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Reynolds JJ, Charest-Morin R, Versteeg AL, Galgano M, Lubelski D, Newman WC, Patel SS, Sullivan PLZ, Dea N, Gasbarrini A, Lazary A, Rhines LD, Sahgal A, Verlaan JJ, Fisher CG, Laufer I. Streamlining the Journey of Research Into Clinical Practice: Making Your Patients and Practice Flourish Understanding and Setting Treatment Expectations for Patients With Metastatic Spine Tumors. Global Spine J 2024; 14:1880-1888. [PMID: 39052928 DOI: 10.1177/21925682241264406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
STUDY DESIGN Literature review with clinical recommendation. OBJECTIVE A concise curation of the latest spine literature exploring the relationship between expectations and satisfaction for patients with metastatic spinal disease (MSD). Deliver recommendations to practicing clinicians regarding interpretation and utilisation of this evidence. METHODS The latest spine literature in the topic of factors affecting the expectations of patients with MSD was reviewed and clinical recommendations were formulated. Recommendations are graded as strong or Conditional. RESULTS 5 articles were selected. Article 1: risk factors for the development of dissatisfaction from a cohort of 362 MSD patients. Strong recommendation to incorporate risk factor assessment when considering treatment. Article 2: systematic review assessing the relationship between pre-operative patient expectations and subsequent satisfaction in allied disciplines. Conditional recommendation to optimize patient expectation to positively modify patient satisfaction. Article 3: qualitative study of how clinicians, from different specialties, counsel patients with MSD pre-treatment. Strong recommendation to use a multidisciplinary approach. Article 4 qualitative study of how MSD patients experience their pre-treatment counselling and how that affected their appreciation of treatment success. Conditional recommendation to furnish patients with tailored, expected outcomes in the context of systemic progression. Article 5 Design and validation of a pre-treatment questionnaire specific to MSD. A conditional recommendation to incorporate this questionnaire in clinical and research MSD practice. CONCLUSION Patients with MSD are approaching end of life care and high levels of treatment satisfaction are crucial at this juncture. The role of expectation management and comprehensive counselling is critical.
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Affiliation(s)
| | - Raphaële Charest-Morin
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, BC, Canada
| | | | - Michael Galgano
- Department of Neurosurgery, University of North Carolina, Chapel Hill, NC, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - W Christopher Newman
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shalin S Patel
- Orthopaedic Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Nicolas Dea
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, BC, Canada
| | - Alessandro Gasbarrini
- Oncologic and Degenerative Spine Surger, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Aron Lazary
- Department of Spinal Surgery, National Center for Spinal Disorders, Budapest, Hungary
| | | | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Science Center, Toronto, ON, Canada
| | - Jorrit-Jan Verlaan
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Charles G Fisher
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, BC, Canada
| | - Ilya Laufer
- Department of Neurosurgery, New York University Langone Health, New York, NY, USA
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Sangeorzan I, Antonacci G, Martin A, Grodzinski B, Zipser CM, Murphy RKJ, Andriopoulou P, Cook CE, Anderson DB, Guest J, Furlan JC, Kotter MRN, Boerger TF, Sadler I, Roberts EA, Wood H, Fraser C, Fehlings MG, Kumar V, Jung J, Milligan J, Nouri A, Martin AR, Blizzard T, Vialle LR, Tetreault L, Kalsi-Ryan S, MacDowall A, Martin-Moore E, Burwood M, Wood L, Lalkhen A, Ito M, Wilson N, Treanor C, Dugan S, Davies BM. Toward Shared Decision-Making in Degenerative Cervical Myelopathy: Protocol for a Mixed Methods Study. JMIR Res Protoc 2023; 12:e46809. [PMID: 37812472 PMCID: PMC10594151 DOI: 10.2196/46809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Health care decisions are a critical determinant in the evolution of chronic illness. In shared decision-making (SDM), patients and clinicians work collaboratively to reach evidence-based health decisions that align with individual circumstances, values, and preferences. This personalized approach to clinical care likely has substantial benefits in the oversight of degenerative cervical myelopathy (DCM), a type of nontraumatic spinal cord injury. Its chronicity, heterogeneous clinical presentation, complex management, and variable disease course engenders an imperative for a patient-centric approach that accounts for each patient's unique needs and priorities. Inadequate patient knowledge about the condition and an incomplete understanding of the critical decision points that arise during the course of care currently hinder the fruitful participation of health care providers and patients in SDM. This study protocol presents the rationale for deploying SDM for DCM and delineates the groundwork required to achieve this. OBJECTIVE The study's primary outcome is the development of a comprehensive checklist to be implemented upon diagnosis that provides patients with essential information necessary to support their informed decision-making. This is known as a core information set (CIS). The secondary outcome is the creation of a detailed process map that provides a diagrammatic representation of the global care workflows and cognitive processes involved in DCM care. Characterizing the critical decision points along a patient's journey will allow for an effective exploration of SDM tools for routine clinical practice to enhance patient-centered care and improve clinical outcomes. METHODS Both CISs and process maps are coproduced iteratively through a collaborative process involving the input and consensus of key stakeholders. This will be facilitated by Myelopathy.org, a global DCM charity, through its Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy community. To develop the CIS, a 3-round, web-based Delphi process will be used, starting with a baseline list of information items derived from a recent scoping review of educational materials in DCM, patient interviews, and a qualitative survey of professionals. A priori criteria for achieving consensus are specified. The process map will be developed iteratively using semistructured interviews with patients and professionals and validated by key stakeholders. RESULTS Recruitment for the Delphi consensus study began in April 2023. The pilot-testing of process map interview participants started simultaneously, with the formulation of an initial baseline map underway. CONCLUSIONS This protocol marks the first attempt to provide a starting point for investigating SDM in DCM. The primary work centers on developing an educational tool for use in diagnosis to enable enhanced onward decision-making. The wider objective is to aid stakeholders in developing SDM tools by identifying critical decision junctures in DCM care. Through these approaches, we aim to provide an exhaustive launchpad for formulating SDM tools in the wider DCM community. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/46809.
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Affiliation(s)
| | - Grazia Antonacci
- Department of Primary Care and Public Health, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, Imperial College London, London, United Kingdom
- Centre for Health Economics and Policy Innovation (CHEPI), Business School, Imperial College London, London, United Kingdom
| | - Anne Martin
- Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, Canterbury, United Kingdom
| | - Ben Grodzinski
- University Hospitals Sussex, NHS Foundation Trust, Brighton, United Kingdom
| | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Rory K J Murphy
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Panoraia Andriopoulou
- Psychology Department, School of Social Sciences, University of Ioannina, Ioannina, Greece
| | - Chad E Cook
- Division of Physical Therapy, School of Medicine, Duke University, Durham, CA, United States
- Department of Orthopaedics, School of Medicine, Duke University, Durham, CA, United States
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, CA, United States
- Duke Clinical Research Institute, Duke University, Durham, CA, United States
| | - David B Anderson
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - James Guest
- The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Julio C Furlan
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
- The KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Mark R N Kotter
- Myelopathy.org, Cambridge, United Kingdom
- Department of Clinical Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Timothy F Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | | | - Helen Wood
- Myelopathy.org, Cambridge, United Kingdom
| | - Christine Fraser
- Department of Health Sciences, University of Stirling, Scotland, United Kingdom
- Physiotherapy Department, National Health Service Lothian, Edinburgh, United Kingdom
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Vishal Kumar
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Department of Orthopaedics, All India Institute of Medical Sciences, Deoghar, India
| | - Josephine Jung
- Institute of Psychiatry, Psychology & Neuroscience, King's College, London, United Kingdom
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | - James Milligan
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Aria Nouri
- Division of Neurosurgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Allan R Martin
- Department of Neurological Surgery, University of California, Davis, Davis, CA, United States
| | | | - Luiz Roberto Vialle
- School of Medicine, Pontifical Catholic University of Paraná, Curitiba, Brazil
| | - Lindsay Tetreault
- Department of Neurology, New York University, New York, NY, United States
| | - Sukhvinder Kalsi-Ryan
- The KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anna MacDowall
- Department of Surgical Sciences, Uppsala University and Department of Orthopaedics, The Academic Hospital of Uppsala, Uppsala, Sweden
| | | | | | - Lianne Wood
- Faculty of Health and Life Sciences, University of Exeter, Exeter, United Kingdom
- NeuroSpinal Assessment Unit, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Abdul Lalkhen
- Northern Care Alliance, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Manabu Ito
- Department of Orthopaedic Surgery, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Nicky Wilson
- Physiotherapy Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Caroline Treanor
- Department of Physiotherapy, Beaumont Hospital, Dublin, Ireland
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Benjamin M Davies
- Myelopathy.org, Cambridge, United Kingdom
- Department of Clinical Neurosurgery, University of Cambridge, Cambridge, United Kingdom
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Turner H, Cashman J, Doran C. Can teleconsent improve patient recall of surgical risks in knee arthroplasty? A randomised controlled trial. Ir J Med Sci 2022:10.1007/s11845-022-03158-9. [PMID: 36104548 PMCID: PMC9473741 DOI: 10.1007/s11845-022-03158-9] [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: 06/13/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022]
Abstract
Objectives Informed consent plays a vital role in managing patients undergoing knee arthroplasty (KA). Unfortunately, patient recall of informed consent remains poor. Evidence has suggested that telemedicine and teleconsent can be safe, cost-effective, and well-received by patients. The primary aim of this study was to evaluate the effect of an additional preoperative teleconsent session on patient recall of surgical risks 1 month after knee arthroplasty. The secondary aim was to assess its impact on patient satisfaction. Methods Sixty adult patients awaiting knee arthroplasty were randomly allocated to receive an additional preoperative teleconsent consultation (intervention group) or not (control group), along with the standard informed consent on the day of surgery. Participants were contacted 1 month after surgery to assess recall of surgical risks and satisfaction with the process. Demographics and education levels were recorded for each patient. Results The mean recall rates were 16% and 12% in the study and control groups, respectively, with no significant difference (p = 0.42). There was a significant difference between the mean satisfaction scores in the intervention group and the control group (9.8/10 vs 9/10, p = 0.0004). Lastly, there was a significant positive correlation between the education level and the number of risks recalled in the study (p = 0.05) and control groups (p = 0.04). Conclusion The additional preoperative teleconsent session had no significant effect on the risk recall rate but improved patient satisfaction. Our findings suggest education level may play a role in information recall. We can advocate for the increased use of teleconsent and telemedicine in patients undergoing KA or any elective orthopaedic procedure due to its perceived positive effects on patient satisfaction rates.
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Convie LJ, Clements JM, McCain S, Campbell J, Kirk SJ, Clarke M. Development of a core outcome set for informed consent for therapy: An international key stakeholder consensus study. BMC Med Ethics 2022; 23:79. [PMID: 35945581 PMCID: PMC9364552 DOI: 10.1186/s12910-022-00820-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 07/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background 300 million operations and procedures are performed annually across the world, all of which require a patient’s informed consent. No standardised measure of the consent process exists in current clinical practice. We aimed to define a core outcome set for informed consent for therapy.
Methods The core outcome set was developed in accordance with a predefined research protocol and the Core OutcoMes in Effectiveness Trials (COMET) methodology comprising systematic review, qualitative semi structured interviews, a modified Delphi process and consensus webinars to ratify outcomes for inclusion in the final core outcome set. (Registration—https://www.comet-initiative.org/Studies/Details/1024). Participants from all key stakeholder groups took part in the process, including patients and the public, healthcare practitioners and consent researchers. Results 36 outcome domains were synthesised through systematic review and organised into a consent taxonomy. 41 semi-structured interviews were performed with all consent stakeholders groups. 164 participants from all stakeholder groups across 8 countries completed Delphi Round 1 and 125 completed Round 2. 11 outcomes met the ‘consensus in’ criteria. 6 met ‘consensus in’ all stakeholder groups and were included directly in the final core outcome set. 5 remaining outcomes meeting ‘consensus in’ were ratified over two consensus webinars. 9 core outcomes were included in the final core outcome set: Satisfaction with the quality and amount of information, Patient feeling that there was a choice, Patient feeling that the decision to consent was their own, Confidence in the decision made, Satisfaction with communication, Trust in the clinician, Patient satisfaction with the consent process, Patient rated adequacy of time and opportunity to ask questions. Conclusion This international mixed-methods qualitative study is the first of its kind to define a core outcome set for informed consent for intervention. It defines what outcomes are of importance to key stakeholders in the consent process and is a forward step towards standardising future consent research.
Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00820-w.
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Affiliation(s)
- Liam J Convie
- Department of General Surgery, Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast, BT16 1RH, UK.,Centre for Public Health, Institute of Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - Joshua M Clements
- Department of General Surgery, Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast, BT16 1RH, UK. .,Centre for Public Health, Institute of Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA, UK.
| | - Scott McCain
- Department of General Surgery, Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast, BT16 1RH, UK
| | - Jeffrey Campbell
- Department of General Surgery, Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast, BT16 1RH, UK
| | - Stephen J Kirk
- Department of General Surgery, Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast, BT16 1RH, UK.,Centre for Public Health, Institute of Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - Mike Clarke
- Department of General Surgery, Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast, BT16 1RH, UK.,Centre for Public Health, Institute of Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA, UK
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Paramasivan S, Davies P, Richards A, Wade J, Rooshenas L, Mills N, Realpe A, Raj JP, Subramani S, Ives J, Huxtable R, Blazeby JM, Donovan JL. What empirical research has been undertaken on the ethics of clinical research in India? A systematic scoping review and narrative synthesis. BMJ Glob Health 2021; 6:e004729. [PMID: 34006518 PMCID: PMC8137180 DOI: 10.1136/bmjgh-2020-004729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/13/2021] [Accepted: 02/24/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The post-2005 rise in clinical trials and clinical research conducted in India was accompanied by frequent reports of unethical practices, leading to a series of regulatory changes. We conducted a systematic scoping review to obtain an overview of empirical research pertaining to the ethics of clinical trials/research in India. METHODS Our search strategy combined terms related to ethics/bioethics, informed consent, clinical trials/research and India, across nine databases, up to November 2019. Peer-reviewed research exploring ethical aspects of clinical trials/research in India with any stakeholder groups was included. We developed an evidence map, undertook a narrative synthesis and identified research gaps. A consultation exercise with stakeholders in India helped contextualise the review and identify additional research priorities. RESULTS Titles/Abstracts of 9699 articles were screened, full text of 282 obtained and 80 were included. Research on the ethics of clinical trials/research covered a wide range of topics, often conducted with little to no funding. Studies predominantly examined what lay (patients/public) and professional participants (eg, healthcare staff/students/faculty) know about topics such as research ethics or understand from the information given to obtain their consent for research participation. Easily accessible groups, namely ethics committee members and healthcare students were frequently researched. Research gaps included developing a better understanding of the recruitment-informed consent process, including the doctor-patient interaction, in multiple contexts and exploring issues of equity and justice in clinical trials/research. CONCLUSION The review demonstrates that while a wide range of topics have been studied in India, the focus is largely on assessing knowledge levels across different population groups. This is a useful starting point, but fundamental questions remain unanswered about informed consent processes and broader issues of inequity that pervade the clinical trials/research landscape. A priority-setting exercise and appropriate funding mechanisms to support researchers in India would help improve the clinical trials/research ecosystem.
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Affiliation(s)
- Sangeetha Paramasivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
| | - Philippa Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Medical Research Council (MRC) ConDuCT-II Trials Methodology Hub, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alison Richards
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Medical Research Council (MRC) ConDuCT-II Trials Methodology Hub, Bristol Medical School, University of Bristol, Bristol, UK
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
| | - Nicola Mills
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
| | - Jeffrey Pradeep Raj
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Supriya Subramani
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Jonathan Ives
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR Bristol Biomedical Research Centre, Bristol, UK
| | - Jenny L Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
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Hagopian CO, Hagopian TM, Wolfswinkel EM, Ades TB, Stevens WG. An Expert Consensus Study for Informed Consent in Primary Breast Augmentation Surgery. Aesthet Surg J 2021; 41:NP162-NP176. [PMID: 33279953 DOI: 10.1093/asj/sjaa341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND What constitutes adequate information for decision-making and informed consent is a practical question appropriately answered with deference to expertise. OBJECTIVES The aims of this study were: (1) to establish consensus on a procedure-specific core information set of essential informed consent information by relevant medical experts for primary breast augmentation surgery; and (2) to define from the clinical perspective the data source and imminence elements of evidence-based risk communication. METHODS The study followed a modified Delphi expert consensus model. Active members of The Aesthetic Society were identified as the relevant clinician experts and were recruited by email. Survey round 1 was informed by a scoping review of the relevant scientific and gray literature. Round 2 was informed by the initial survey round. Consensus was defined a priori as a 75% majority rating. RESULTS Expert consensus of essential information was achieved for 16 risk items, 1 risk factor, and 8 expectations-including benefits and burdens-along with clarification of clinically appropriate options to present to all patients considering primary implant-based breast augmentation surgery. A basic, procedure-specific, structure for evidence-based risk data is also described. CONCLUSIONS This paper reports results for the first phase of a larger pilot study aiming to develop a patient decision aid to replace traditional informed consent documents for the specified procedure. Implications for practice are encouraging in terms of reducing unwanted variation in disclosure practices and information overload.
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Affiliation(s)
- Chelsea O Hagopian
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | | | - Erik M Wolfswinkel
- Children’s Hospital Los Angeles, University of Southern California School of Medicine, Division of Plastic Surgery, Los Angeles, CA
| | - Teresa B Ades
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - W Grant Stevens
- University of Southern California School of Medicine, Division of Plastic Surgery, Los Angeles, CA, USA
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Zahra J, Paramasivan S, Blencowe NS, Cousins S, Avery K, Mathews J, Main BG, McNair AGK, Hinchliffe R, Blazeby JM, Elliott D. Discussing surgical innovation with patients: a qualitative study of surgeons' and governance representatives' views. BMJ Open 2020; 10:e035251. [PMID: 33158818 PMCID: PMC7651722 DOI: 10.1136/bmjopen-2019-035251] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 08/18/2020] [Accepted: 09/25/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Little is known about how innovative surgical procedures are introduced and discussed with patients. This qualitative study aimed to explore perspectives on information provision and consent prior to innovative surgical procedures. DESIGN Qualitative study involving semi-structured interviews. Interviews were audio recorded, transcribed and analysed thematically. PARTICIPANTS 42 interviews were conducted (26 surgeons and 16 governance representatives). SETTING Surgeons and governance representatives recruited from various surgical specialties and National Health Service (NHS) Trusts across England, UK. RESULTS Participants stated that if a procedure was innovative, patients should be provided with additional information extending beyond that given during routine surgical consultations. However, difficulty defining innovation had implications for whether patients were informed about novel components of surgery and how the procedure was introduced (ie, as part of a research study, trust approval or in routine clinical practice). Furthermore, data suggest surgeons found it difficult to establish what information is essential and how much detail is sufficient, and governance surrounding written and verbal information provision differed between NHS Trusts. Generally, surgeons believed patients held a view that 'new' was best and reported that managing these expectations could be difficult, particularly if patient views aligned with their own. CONCLUSIONS This study highlights the challenges of information provision and obtaining informed consent in the context of innovative surgery, including establishing if and how a procedure is truly innovative, determining the key information to discuss with patients, ensuring information provision is objective and balanced, and managing patient expectations and preferences. This suggests that surgeons may require support and training to discuss novel procedures with patients. Further work should capture consultations where new procedures are discussed with patients and patients' views of these information exchanges.
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Affiliation(s)
- Jesmond Zahra
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Sangeetha Paramasivan
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Natalie S Blencowe
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sian Cousins
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Kerry Avery
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Johnny Mathews
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Barry G Main
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
- Division of Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Angus G K McNair
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
- GI Surgery, North Bristol NHS Trust, Bristol, UK
| | - Robert Hinchliffe
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
- Vascular Services, North Bristol NHS Trust, Bristol, UK
| | - Jane M Blazeby
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
- Division of Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Daisy Elliott
- National Institute for Health Research Bristol Biomedical Research Centre Surgical Innovation Theme, University of Bristol, Bristol, UK
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
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Li Ching Ng A, McRobb LS, White SJ, Cartmill JA, Cyna AM, Seex K. Consent for spine surgery: an observational study. ANZ J Surg 2020; 91:1220-1225. [PMID: 33021031 DOI: 10.1111/ans.16348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/11/2020] [Accepted: 09/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The tension between the ideal of informed consent and the reality of the process is under-investigated in spine surgery. Guidelines around consent imply a logical, plain-speaking process with a clear endpoint, agreement and signature yet surgeons' surveys and patient interviews suggest that surgeons' explanation is anecdotally variable and patient understanding remains poor. To obtain a more authentic reflection of practice, spine surgeons obtaining 'informed consent' for non-instrumented spine surgery were studied via video recording and risk/benefit discussions were analysed. METHODS A prospective observational study was conducted at a single neurosurgical institution. Twelve video recordings involving six surgeons obtaining an informed consent for non-instrumented spine surgery were transcribed verbatim and blindly analysed using descriptive quantification and linguistic ethnography. RESULTS Ten (83%) consultations discussed surgical benefit but less than half (41%) quantified the likelihood of benefit from surgery. The most discussed risks were nerve damage or paralysis (92%), bleeding (92%), infection (92%), cerebrospinal fluid leak (83%) and bowel and bladder dysfunction (75%). Surgeons commonly used a quantitative statement of risk (58%) but only half of the risks were explained in words patients were likely to understand. CONCLUSIONS This study highlights inconsistencies in the way spine surgeons explain risks and obtain informed consent for 'simple' spine procedures in a real-world setting. There are wide disparities in the provision of informed consent, which may be encountered in other surgical fields. Direct observation and qualitative analysis can provide insights into the limitations of current informed consent practice and help guide future practice.
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Affiliation(s)
- Angela Li Ching Ng
- Macquarie Neurosurgery, Macquarie University Clinic, Sydney, New South Wales, Australia
| | - Lucinda S McRobb
- Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Sarah J White
- Department of Biomedical Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - John A Cartmill
- Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Allan M Cyna
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Kevin Seex
- Macquarie Neurosurgery, Macquarie University Clinic, Sydney, New South Wales, Australia
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9
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Convie LJ, Carson E, McCusker D, McCain RS, McKinley N, Campbell WJ, Kirk SJ, Clarke M. The patient and clinician experience of informed consent for surgery: a systematic review of the qualitative evidence. BMC Med Ethics 2020; 21:58. [PMID: 32653008 PMCID: PMC7353438 DOI: 10.1186/s12910-020-00501-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/05/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Informed consent is an integral component of good medical practice. Many researchers have investigated measures to improve the quality of informed consent, but it is not clear which techniques work best and why. To address this problem, we propose developing a core outcome set (COS) to evaluate interventions designed to improve the consent process for surgery in adult patients with capacity. Part of this process involves reviewing existing research that has reported what is important to patients and doctors in the informed consent process. METHODS This qualitative synthesis comprises four phases: identification of published papers and determining their relevance; appraisal of the quality of the papers; identification and summary of the key findings from each paper while determining the definitiveness of each finding against the primary data; comparison of key themes between papers such that findings are linked across studies. RESULTS Searches of bibliographic databases returned 11,073 titles. Of these, 16 studies met the inclusion criteria. Studies were published between 1996 and 2016 and included a total of 367 patients and 74 health care providers. Thirteen studies collected data using in-depth interviews and constant comparison was the most common means of qualitative analysis. A total of 94 findings were extracted from the primary papers and divided into 17 categories and ultimately 6 synthesised findings related to: patient characteristics, knowledge, communication, the model patient, trust and decision making. CONCLUSIONS This qualitative meta-aggregation is the first to examine the issue of informed consent for surgery. It has revealed several outcomes deemed important to capture by patients and clinicians when evaluating the quality of a consent process. Some of these outcomes have not been examined previously in research comparing methods for informed consent. This review is an important step in the development of a COS to evaluate interventions designed to improve the consent process for surgery. REGISTRATION The study protocol was registered on the international prospective register for systematic reviews (PROSPERO ID: CRD42017077101).
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Affiliation(s)
- L. J. Convie
- Department of General Surgery, Ulster Hospital Dundonald, Belfast, UK
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
| | - E. Carson
- Department of General Surgery, Ulster Hospital Dundonald, Belfast, UK
| | - D. McCusker
- Department of General Surgery, Ulster Hospital Dundonald, Belfast, UK
| | - R. S. McCain
- Department of General Surgery, Ulster Hospital Dundonald, Belfast, UK
| | - N. McKinley
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
| | - W. J. Campbell
- Department of General Surgery, Ulster Hospital Dundonald, Belfast, UK
| | - S. J. Kirk
- Department of General Surgery, Ulster Hospital Dundonald, Belfast, UK
| | - M. Clarke
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
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10
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Normahani P, Sounderajah V, Harrop-Griffiths W, Chukwuemeka A, Peters NS, Standfield NJ, Collins M, Jaffer U. Achieving good-quality consent: review of literature, case law and guidance. BJS Open 2020; 4:757-763. [PMID: 32475083 PMCID: PMC7528509 DOI: 10.1002/bjs5.50306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/20/2020] [Accepted: 05/05/2020] [Indexed: 01/22/2023] Open
Abstract
Background Informed consent is an integral part of clinical practice. There is widespread agreement amongst health professionals that obtaining procedural consent needs to move away from a unidirectional transfer of information to a process of supporting patients in making informed, self‐determined decisions. This review aimed to identify processes and measures that warrant consideration when engaging in consent‐based discussions with competent patients undergoing elective procedures. Methods Formal written guidance from the General Medical Council and Royal College of Surgeons of England, in addition to peer‐reviewed literature and case law, was considered in the formulation of this review. Results A framework for obtaining consent is presented that is informed by the key tenets of shared decision‐making (SDM), a model that advocates the contribution of both the clinician and patient to the decision‐making process through emphasis on patient participation, analysis of empirical evidence, and effective information exchange. Moreover, areas of contention are highlighted in which further guidance and research are necessary for improved enhancement of the consent process. Conclusion This SDM‐centric framework provides structure, detail and suggestions for achieving meaningful consent.
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Affiliation(s)
- P Normahani
- Imperial Vascular Unit, London, UK.,Department of Surgery and Cancer, London, UK
| | - V Sounderajah
- Imperial Vascular Unit, London, UK.,Department of Surgery and Cancer, London, UK
| | - W Harrop-Griffiths
- Anaesthetic Department, London, UK.,Department of Surgery and Cancer, London, UK
| | - A Chukwuemeka
- Department of Cardiothoracic Surgery, London, UK.,Department of Surgery and Cancer, London, UK
| | - N S Peters
- Connected Care Bureau, Imperial College NHS Healthcare Trust, London, UK.,National Lung and Heart Institute, Imperial College London, London, UK
| | - N J Standfield
- Imperial Vascular Unit, London, UK.,Department of Surgery and Cancer, London, UK
| | - M Collins
- London Borough of Hounslow Council, London, UK
| | - U Jaffer
- Imperial Vascular Unit, London, UK.,Department of Surgery and Cancer, London, UK
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11
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Lee MJ, Marshall JH, Jones GL, Lobo AJ, Brown SR. The informational and decisional preferences of patients undergoing surgery for Crohn's anal fistula: a qualitative study. Colorectal Dis 2020; 22:703-712. [PMID: 31868981 DOI: 10.1111/codi.14936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 10/08/2019] [Indexed: 12/17/2022]
Abstract
AIM One in three patients with Crohn's disease will develop a perianal fistula, but only a few achieve long-term healing. Treatment is both medical and surgical. Since there is no 'best' surgical procedure, patient preference is important in selecting the appropriate treatment for this condition. The aim of this study was to investigate the informational and decisional preferences of patients when surgical treatment is being considered. METHOD Patients who had undergone surgery for Crohn's anal fistula underwent face-to-face semi-structured interviews. These explored the experience of treatments for fistula, of receiving information and of participation in decision-making. Transcripts were analysed by two investigators through inductive thematic analysis. Saturation was assessed for at 12 interviews and then after each subsequent interview. RESULTS Seventeen patients completed interviews, and saturation was achieved. Five themes were identified, of which two (desired information and decision-making) were relevant to this study. Other themes included experience of Crohn's disease, experience of receiving information and procedure-specific comments. Participants wanted to have information on any risks, high-level outcomes (e.g. success), impact on day-to-day life and aftercare. Participants felt they did not always receive the information they needed to select the best treatment option. Participants felt uninvolved in treatment decisions and would have liked to trade off operations to reach their treatment goal. CONCLUSION Information provided to patients about surgical treatment of Crohn's perianal fistula does not meet their needs. Clinicians should address aftercare, impact on quality of life and the risks and benefits of the any proposed procedure.
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Affiliation(s)
- M J Lee
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | - J H Marshall
- The Medical School, University of Sheffield, Sheffield, UK
| | - G L Jones
- Department of Psychology, Leeds Beckett University, Leeds, UK
| | - A J Lobo
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S R Brown
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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12
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McNair AGK, Main BJ, Elliott D. Comment on: Bioethical approach to robot-assisted surgery. Br J Surg 2019; 107:150. [PMID: 31869458 DOI: 10.1002/bjs.11413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/02/2019] [Indexed: 11/12/2022]
Affiliation(s)
- A G K McNair
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK.,Department of Gastrointestinal Surgery, North Bristol NHS Trust, Bristol, UK
| | - B J Main
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK.,Division of Surgery Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - D Elliott
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
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13
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McNair AGK, Whistance RN, Main B, Forsythe R, Macefield R, Rees J, Pullyblank A, Avery K, Brookes S, Thomas MG, Sylvester PA, Russell A, Oliver A, Morton D, Kennedy R, Jayne D, Huxtable R, Hackett R, Dutton S, Coleman MG, Card M, Brown J, Blazeby J. Development of a core information set for colorectal cancer surgery: a consensus study. BMJ Open 2019; 9:e028623. [PMID: 31727644 PMCID: PMC6886994 DOI: 10.1136/bmjopen-2018-028623] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE 'Core information sets' (CISs) represent baseline information, agreed by patients and professionals, to stimulate individualised patient-centred discussions. This study developed a CIS for use before colorectal cancer (CRC) surgery. DESIGN Three phase consensus study: (1) Systematic literature reviews and patient interviews to identify potential information of importance to patients, (2) UK national Delphi survey of patients and professionals to rate the importance of the information, (3) international consensus meeting to agree on the final CIS. SETTING UK CRC centres. PARTICIPANTS Purposive sampling was conducted to ensure CRC centre representation based upon geographical region and caseload volume. Responses were received from 63/81 (78%) centres (90 professionals). Adult patients who had undergone CRC surgery were eligible, and purposive sampling was conducted to ensure representation based on age, sex and cancer location (rectum, left and right colon). Responses were received from 97/267 (35%) patients with a wide age range (29-87), equal sex ratio and cancer location. Attendees of the international Tripartite Colorectal Conference were eligible for the consensus meeting. OUTCOMES Phase 1: Information of potential importance to patients was extracted verbatim and operationalised into a Delphi questionnaire. Phase 2: Patients and professionals rated the importance information on a 9-point Likert scale, and resurveyed following group feedback. Information rated of low importance were discarded using predefined criteria. Phase 3: A modified nominal group technique was used to gain final consensus in separate consensus meetings with patients and professionals. RESULTS Data sources identified 1216 pieces of information that informed a 98-item questionnaire. Analysis led to 50 and 23 information domains being retained after the first and second surveys, respectively. The final CIS included 11 concepts including specific surgical complications, short and long-term survival, disease recurrence, stoma and quality of life issues. CONCLUSIONS This study has established a CIS for professionals to discuss with patients before CRC surgery.
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Affiliation(s)
- Angus G K McNair
- Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
- GI Surgery, North Bristol NHS Trust, Bristol, UK
| | - Robert N Whistance
- Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Barry Main
- Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Rachael Forsythe
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Rhiannon Macefield
- Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Jonathan Rees
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Anne Pullyblank
- GI Surgery, North Bristol NHS Trust, Bristol, UK
- West of England Academic Health Science Network, Bristol, UK
| | - Kerry Avery
- Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Sara Brookes
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Michael G Thomas
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Paul A Sylvester
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ann Russell
- Consumer Liaison Group, National Cancer Research Institute, London, UK
| | - Alfred Oliver
- Consumer Liaison Group, National Cancer Research Institute, London, UK
| | - Dion Morton
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - Robin Kennedy
- Department of Surgery, St Mark's Hospital, London, UK
| | - David Jayne
- Department of Academic Surgery, Leeds Institute of Biological and Clinical Sciences, Leeds Teaching Hospitals, Leeds, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Roland Hackett
- Colorectal Site Specific Group, South West Cancer Network, Bristol, UK
| | | | - Mark G Coleman
- Department of Surgery, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Mia Card
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Julia Brown
- Consultant Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jane Blazeby
- Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
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14
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Currie AC, Bright T, Thompson SK, Smith L, Devitt PG, Watson DI. Acceptable outcomes after fundoplication-different views are held by patients, GPs, and surgeons. Dis Esophagus 2019; 32:5479249. [PMID: 31323089 DOI: 10.1093/dote/doz025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Antireflux surgery aims to improve quality of life. However, whether patients and clinicians agree on what this means, and what is an acceptable outcome following fundoplication, is unknown. This study used clinical scenarios pertinent to laparoscopic fundoplication for gastroesophageal reflux to define acceptable outcomes from the perspective of patients, surgeons, and general practitioners (GPs). Patients who had previously undergone a laparoscopic fundoplication, general practitioners, and esophagogastric surgeons were invited to rank 11 clinical scenarios of outcomes following laparoscopic fundoplication for acceptability. Clinicopathological and practice variables were collated for patients and clinicians, respectively. GPs and esophagogastric surgeons additionally were asked to estimate postfundoplication outcome probabilities. Descriptive and multivariate statistical analyses were undertaken to examine for associations with acceptability. Reponses were received from 331 patients (36.4% response rate), 93 GPs (13.4% response), and 60 surgeons (36.4% response). Bloating and inability to belch was less acceptable and dysphagia requiring intervention more acceptable to patients compared to clinicians. On regression analysis, female patients found bloating to be less acceptable (OR: 0.51 [95%CI: 0.29-0.91]; P = 0.022), but dysphagia more acceptable (OR: 1.93 [95%CI: 1.17-3.21]; P = 0.011). Postfundoplication estimation of reflux resolution was higher and that of bloating was lower for GPs compared to esophagogastric surgeons. Patients and clinicians have different appreciations of an acceptable outcome following antireflux surgery. Female patients are more concerned about wind-related side effects than male patients. The opposite holds true for dysphagia. Surgeons and GPs differ in their estimation of event probability for patient recovery following antireflux surgery, and this might explain their differing considerations of acceptable outcomes.
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Affiliation(s)
- Andrew C Currie
- Discipline of Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
| | - Tim Bright
- Discipline of Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
| | - Sarah K Thompson
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia
| | - Lorelle Smith
- Discipline of Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia.,Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter G Devitt
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia
| | - David I Watson
- Discipline of Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia
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15
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Lin YK, Liu KT, Chen CW, Lee WC, Lin CJ, Shi L, Tien YC. How to effectively obtain informed consent in trauma patients: a systematic review. BMC Med Ethics 2019; 20:8. [PMID: 30674301 PMCID: PMC6343333 DOI: 10.1186/s12910-019-0347-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/14/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Obtaining adequate informed consent from trauma patients is challenging and time-consuming. Healthcare providers must communicate complicated medical information to enable patients to make informed decisions. This study aimed to explore the challenges of obtaining valid consent and methods of improving the quality of the informed consent process for surgical procedures in trauma patients. METHODS We conducted a systematic review of relevant English-language full-text original articles retrieved from PubMed (1961-August 2018) that had experimental or observational study design and involved adult trauma patients. Studies involving informed consent in clinical or research trials were excluded. Titles and abstracts of searched articles were reviewed and relevant data were extracted with a structured form. Results were synthesized with a narrative approach. RESULTS A total of 2044 articles were identified in the initial search. Only eight studies were included in the review for narrative synthesis. Six studies involved orthopedic surgeries, one involved nasal bone surgeries, and one involved trauma-related limb debridement. Only one study was conducted in an emergency department. Information recall was poor for trauma patients. Risk recall and comprehension were greater when written or video information was provided than when information was provided only verbally. Patient satisfaction was also greater when both written and verbal information were provided than when verbal information alone was provided; patients who received video information were more satisfied than patients who received written or verbal information. CONCLUSIONS Many articles have been published on the subject of informed consent, but very few of these have focused on trauma patients. More empirical evidence is needed to support the success of informed consent for trauma patients in the emergency department, especially within the necessarily very limited time frame. To improve the informed consent process for trauma patients, developing a structured and standardized informed consent process may be necessary and achievable; its effectiveness would require evaluation. Adequately educating and training healthcare providers to deliver structured, comprehensive information to trauma patients is crucial. Institutions should give top priority to ensuring patient-centered health care and improved quality of care for trauma patients.
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Affiliation(s)
- Yen-Ko Lin
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Medical Humanities and Education, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Emergency Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuan-Ting Liu
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Emergency Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chao-Wen Chen
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Emergency Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Che Lee
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Emergency Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Ju Lin
- College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Leiyu Shi
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Yin-Chun Tien
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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16
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Buchlak QD, Kowalczyk M, Leveque JC, Wright A, Farrokhi F. Risk stratification in deep brain stimulation surgery: Development of an algorithm to predict patient discharge disposition with 91.9% accuracy. J Clin Neurosci 2018; 57:26-32. [DOI: 10.1016/j.jocn.2018.08.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 08/12/2018] [Accepted: 08/21/2018] [Indexed: 01/25/2023]
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17
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Gröne J, Lorenz EM, Seifarth C, Seeliger H, Kreis ME, Mueller MH. Timing of surgery in ulcerative colitis in the biologic therapy era-the patient's perspective. Int J Colorectal Dis 2018; 33:1429-1435. [PMID: 30003360 DOI: 10.1007/s00384-018-3129-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is no general consensus regarding the ideal timing of surgery in patients with refractory ulcerative colitis (UC). Decision-making and timing of restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is influenced by treating physicians and patients themselves. The aim of this study was to determine whether or not patients would have preferred the operation to be performed earlier, at the same time, or at a later point of time and to determine the reasons for their preference. METHODS Clinical data of 193 patients with UC who have undergone IPAA were documented in a prospective database at our institution between 2004 and 2015. From this database, 190 patients were identified and a standardized custom-made questionnaire was mailed for follow-up survey. Patients who did not respond were called by telephone and encouraged to complete the questionnaire. RESULTS One hundred nine questionnaires were eligible for analysis (57.4%). Average time between diagnosis and surgery was 11.2 ± 10.8 years (mean ± SD). Indications for surgery were refractory disease (70.6%), colitis-associated colorectal cancer (11.0%), high-grade dysplasia or stenosis (11.9%), and septic complications of UC (6.4%); 39 of 77 patients (50.6%) with refractory UC reported to have preferred their operation to be carried out earlier as it was actually performed (16.8 ± 11.9 months). Refractory course of the disease was identified as a predictor for a retrospectively desired earlier surgical approach (p = 0.014). CONCLUSION A substantial proportion of patients felt that they should have undergone surgery earlier than actually performed. It appears that timing of the decision to undergo surgery is suboptimal. This situation may be improved by earlier surgical consultation in the course of the disease.
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Affiliation(s)
- Jörn Gröne
- Department of Surgery, Campus Benjamin Franklin, Charité University Medicine, Berlin, Germany.,Department of Surgery, Rotes Kreuz Krankenhaus, Bremen, Germany
| | - Eva-Maria Lorenz
- Department of Surgery, Campus Benjamin Franklin, Charité University Medicine, Berlin, Germany
| | - Claudia Seifarth
- Department of Surgery, Campus Benjamin Franklin, Charité University Medicine, Berlin, Germany
| | - Hendrik Seeliger
- Department of Surgery, Campus Benjamin Franklin, Charité University Medicine, Berlin, Germany
| | - Martin E Kreis
- Department of Surgery, Campus Benjamin Franklin, Charité University Medicine, Berlin, Germany
| | - Mario H Mueller
- Department of Surgery, Vivantes Hospital Neukölln, Rudower Straße 48, 12351, Berlin, Germany.
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18
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Between the Reasonable and the Particular: Deflating Autonomy in the Legal Regulation of Informed Consent to Medical Treatment. HEALTH CARE ANALYSIS 2018; 27:110-127. [DOI: 10.1007/s10728-018-0358-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Shared Decision-Making in Acute Surgical Illness: The Surgeon's Perspective. J Am Coll Surg 2018; 226:784-795. [PMID: 29382560 DOI: 10.1016/j.jamcollsurg.2018.01.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/31/2017] [Accepted: 01/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical patients increasingly have more comorbidities and are of an older age, complicating surgical decision-making in emergent situations. Little is known about surgeons' perceptions of shared decision-making in these settings. STUDY DESIGN Twenty semi-structured interviews were conducted with practicing surgeons at 2 large academic medical centers. Thirteen questions and 2 case vignettes were used to assess perceptions of decision-making, considerations when deciding whether to offer to operate, and communication patterns with patients and families. RESULTS Thematic analysis revealed 6 major themes: responsibility for the decision to operate, perceived futility, surgeon judgment, surgeon introspection, pressure to operate, and costs of the operation. Perceived futility was universally considered a contraindication to surgical intervention. However, the challenge of defining futility led participants to emphasize the importance of patients' self-determined risk-to-benefit analysis when considering surgical intervention. More experienced surgeons reported greater comfort with communicating to patients that a condition was not amenable to an operation and reserved the right to refuse to operate. CONCLUSIONS Due to external pressures and uncertainty, some providers err on the side of operative intervention, despite suspected futility. Greater experience allows surgeons to withstand external pressures, be confident in their assessments of perceived futility, and guide patients and their families away from additional interventions.
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20
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Main B, McNair A, Haworth S, Rooshenas L, Hughes C, Tierney P, Donovan J, Thomas S, Blazeby J. Core information set for informed consent to surgery for oral or oropharyngeal cancer: A mixed-methods study. Clin Otolaryngol 2017; 43:624-631. [DOI: 10.1111/coa.13037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2017] [Indexed: 11/29/2022]
Affiliation(s)
- B.G. Main
- School of Social and Community Medicine; University of Bristol; Bristol UK
- University Hospitals Bristol NHS Foundation Trust; Bristol UK
| | - A.G.K. McNair
- School of Social and Community Medicine; University of Bristol; Bristol UK
| | - S. Haworth
- School of Social and Community Medicine; University of Bristol; Bristol UK
- School of Oral and Dental Sciences; University of Bristol; Bristol UK
| | - L. Rooshenas
- School of Social and Community Medicine; University of Bristol; Bristol UK
| | - C.W. Hughes
- University Hospitals Bristol NHS Foundation Trust; Bristol UK
- School of Oral and Dental Sciences; University of Bristol; Bristol UK
| | - P. Tierney
- University Hospitals Bristol NHS Foundation Trust; Bristol UK
| | - J.L. Donovan
- School of Social and Community Medicine; University of Bristol; Bristol UK
| | - S.J. Thomas
- University Hospitals Bristol NHS Foundation Trust; Bristol UK
- School of Oral and Dental Sciences; University of Bristol; Bristol UK
| | - J.M. Blazeby
- School of Social and Community Medicine; University of Bristol; Bristol UK
- University Hospitals Bristol NHS Foundation Trust; Bristol UK
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Williamson PR, Altman DG, Bagley H, Barnes KL, Blazeby JM, Brookes ST, Clarke M, Gargon E, Gorst S, Harman N, Kirkham JJ, McNair A, Prinsen CAC, Schmitt J, Terwee CB, Young B. The COMET Handbook: version 1.0. Trials 2017; 18:280. [PMID: 28681707 PMCID: PMC5499094 DOI: 10.1186/s13063-017-1978-4] [Citation(s) in RCA: 1077] [Impact Index Per Article: 153.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The selection of appropriate outcomes is crucial when designing clinical trials in order to compare the effects of different interventions directly. For the findings to influence policy and practice, the outcomes need to be relevant and important to key stakeholders including patients and the public, health care professionals and others making decisions about health care. It is now widely acknowledged that insufficient attention has been paid to the choice of outcomes measured in clinical trials. Researchers are increasingly addressing this issue through the development and use of a core outcome set, an agreed standardised collection of outcomes which should be measured and reported, as a minimum, in all trials for a specific clinical area.Accumulating work in this area has identified the need for guidance on the development, implementation, evaluation and updating of core outcome sets. This Handbook, developed by the COMET Initiative, brings together current thinking and methodological research regarding those issues. We recommend a four-step process to develop a core outcome set. The aim is to update the contents of the Handbook as further research is identified.
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Affiliation(s)
- Paula R. Williamson
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Douglas G. Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Heather Bagley
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Karen L. Barnes
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Jane M. Blazeby
- MRC ConDuCT II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sara T. Brookes
- MRC ConDuCT II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mike Clarke
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
- National University of Ireland Galway and HRB Trials Methodology Research Network, Galway, Ireland
| | - Elizabeth Gargon
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Sarah Gorst
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Nicola Harman
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Jamie J. Kirkham
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Angus McNair
- MRC ConDuCT II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Cecilia A. C. Prinsen
- Department of Epidemiology and Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, Medizinische Fakultät, Technische Univesität Dresden, Dresden, Germany
| | - Caroline B. Terwee
- Department of Epidemiology and Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Bridget Young
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
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