standard) consent in surgery were included. Each included study underwent an evaluation of methodological quality using the Cochrane risk of bias (2.0) tool. Outcomes assessed included comprehension, level of satisfaction and anxiety, and feasibility of digital interventions in practice.

RESULTS

A total of 40 studies, across 13 countries and 15 surgical specialties were included in this analysis. Digital consent interventions used active patient participation and passive patient participation in 15 and 25 studies respectively. Digital consent had a positive effect on early comprehension in 21 of 30 (70 per cent) studies and delayed comprehension in 9 of 20 (45 per cent) studies. Only 16 of 38 (42 per cent) studies assessed all four elements of informed consent: general information, risks, benefits, and alternatives. Most studies showed no difference in satisfaction or anxiety. A minority of studies reported on feasibility of digital technology in practice.

CONCLUSION

Digital technologies in informed consent for surgery were found to have a positive effect on early comprehension, without any negative effect on satisfaction or anxiety. It is recommended that future studies explore the feasibility of these applications for vulnerable patient groups and busy surgical practice.

Does the standard medical procedure consent process meet the criteria required for informed consent? - A concept analysis

BACKGROUND

Informed consent is a complex process that is legally required before any surgical procedure.

PURPOSE

The purpose of this manuscript was to perform a concept analysis of the informed consent process.

METHODS

The use of dimensional analysis identified three separate yet related perspectives of the informed consent process: legal, health care, and patients. A database search using the Cumulative Index to Nursing and Allied Health Literature and PubMed were performed.

FINDINGS

A total of 27 publications were reviewed. The legal perspective addresses the requirement of informed consent, which starts with the discussion between the health care provider and the patient undergoing the surgical procedure and ends with a signature on a piece of paper. The health care perspective also addresses the legal requirement but incorporates the goals and objectives of the individual initiating the informed consent discussion. The patients' perspectives also incorporate goals and objectives; however, they differ from that of the health care provider in that they go beyond what happens in the operating room or during hospitalization.

DISCUSSION

Viewing informed consent through these different yet related perspectives provides insight into this complex process and may enhance the researcher's ability to understand and improve the informed consent process.

Practice and Factors Associated with Informed Consenting Process for Major Surgical Procedures Among Health-Care Workers, South Eastern Ethiopia

Background

Medical malpractice, poor patient outcome and medical suits among health-care workers result from improper consenting practices. Therefore, this study aimed to assess practice and factors associated with the informed consenting process for major surgical procedures among health-care workers in public hospitals of Bale Zone, South Eastern Ethiopia.

Methods

An institutional-based cross-sectional study was conducted from March 9 to 24, 2020, among all nurses, midwives, doctors (general physicians, surgeons, gynecologists), emergency surgery officers, anesthetists) who were working at Bale Zone public hospitals during the study period. A self-administered pretested questionnaire was employed. Variables with a p-value of less than 0.25 (age group, sex, educational profession, working unit, work experience, adequate content of consent form, training on informed consent, policy/regulation in institution, administrative support, average number of patient cared per shift, time spent for consent process, knowledge, attitude) at 95% confidence interval in the binary logistic regression analysis were considered for multivariable regression model to control for possible confounding effect.

Results

Of the total sample size (639 health-care workers), 621 (97.2%) were included in this study, of which 311 (50.1%, 95% CI: 46.1-53.8) practiced proper informed consent during major surgical procedures. Being age above 35 (AOR: 3.032, 95% CI: 1.148-8.010), male (AOR: 1.607, 95% CI: 1.047-2.465), above 10 years of working experience (AOR: 2.339, 95% CI: 1.104-4.955), adequate content of consent form (AOR: 2.785, 95% CI: 1.772-4.377), having training on informed consent (AOR: 2.305, 95% CI: 1.204-4.414), spending more time (>30minutes) for consent process (AOR: 3.014, 95% CI: 1.095-8.298), having good knowledge (AOR: 1.808, 95% CI: 1.195-2.737) and favorable attitude (AOR: 2.188, 95% CI: 1.456-3.287) were significantly associated with good informed consent practice.

Conclusion

Only half of health-care workers practiced good informed consent. Further emphasis needs to be given to improve consent practice.

Informed consent: What risks are material to patients consenting for urological procedures?

Objective:

This study aimed to assess patient recall of the consent discussion for urological procedures and to identify which risks were material to urology patients.

Methods:

A total of 102 patients undergoing urological procedures were interviewed in the 24-hour period surrounding the procedure. A self-designed, piloted questionnaire recorded information from the patient’s signed consent form and patient-reported data of the consent discussion.

Results:

The mean patient recall was 2.06 risks, whereas the average number of risks listed by the operating surgeon on the consent form was 5.69 risks. The most frequently recalled risk was impotence (91%), followed by urinary incontinence (63%) and haematuria (61%). The risks associated with poorest patient recall were stent symptoms (0%), urethral catheter insertion (5%) and recurrence (8%).

Conclusions:

Poor patient recall of the consent discussion has again been demonstrated in this study. However, certain urological procedure risks are better recalled by patients, with impotence, urinary incontinence and haematuria being most frequently recalled. Medical terminology such as stent or catheter may be poorly recalled due to a disparity in understanding between patient and clinician. Clinicians should be aware of poor patient recall when consenting for urology procedures and should ensure precise documentation.

Level of evidence:

Level 2b.

Defining ethical challenge(s) in healthcare research: a rapid review

BACKGROUND

Despite its ubiquity in academic research, the phrase 'ethical challenge(s)' appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of 'ethical challenge(s)' and closely related terms as used in current healthcare research literature.

METHODS

Rapid review to identify peer-reviewed reports examining 'ethical challenge(s)' in any context, extracting data on definitions of 'ethical challenge(s)' in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher's Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.

RESULTS

393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of 'ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to 'ethical challenge(s)' within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.

CONCLUSIONS

Only 12/72 studies contained an explicit definition of 'ethical challenge(s)', with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

Confidence level, challenges, and obstacles faced by orthopedic residents in obtaining informed consent

OBJECTIVES

The objective is to evaluate the opinions of orthopedic residents on current practices, experiences, training, confidence level, difficulties, and challenges faced when obtaining informed consent.

DESIGN

This is a cross-sectional, multi-center, and questionnaire-based study.

SETTING

The study was done in forty-four training centers across Saudi Arabia.

PARTICIPANTS

In total, 313 orthopedic residents participated.

MATERIAL AND METHODS

The web-based questionnaire examined the perceptions of residents regarding practices, experience, training, difficulties, and challenges surrounding the obtention of informed consent, as well as residents' confidence in obtaining informed consent for different orthopedic situations and eight common orthopedic procedures.

RESULTS

Most residents were allowed to obtain consent independently for all emergency, trauma, primary, and revision cases at their institution (92.7%). Only 33.5% of the residents received formal training and teaching on obtaining informed consent, with 67.1% having believed that they needed more training. Only 4.2% of the residents routinely disclosed all essential information of informed consent to patients. Inadequate knowledge (86.3%) and communication barriers (84.7%) were the most reported difficulties. Generally, 77.3% of the residents described their confidence level in obtaining informed consent as good or adequate, and 33.9% were confident to discuss all key components of the informed consent. Residents' confidence level to independently obtain informed consent decreased with procedure complexity. Receiving formal training, senior level (postgraduate year (PGY) 4 and 5), and being frequently involved in obtaining informed consent correlated with increased confidence level.

CONCLUSION

Many residents incompletely disclosed key information upon obtaining informed consent and reported lacking confidence in their ability to perform the procedure in their daily practices. To improve patient care and residents' performance and overcome these difficulties and challenges, institutions should develop effective strategies to standardize the informed consent process, provide formal training for obtaining informed consent, and provide supervision for residents during obtention of informed consent.