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Rubin MA, Lewis A, Creutzfeldt CJ, Shrestha GS, Boyle Q, Illes J, Jox RJ, Trevick S, Young MJ. Equity in Clinical Care and Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2024:10.1007/s12028-024-02012-3. [PMID: 38872033 DOI: 10.1007/s12028-024-02012-3] [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: 03/22/2024] [Accepted: 05/09/2024] [Indexed: 06/15/2024]
Abstract
People with disorders of consciousness (DoC) are characteristically unable to synchronously participate in decision-making about clinical care or research. The inability to self-advocate exacerbates preexisting socioeconomic and geographic disparities, which include the wide variability observed across individuals, hospitals, and countries in access to acute care, expertise, and sophisticated diagnostic, prognostic, and therapeutic interventions. Concerns about equity for people with DoC are particularly notable when they lack a surrogate decision-maker (legally referred to as "unrepresented" or "unbefriended"). Decisions about both short-term and long-term life-sustaining treatment typically rely on neuroprognostication and individual patient preferences that carry additional ethical considerations for people with DoC, as even individuals with well thought out advance directives cannot anticipate every possible situation to guide such decisions. Further challenges exist with the inclusion of people with DoC in research because consent must be completed (in most circumstances) through a surrogate, which excludes those who are unrepresented and may discourage investigators from exploring questions related to this population. In this article, the Curing Coma Campaign Ethics Working Group reviews equity considerations in clinical care and research involving persons with DoC in the following domains: (1) access to acute care and expertise, (2) access to diagnostics and therapeutics, (3) neuroprognostication, (4) medical decision-making for unrepresented people, (5) end-of-life decision-making, (6) access to postacute rehabilitative care, (7) access to research, (8) inclusion of unrepresented people in research, and (9) remuneration and reciprocity for research participation. The goal of this discussion is to advance equitable, harmonized, guideline-directed, and goal-concordant care for people with DoC of all backgrounds worldwide, prioritizing the ethical standards of respect for autonomy, beneficence, and justice. Although the focus of this evaluation is on people with DoC, much of the discussion can be extrapolated to other critically ill persons worldwide.
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Affiliation(s)
- Michael A Rubin
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | | | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Quinn Boyle
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Neurocritical Care, Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, USA.
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Seeger R, Udoh U, Dewar B, Nicholls S, Fedyk M, Fahed R, Perry J, Hill MD, Menon B, Swartz RH, Poppe AY, Gocan S, Brehaut J, Dainty K, Shepherd V, Dowlatshahi D, Shamy M. Advance Consent in Acute Stroke Trials: Survey of Canadian Research Ethics Board Chairs. Can J Neurol Sci 2024; 51:285-288. [PMID: 37485900 DOI: 10.1017/cjn.2023.247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Advance consent could allow individuals at high risk of stroke to provide consent before they might become eligible for enrollment in acute stroke trials. This survey explores the acceptability of this novel technique to Canadian Research Ethics Board (REB) chairs that review acute stroke trials. Responses from 15 REB chairs showed that majority of respondents expressed comfort approving studies that adopt advance consent. There was no clear preference for advance consent over deferral of consent, although respondents expressed significant concern with broad rather than trial-specific advance consent. These findings shed light on the acceptability of advance consent to Canadian ethics regulators.
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Affiliation(s)
- Rena Seeger
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ubong Udoh
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Stuart Nicholls
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mark Fedyk
- School of Medicine, University of California, Davis, Davis, CA, USA
| | - Robert Fahed
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jeff Perry
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary and Calgary Stroke Program, Calgary, AB, Canada
| | - Bijoy Menon
- Department of Clinical Neurosciences, University of Calgary and Calgary Stroke Program, Calgary, AB, Canada
| | - Richard H Swartz
- Department of Medicine, University of Toronto & Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexandre Y Poppe
- Department of Neurosciences, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Sophia Gocan
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jamie Brehaut
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Katie Dainty
- Department of Research and Innovation, North York General Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | - Dar Dowlatshahi
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Michel Shamy
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
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3
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Dippel DWJ, Warach SJ. Deferral of Consent in Randomized Clinical Trials of Acute Stroke: Ethical, Methodologic, and Practical Challenges. Neurology 2023; 100:273-274. [PMID: 36414422 DOI: 10.1212/wnl.0000000000201724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Diederik W J Dippel
- From the Department of Neurology (D.W.J.D.), Erasmus University Medical Center Rotterdam, the Netherlands; and Department of Neurology (S.J.W.), Dell Medical School, The University of Texas at Austin.
| | - Steven J Warach
- From the Department of Neurology (D.W.J.D.), Erasmus University Medical Center Rotterdam, the Netherlands; and Department of Neurology (S.J.W.), Dell Medical School, The University of Texas at Austin
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