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Skelton H, Goyen TA, Viola P, Marceau J, D'Cruz D, Maheshwari R, Shah D, Edney B, Luig M, Jani PR. Parental views on prospective consent: Experience from a pilot randomised trial recruiting extremely preterm infants during the perinatal period. J Paediatr Child Health 2024; 60:561-568. [PMID: 39140358 DOI: 10.1111/jpc.16645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 08/15/2024]
Abstract
AIM To explore parental perceptions of the consenting process and understanding of the study in a pilot randomised controlled trial wherein extremely premature infants (<29 weeks' gestation) were recruited either antenatally or by 4 h of life. METHODS We prospectively surveyed parents who had consented, declined consent or were eligible infants in the Positioning Preterm Infants for Neuroprotection study, a low-risk intervention study in the first 72 h of life. Structured interview questions explored the process and acceptability of the consenting approach by the parents and their knowledge of the study. Additional comments made by the parents were transcribed verbatim. RESULTS Sixty-two parents participated in the surveys; of those, 41 had provided their consent, 8 declined consent and 13 were parents of missed eligible infants. Overall, most parents reported they understood the study well before providing their consent and approaching them for consenting did not create a burden for them. A verbal explanation of the study by the study team, especially by the medical practitioners, was viewed as beneficial. Where consent was obtained in the birthing unit (imminent births and within 4 h of birthing), it was suggested that the 4-h period for obtaining post-natal consent may be too short. A deferred consent with a follow-up opportunity for obtaining informed consent could be a suitable alternative. CONCLUSION Parents found the consenting process acceptable and indicated they had sufficient understanding of the study to provide an informed consent. Deferred consent should be explored for future, low-risk intervention studies as an alternative to prospective consent where extremely preterm infants need to be recruited in the immediate neonatal period.
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Affiliation(s)
- Hannah Skelton
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
| | - Traci-Anne Goyen
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Patricia Viola
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - James Marceau
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Daphne D'Cruz
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Rajesh Maheshwari
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
- The Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Dharmesh Shah
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
- The Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Bronwyn Edney
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Melissa Luig
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Pranav R Jani
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
- The Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Cyrus KE, Jerome ML, Reeves AV, Nguyen K, Shankaran M, Evans WJ, Salas AA. Correlation Between Skeletal Muscle Mass and Fat-Free Mass in Infants Born Very Preterm. J Pediatr 2024; 276:114272. [PMID: 39218204 DOI: 10.1016/j.jpeds.2024.114272] [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] [Received: 05/01/2024] [Revised: 08/12/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024]
Abstract
Assessing growth quality in preterm infants present challenges, particularly with the use of the standard fat-free mass measurement. We report here a moderate correlation between indirect skeletal muscle mass measurements using the D3-creatine dilution method and fat-free mass measured with air-displacement plethysmography. Skeletal muscle mass could serve as an indicator of growth quality.
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Affiliation(s)
- Kathryn E Cyrus
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL; Section of Neonatology, Department of Pediatrics, Louisiana State University Health Science Center, New Orleans, LA
| | - Maggie L Jerome
- Graduate Programs in Human Nutrition, Oregon Health and Science University, Portland, OR
| | - Audrey V Reeves
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Kelly Nguyen
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Mahalakshmi Shankaran
- Department of Nutritional Sciences and Toxicology, University of California Berkeley, Berkeley, CA
| | - William J Evans
- Department of Nutritional Sciences and Toxicology, University of California Berkeley, Berkeley, CA; Division of Geriatrics, Duke University Medical Center, Durham, NC
| | - Ariel A Salas
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL.
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Nurses' Knowledge, Communication Needs, and Future Directions in Neonatal Research: Results of an International Survey. Adv Neonatal Care 2023:00149525-990000000-00051. [PMID: 36735748 PMCID: PMC10371058 DOI: 10.1097/anc.0000000000001059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Preterm birth is a significant contributor to neonatal morbidity and mortality. Despite legislative efforts to increase pediatric drug development, neonatal clinical trials continue to be infrequent. The International Neonatal Consortium (INC) includes nurses as key stakeholders in their mission to accelerate safe and effective therapies for neonates. PURPOSE INC developed a survey for nurses, physicians, and parents to explore communication practices and stakeholders' perceptions and knowledge regarding clinical trials in neonatal intensive care units (NICUs). METHODS A stepwise consensus approach was used to solicit responses to an online survey. The convenience sample was drawn from INC organizations representing the stakeholder groups. Representatives from the National Association of Neonatal Nurses and the Council of International Neonatal Nurses, Inc, participated in all stages of the survey development process, results analysis, and publication of results. RESULTS Participants included 188 nurses or nurse practitioners, mainly from the United States, Canada, the European Union, and Japan; 68% indicated some level of research involvement. Nurses expressed a lack of effective education to prepare them for participation in research. Results indicated a lack of a central information source for staff and systematic approaches to inform families of studies. The majority of nurses indicated they were not asked to provide input into clinical trials. Nurses were uncertain about research consent and result disclosure processes. IMPLICATIONS FOR PRACTICE AND RESEARCH This study indicates the need to educate nurses in research, improve NICU research communication through standardized, systematic pathways, and leverage nurse involvement to enhance research communication.
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McLeish J, Alderdice F, Robberts H, Cole C, Dorling J, Gale C. Challenges of a simplified opt-out consent process in a neonatal randomised controlled trial: qualitative study of parents' and health professionals' views and experiences. Arch Dis Child Fetal Neonatal Ed 2021; 106:244-250. [PMID: 33139313 PMCID: PMC8070626 DOI: 10.1136/archdischild-2020-319545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND More effective recruitment strategies like alternative approaches to consent are needed to facilitate adequately powered trials. Witholding Enteral feeds Around Transfusion was a multicentre, randomised, pilot trial that compared withholding and continuing feeds around transfusion. The primary clinical outcome was necrotising enterocolitis. The trial used simplified opt-out consent with concise parent information and no consent form. OBJECTIVE To explore the views and experiences of parents and health professionals on the acceptability and feasibility of opt-out consent in randomised comparative effectiveness trials. METHODS A qualitative, descriptive interview-based study nested within a randomised trial. Semistructured interview transcripts were analysed using inductive thematic analysis. SETTING Eleven neonatal units in England. PARTICIPANTS Eleven parents and ten health professionals with experience of simplified consent. RESULTS Five themes emerged: 'opt-out consent operationalised as verbal opt-in consent', 'opt-out consent normalises participation while preserving parental choice', 'opt-out consent as an ongoing process of informed choice', 'consent without a consent form' and 'choosing to opt out of a comparative effectiveness trial', with two subthemes: 'wanting "normal care"' and 'a belief that feeding is better'. CONCLUSION Introducing a novel form of consent proved challenging in practice. The principle of a simplified, opt-out approach to consent was generally considered feasible and acceptable by health professionals for a neonatal comparative effectiveness trial. The priority for parents was having the right to decide about trial participation, and they did not see opt-out consent as undermining this. Describing a study as 'opt-out' can help to normalise participation and emphasise that parents can withdraw consent.
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Affiliation(s)
- Jenny McLeish
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, UK
| | - Fiona Alderdice
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, UK
| | | | - Christina Cole
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, UK
| | - Jon Dorling
- Division of Neonatal–Perinatal Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Chris Gale
- Academic Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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Aurich B, Vermeulen E, Elie V, Driessens MHE, Kubiak C, Bonifazi D, Jacqz-Aigrain E. Informed consent for neonatal trials: practical points to consider and a check list. BMJ Paediatr Open 2020; 4:e000847. [PMID: 33437878 PMCID: PMC7778778 DOI: 10.1136/bmjpo-2020-000847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/23/2020] [Accepted: 11/29/2020] [Indexed: 12/04/2022] Open
Abstract
Obtaining informed consent from parents of critically ill neonates can be challenging. The parental decision-making process is influenced by the severity of the child's condition, the benefit-risk balance, their emotional state and the quality of the relationship with the clinical team. Independent of local legislation, parents may prefer that consent is sought from both. Misconceptions about the absence of risks or unrealistic expectations about benefits should be openly addressed to avoid misunderstandings which may harm the relationship with the clinical team. Continuous consent can be sought where it is unclear whether the free choice of parental consent has been compromised. Obtaining informed consent is a dynamic process building on trusting relationships. It should include open and honest discussions about benefits and risks. Investigators may benefit from training in effective communication. Finally, involving parents in neonatal research including the development of the informed consent form and the process of obtaining consent should be considered standard practice.
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Affiliation(s)
- Beate Aurich
- Department of Paediatric Clinical Pharmacology and Pharmacogenetics, Robert Debré Hospital, 48 Boulevard Sérurier, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Eric Vermeulen
- Dutch patient association for rare and genetic diseases (VSOP), Soest, The Netherlands
| | - Valéry Elie
- Department of Paediatric Clinical Pharmacology and Pharmacogenetics, Robert Debré Hospital, 48 Boulevard Sérurier, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | | | - Christine Kubiak
- The European Clinical Research Infrastructure Network (ECRIN), 5-7 Rue Watt, Paris, France
| | - Donato Bonifazi
- Consorzio per le Valutazioni Biologiche e Farmacologiche, Via Nicolo Putignani, Bari, Italy.,TEDDY European Network of Excellence for Paediatric Research, Via Luigi Porta 14, Pavia, Italy
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Clinical Phramcology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 Boulevard Sérurier, Paris, France.,Paris University, Paris, France
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Special issues raised by evolving areas of clinical research. ETHICAL CONSIDERATIONS WHEN PREPARING A CLINICAL RESEARCH PROTOCOL 2020. [PMCID: PMC7329119 DOI: 10.1016/b978-0-12-386935-7.00014-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Each study presents its own set of ethical considerations. Certain kinds of ethical issues are inherent in particular areas of clinical research, regardless of specific ethical questions associated with a specific study. In this chapter, some of the most common special areas of clinical research are presented, highlighting the ethical issues most frequently associated with each.
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Duley L, Dorling J, Ayers S, Oliver S, Yoxall CW, Weeks A, Megone C, Oddie S, Gyte G, Chivers Z, Thornton J, Field D, Sawyer A, McGuire W. Improving quality of care and outcome at very preterm birth: the Preterm Birth research programme, including the Cord pilot RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2019. [DOI: 10.3310/pgfar07080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background
Being born very premature (i.e. before 32 weeks’ gestation) has an impact on survival and quality of life. Improving care at birth may improve outcomes and parents’ experiences.
Objectives
To improve the quality of care and outcomes following very preterm birth.
Design
We used mixed methods, including a James Lind Alliance prioritisation, a systematic review, a framework synthesis, a comparative review, qualitative studies, development of a questionnaire tool and a medical device (a neonatal resuscitation trolley), a survey of practice, a randomised trial and a protocol for a prospective meta-analysis using individual participant data.
Setting
For the prioritisation, this included people affected by preterm birth and health-care practitioners in the UK relevant to preterm birth. The qualitative work on preterm birth and the development of the questionnaire involved parents of infants born at three maternity hospitals in southern England. The medical device was developed at Liverpool Women’s Hospital. The survey of practice involved UK neonatal units. The randomised trial was conducted at eight UK tertiary maternity hospitals.
Participants
For prioritisation, 26 organisations and 386 individuals; for the interviews and questionnaire tool, 32 mothers and seven fathers who had a baby born before 32 weeks’ gestation for interviews evaluating the trolley, 30 people who had experienced it being used at the birth of their baby (19 mothers, 10 partners and 1 grandmother) and 20 clinicians who were present when it was being used; for the trial, 261 women expected to have a live birth before 32 weeks’ gestation, and their 276 babies.
Interventions
Providing neonatal care at very preterm birth beside the mother, and with the umbilical cord intact; timing of cord clamping at very preterm birth.
Main outcome measures
Research priorities for preterm birth; feasibility and acceptability of the trolley; feasibility of a randomised trial, death and intraventricular haemorrhage.
Review methods
Systematic review of Cochrane reviews (umbrella review); framework synthesis of ethics aspects of consent, with conceptual framework to inform selection criteria for empirical and analytical studies. The comparative review included studies using a questionnaire to assess satisfaction with care during childbirth, and provided psychometric information.
Results
Our prioritisation identified 104 research topics for preterm birth, with the top 30 ranked. An ethnographic analysis of decision-making during this process suggested ways that it might be improved. Qualitative interviews with parents about their experiences of very preterm birth identified two differences with term births: the importance of the staff appearing calm and of staff taking control. Following a comparative review, this led to the development of a questionnaire to assess parents’ views of care during very preterm birth. A systematic overview summarised evidence for delivery room neonatal care and revealed significant evidence gaps. The framework synthesis explored ethics issues in consent for trials involving sick or preterm infants, concluding that no existing process is ideal and identifying three important gaps. This led to the development of a two-stage consent pathway (oral assent followed by written consent), subsequently evaluated in our randomised trial. Our survey of practice for care at the time of birth showed variation in approaches to cord clamping, and that no hospitals were providing neonatal care with the cord intact. We showed that neonatal care could be provided beside the mother using either the mobile neonatal resuscitation trolley we developed or existing equipment. Qualitative interviews suggested that neonatal care beside the mother is valued by parents and acceptable to clinicians. Our pilot randomised trial compared cord clamping after 2 minutes and initial neonatal care, if needed, with the cord intact, with clamping within 20 seconds and initial neonatal care after clamping. This study demonstrated feasibility of a large UK randomised trial. Of 135 infants allocated to cord clamping ≥ 2 minutes, 7 (5.2%) died and, of 135 allocated to cord clamping ≤ 20 seconds, 15 (11.1%) died (risk difference –5.9%, 95% confidence interval –12.4% to 0.6%). Of live births, 43 out of 134 (32%) allocated to cord clamping ≥ 2 minutes had intraventricular haemorrhage compared with 47 out of 132 (36%) allocated to cord clamping ≤ 20 seconds (risk difference –3.5%, 95% CI –14.9% to 7.8%).
Limitations
Small sample for the qualitative interviews about preterm birth, single-centre evaluation of neonatal care beside the mother, and a pilot trial.
Conclusions
Our programme of research has improved understanding of parent experiences of very preterm birth, and informed clinical guidelines and the research agenda. Our two-stage consent pathway is recommended for intrapartum clinical research trials. Our pilot trial will contribute to the individual participant data meta-analysis, results of which will guide design of future trials.
Future work
Research in preterm birth should take account of the top priorities. Further evaluation of neonatal care beside the mother is merited, and future trial of alternative policies for management of cord clamping should take account of the meta-analysis.
Study registration
This study is registered as PROSPERO CRD42012003038 and CRD42013004405. In addition, Current Controlled Trials ISRCTN21456601.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jon Dorling
- Department of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Susan Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
| | - Sandy Oliver
- Social Science Research Unit and EPPI-Centre, Institute of Education, University of London, London, UK
| | | | - Andrew Weeks
- University of Liverpool and Liverpool Women’s Hospital, Members of Liverpool Health Partners, UK
| | - Chris Megone
- Inter Disciplinary Ethics Applied, University of Leeds, Leeds, UK
| | - Sam Oddie
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Gill Gyte
- National Childbirth Trust, London, UK
| | | | - Jim Thornton
- Department of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - David Field
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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Walsh V, Oddie S, McGuire W. Ethical Issues in Perinatal Clinical Research. Neonatology 2019; 116:52-57. [PMID: 30947194 DOI: 10.1159/000494934] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/28/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Perinatal clinical research to improve the quality of care and outcomes for newborn infants relies on transparency, trust, and respect for the autonomy and well-being of study participants and their families. METHODS Here we consider the underpinning principles of ethical research with a focus on perinatal clinical research in the acute care or emergency setting where particular challenges to parental engagement and informed consent exist. RESULTS Several approaches to improving the validity of the consent process for perinatal research have been proposed and evaluated. These include consent waiver, antenatal consent, deferred consent preceded by verbal assent, and continuous consent. These have strengths and weaknesses and uncertainty remains about their validity and acceptability in certain research contexts. Prior exploration with parents and parent-advocacy groups of approaches to engagement and consent, and independent evaluation and ongoing monitoring of research studies, can enhance adherence to the ethical principles of justice and autonomy, and ensure that benefits to participants and their families exceed harm. CONCLUSIONS High-quality research and ethics are interdependent. Only research that meets ethical standards can be regarded as valid and applicable, and only research designs that are methodologically rigorous and appropriate can be regarded as ethical.
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Affiliation(s)
- Verena Walsh
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Sam Oddie
- Centre for Reviews and Dissemination, University of York, York, United Kingdom.,Neonatal Unit, Bradford Royal Infirmary, Bradford, United Kingdom
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, United Kingdom,
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A Qualitative Study of the Experiences of Norwegian Parents of Very Low Birthweight Infants Enrolled in a Randomized Nutritional Trial. J Pediatr Nurs 2018; 43:e66-e74. [PMID: 30077471 DOI: 10.1016/j.pedn.2018.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 07/11/2018] [Accepted: 07/14/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE The aim of this study was to examine how parents of very low birth weight (VLBW) infants experienced having their newborn infant enrolled in a randomized controlled intervention trial (RCT). DESIGN AND METHODS A qualitative descriptive design was used. Data were collected through individual semi-structured interviews with 15 parents of 9 participating VLBW infants. The data were then made the object of an inductive qualitative content analysis. RESULTS The parents expressed trust in the competence and motivation of the researchers and were confident that participating in the project would do no harm, but instead would potentially benefit their infant. The parents felt privileged for being given the chance to participate, to commit to the project; they were willing to invest their time and effort in the project. Participation could be stressful for the parents, ranging from minor irritation to situations in which they felt overwhelmed and not entirely in control. Many families lived stressful lives, and participation, particularly the follow-up after being discharged, may have added to this. CONCLUSIONS Infant participation in an RCT can be a positive experience, making the parents feel that they are given a chance to both contribute and receive something special. Participation can also be stressful because of conditions both related and unrelated to the RCT. PRACTICE IMPLICATIONS We identified several issues that researchers in future trials with VLBW infants need to address to minimize parental stress. Recruitment to intervention studies within the immediate period around birth should be avoided, if possible.
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10
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Shepherd V, Hood K, Sheehan M, Griffith R, Jordan A, Wood F. Ethical understandings of proxy decision making for research involving adults lacking capacity: A systematic review (framework synthesis) of empirical research. AJOB Empir Bioeth 2018; 9:267-286. [PMID: 30321110 DOI: 10.1080/23294515.2018.1513097] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Research involving adults lacking mental capacity relies on the involvement of a proxy or surrogate, although this raises a number of ethical concerns. Empirical studies have examined attitudes towards proxy decision-making, proxies' authority as decision-makers, decision accuracy, and other relevant factors. However, a comprehensive evidence-based account of proxy decision-making is lacking. This systematic review provides a synthesis of the empirical data reporting the ethical issues surrounding decisions made by research proxies, and the development of a conceptual framework of proxy decision-making for research. METHODS A systematic review was conducted according to PRISMA guidelines. Databases including MEDLINE, EMBASE, and CINAHL were searched using a combination of search terms, and empirical data from eligible studies were retrieved. The review followed the framework synthesis approach to refine and develop a conceptual framework. RESULTS Thirty-four studies were included in the review. Two dimensions of proxy decision-making emerged. The ethical framing criteria of decision-making used by proxies: use of a substituted judgement, use of a best interests approach, combination of substituted judgement and best interests, and 'something else', and the active elements of proxy decision-making: 'knowing the person', patient-proxy relationship, accuracy of the decision, and balancing risks, benefits and burdens, and attitudes towards proxy decision-making. Interactions between the framing criteria and the elements of decision-making are complex and contextually-situated. CONCLUSIONS The findings from this systematic review challenge the accepted reductionist account of proxy decision-making. Decision-making by research proxies is highly contextualized and multifactorial in nature. The choice of proxy and the relational features of decision-making play a fundamental role: both in providing the proxy's authority as decision-maker, and guiding the decision-making process. The conceptual framework describes the relationship between the framing criteria used by the proxy, and the active elements of decision-making. Further work to develop, and empirically test the proposed framework is needed.
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Affiliation(s)
- Victoria Shepherd
- a Division of Population Medicine , Cardiff University , Cardiff , UK
- b Centre for Trials Research , Cardiff University , Cardiff , UK
| | - Kerenza Hood
- b Centre for Trials Research , Cardiff University , Cardiff , UK
| | - Mark Sheehan
- c Ethox Centre , University of Oxford, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery , Oxford , UK
| | - Richard Griffith
- d College of Human and Health Sciences , Swansea University , Swansea , UK
| | - Amber Jordan
- a Division of Population Medicine , Cardiff University , Cardiff , UK
| | - Fiona Wood
- a Division of Population Medicine , Cardiff University , Cardiff , UK
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11
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McGuire W, Halliday HL. The Research Cycle: Improving Care and Outcomes for Newborn Infants. Neonatology 2018; 114:2-6. [PMID: 29566381 DOI: 10.1159/000487990] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 02/17/2018] [Indexed: 11/19/2022]
Abstract
Ensuring that policies and practice in perinatal care are informed by evidence from high-quality research is fundamental to improving outcomes for newborn infants and their families. Effective interventions in the perinatal period can have a life-long impact disproportionate to their costs. Many of the major advances in care that have transformed outcomes for preterm and sick newborn infants have been informed by empirical and applied health research. Conversely, there are examples of life-long adverse consequences for infants and families that are a legacy of practices based on poor-quality evidence. The challenge in the 21st century is to maintain the trajectory of improvements in care and outcomes. This will most likely be achieved via marginal gains from new or improved care practices underpinned by a range of research approaches, from preclinical and laboratory-based empirical studies that uncover pathogenic pathways or therapeutic mechanisms, to large-scale, applied research such as multicentre, randomised controlled trials. This will involve the coordination and collaboration of research efforts globally. Strategies to develop and prioritise research questions need to involve parents and families. Given the context in which much perinatal research is conducted, particularly in emergency situations around the time of birth, robust and transparent ethics and governance frameworks are essential to maintain the trust and engagement of communities. An ethical imperative exists to ensure that research output is disseminated effectively, and that effective and cost-effective interventions are implemented and integrated within a cycle that audits and benchmarks good practice and outcomes, and informs research evidence-based continuous quality improvement. This is the first in a series of articles on research methodology in neonatal medicine to be published in Neonatology, in response to a request from trainee researchers. We introduce the series by describing the research cycle, in particular how it is applied in neonatal medicine. Subsequent articles will cover translational research, clinical trials, diagnostic tests, global challenges, and the ethical issues relating to neonatal/perinatal research.
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Affiliation(s)
- William McGuire
- Centre for Reviews and Dissemination and Hull York Medical School (HYMS), University of York, York, United Kingdom
| | - Henry L Halliday
- Retired Professor of Child Health, Queen's University of Belfast, Belfast, United Kingdom
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12
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Clinicians' views and experiences of offering two alternative consent pathways for participation in a preterm intrapartum trial: a qualitative study. Trials 2017; 18:196. [PMID: 28446203 PMCID: PMC5406899 DOI: 10.1186/s13063-017-1940-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 04/11/2017] [Indexed: 11/15/2022] Open
Abstract
Background The Cord Pilot Trial compared alternative policies for timing of cord clamping at very preterm birth at eight UK hospitals. Preterm birth can be rapid and unexpected, allowing little time for the usual consent process. Therefore, in addition to the usual procedure for written consent, a two-stage pathway for consent for use when birth was imminent was developed. The aims of this study were to explore clinicians’ views and experiences of offering two consent pathways for recruitment to a randomised trial of timing of cord clamping at very preterm birth. Methods This was a qualitative study using semi-structured interviews. Clinicians from eight hospitals in the UK who had been involved in offering consent to the Cord Pilot Trial were invited to take part in an interview. Clinicians were interviewed in person or by telephone. Interviews were analysed using inductive systematic thematic analysis. Results Seventeen clinicians who had either offered usual written consent only (n = 6) or both the two-stage pathway (with oral assent before the birth and written consent after the birth) and usual written consent (n = 11) were interviewed. Six themes were identified: (1) team approach to offering participation; (2) consent form as a record; (3) consent and participation as a continual process; (4) different consent pathways for different trials; (5) balance between time, information, and understanding; and (6) validity of consent. Overall, clinicians were supportive of the two-stage consent pathway. Some clinicians felt that in time-critical situations oral assent presented an advantage over the usual written consent as they provided information on a “need to know” basis. However, there was some concern about how much information should be given for oral assent, and how this is understood by women when birth is imminent. Conclusions The two-stage pathway for consent developed for use in the Cord Pilot Trial when birth was imminent was acceptable to clinicians for comparable low-risk studies, although some concerns were raised about the practicalities of obtaining oral assent. Trial registration ISRCTN Registry, ISRCTN21456601. Registered on 28 February 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1940-5) contains supplementary material, which is available to authorized users.
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