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Mozersky J, Solomon ED, Baldwin K, Wroblewski M, Parsons M, Goodman M, DuBois JM. Barriers to Using Legally Authorized Representatives in Clinical Research with Older Adults. J Alzheimers Dis Rep 2023; 7:135-149. [PMID: 36891257 PMCID: PMC9986706 DOI: 10.3233/adr-220103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/09/2023] [Indexed: 02/10/2023] Open
Abstract
Background Older adults are at increased risk of cognitive impairments including Alzheimer's disease dementia. Legally authorized representatives (LARs) can provide informed consent when a participant is no longer able to, but little is known about barriers to incorporating them in research. Objective Explore reasons for not asking and documenting participant decisions to appoint LARs among researchers conducting clinical intervention trials studying older adults or individuals with cognitive impairments. Methods Mixed method design consisting of a survey (N = 1,284) and qualitative interviews (N = 40) regarding barriers to incorporating LARs. Participants were principal investigators and clinical research coordinators. Results 37% (N = 469) had not asked and documented participant decisions about appointing LARs in the prior year. They had significantly lower confidence in resources available to incorporate LARs and lower positive attitudes compared to their counterparts who had done so. The majority (83%) had no trials studying individuals with cognitive impairments and reported LARs were not applicable. A minority (17%) had at least one trial studying individuals with cognitive impairments and reported being unaware of LARs. Qualitative findings indicate discomfort broaching a sensitive topic especially with individuals who are not yet impaired. Conclusion Resources and education to increase awareness and knowledge of LARs are needed. Researchers studying older adults should, at minimum, have the knowledge and resources to incorporate LARs when necessary. Stigma and discomfort discussing LARs will need to be overcome, as early proactive discussions before a participant loses decisional capacity could enhance participant autonomy and facilitate recruitment and retention of older adults to research.
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Affiliation(s)
- Jessica Mozersky
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Erin D. Solomon
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Kari Baldwin
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew Wroblewski
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Meredith Parsons
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Melody Goodman
- School of Global Public Health, New York University, New York, NY, USA
| | - James M. DuBois
- Bioethics Research Center, Washington University School of Medicine, St. Louis, MO, USA
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2
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Wendler D, Kim SYH. Implementing supported decision making in clinical research. Int J Geriatr Psychiatry 2023; 38:e5860. [PMID: 36484438 DOI: 10.1002/gps.5860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 11/03/2022] [Indexed: 11/30/2022]
Affiliation(s)
- David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
| | - Scott Y H Kim
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
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3
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Cascio MA, Weiss JA, Racine E. Person-Oriented Research Ethics to Address the Needs of Participants on the Autism Spectrum. Ethics Hum Res 2021; 42:2-16. [PMID: 32937033 DOI: 10.1002/eahr.500064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Research ethics scholarship often attends to vulnerability. People with autism may be vulnerable in research, but are also vulnerable to unjust exclusion from participation. Addressing the needs of participants with autism can facilitate inclusion and honor the bioethics principle of respect for persons while accounting for risk and vulnerability. Drawing from a review of the literature and informed by a moral deliberation process involving a task force of stakeholders (including autistic people and parents of autistic people), we use the model of person-oriented research ethics to identify several practical strategies researchers can use to address these needs and foster inclusion. Strategies include using multiple means of communication, addressing the sensory environment, preparing participants in advance, and accounting for social context. These practical strategies are not just methodological or design choices; they are inherently related to ethical issues. Method and design choices fulfill ethical aspirations by facilitating inclusion, reducing discomfort, and focusing on individuals.
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Affiliation(s)
- M Ariel Cascio
- Assistant professor in the art of medicine at Central Michigan University College of Medicine and was a postdoctoral fellow at the Pragmatic Health Ethics Research Unit at the Institut de recherches cliniques de Montréal when this work was conducted
| | - Jonathan A Weiss
- Associate professor in the Department of Psychology at York University
| | - Eric Racine
- Full research professor at the Institut de recherches cliniques de Montréal and Université de Montréal as well as the director of Pragmatic Health Ethics
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4
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Jaramillo Vélez AG, Aguas Compaired M, Granados Plaza M, Mariño EL, Modamio P. Assessment of the quality of patient information sheets and informed consent forms for clinical trials at a hospital neurology service. Eur J Neurol 2020; 27:1825-1831. [DOI: 10.1111/ene.14420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/08/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022]
Affiliation(s)
- A. G. Jaramillo Vélez
- Clinical Pharmacy and Pharmaceutical Care Unit Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry Faculty of Pharmacy and Food Sciences University of Barcelona Barcelona Spain
| | - M. Aguas Compaired
- Clinical Pharmacy and Pharmaceutical Care Unit Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry Faculty of Pharmacy and Food Sciences University of Barcelona Barcelona Spain
- Research Ethics Committee (CEIm) Idcsalud a Catalunya Hospital Universitari General de Catalunya Barcelona Spain
| | - M. Granados Plaza
- Research Ethics Committee (CEIm) Idcsalud a Catalunya Hospital Universitari General de Catalunya Barcelona Spain
| | - E. L. Mariño
- Clinical Pharmacy and Pharmaceutical Care Unit Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry Faculty of Pharmacy and Food Sciences University of Barcelona Barcelona Spain
| | - P. Modamio
- Clinical Pharmacy and Pharmaceutical Care Unit Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry Faculty of Pharmacy and Food Sciences University of Barcelona Barcelona Spain
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5
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Biller-Andorno N, Biller A. Algorithm-Aided Prediction of Patient Preferences - An Ethics Sneak Peek. N Engl J Med 2019; 381:1480-1485. [PMID: 31597026 DOI: 10.1056/nejmms1904869] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Nikola Biller-Andorno
- From the Institute of Biomedical Ethics and History of Medicine, University of Zurich, and the Collegium Helveticum - both in Zurich, Switzerland (N.B.-A.); and the Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany (A.B.)
| | - Armin Biller
- From the Institute of Biomedical Ethics and History of Medicine, University of Zurich, and the Collegium Helveticum - both in Zurich, Switzerland (N.B.-A.); and the Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany (A.B.)
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Carpenter CR, McFarland F, Avidan M, Berger M, Inouye SK, Karlawish J, Lin FR, Marcantonio E, Morris J, Reuben D, Shah R, Whitson H, Asthana S, Verghese J. Impact of Cognitive Impairment Across Specialties: Summary of a Report From the U13 Conference Series. J Am Geriatr Soc 2019; 67:2011-2017. [PMID: 31436318 PMCID: PMC6800784 DOI: 10.1111/jgs.16093] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/27/2019] [Accepted: 06/30/2019] [Indexed: 11/28/2022]
Abstract
Although declines in cognitive capacity are assumed to be a characteristic of aging, increasing evidence shows that it is age-related disease, rather than age itself, that causes cognitive impairment. Even so, older age is a primary risk factor for cognitive decline, and with individuals living longer as a result of medical advances, cognitive impairment and dementia are increasing in prevalence. On March 26 to 27, 2018, the American Geriatrics Society convened a conference in Bethesda, MD, to explore cognitive impairment across the subspecialties. Bringing together representatives from several subspecialties, this was the third of three conferences, supported by a U13 grant from the National Institute on Aging, to aid recipients of Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) in integrating geriatrics into their subspecialties. Scientific sessions focused on the impact of cognitive impairment, sensory contributors, comorbidities, links between delirium and dementia, and issues of informed consent in cognitively impaired populations. Discussions highlighted the complexity not only of cognitive health itself, but also of the bidirectional relationship between cognitive health and the health of other organ systems. Thus, conference participants noted the importance of multidisciplinary team science in future aging research. This article summarizes the full conference report, "The Impact of Cognitive Impairment Across Specialties," and notes areas where GEMSSTAR scholars can contribute to progress as they embark on their careers in aging research. J Am Geriatr Soc 67:2011-2017, 2019.
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Affiliation(s)
| | | | | | | | | | | | | | | | - John Morris
- Washington University School of Medicine, St. Louis, MO
| | | | - Raj Shah
- Rush University Medical Center, Chicago, IL
| | - Heather Whitson
- Duke University School of Medicine, Durham, NC and Geriatrics Research Education and Clinical Center, Durham VA, Durham, NC
| | - Sanjay Asthana
- University of Wisconsin, Madison, WI
- Albert Einstein College of Medicine, Bronx, NY
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Hérault É, Bravo G, Trottier L. Advance Directives for Research: How Do They Compare with Surrogates’ Predictions of Older Adults’ Preferences? ACTA ACUST UNITED AC 2018. [DOI: 10.1002/eahr.405002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Élodie Hérault
- University Institute of Geriatrics of Sherbrooke; Research Center on Aging
| | - Gina Bravo
- Research Center on Aging; Université de Sherbrooke; Department of Community Health Sciences, Faculty of Medicine and Health Sciences
| | - Lise Trottier
- University Institute of Geriatrics of Sherbrooke; Research Center on Aging
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Johansson M, Broström L. Surrogate consent to non-beneficial research: erring on the right side when substituted judgments may be inaccurate. THEORETICAL MEDICINE AND BIOETHICS 2016; 37:149-160. [PMID: 27130296 PMCID: PMC4854930 DOI: 10.1007/s11017-016-9363-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Part of the standard protection of decisionally incapacitated research subjects is a prohibition against enrolling them unless surrogate decision makers authorize it. A common view is that surrogates primarily ought to make their decisions based on what the decisionally incapacitated subject would have wanted regarding research participation. However, empirical studies indicate that surrogate predictions about such preferences are not very accurate. The focus of this article is the significance of surrogate accuracy in the context of research that is not expected to benefit the research subject. We identify three morally relevant asymmetries between being enrolled and not being enrolled in such non-beneficial research, and conclude that when there is a non-negligible probability that surrogates' predictions are wrong, it will generally be better to err on the side of not authorizing enrollment.
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Affiliation(s)
- Mats Johansson
- Department of Medical Ethics, Lund University, BMC I12, 221 84, Lund, Sweden.
| | - Linus Broström
- Department of Medical Ethics, Lund University, BMC I12, 221 84, Lund, Sweden
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9
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Bolcic-Jankovic D, Clarridge BR, LeBlanc JL, Mahmood RS, Roman AM, Freeman BD. Exploring determinants of surrogate decision-maker confidence: an example from the ICU. J Empir Res Hum Res Ethics 2014; 9:76-85. [PMID: 25747298 DOI: 10.1177/1556264614545036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article is an exploratory data analysis of the determinants of confidence in a surrogate decision maker who has been asked to permit an intensive care unit (ICU) patient's participation in genetic research. We pursue the difference between surrogates' and patients' confidence that the surrogate can accurately represent the patient's wishes. The article also explores whether greater confidence leads to greater agreement between patients and surrogates. Our data come from a survey conducted in three hospital ICUs. We interviewed 445 surrogates and 214 patients. The only thing that influences patients' confidence in their surrogate's decision is whether they had prior discussions with him or her; however, there are more influences operating on the surrogate's self-confidence. More confident surrogates are more likely to match their patients' wishes. Patients are more likely to agree to research participation than their surrogates would allow. The surrogates whose response did not match as closely were less trusting of the hospital staff, were less likely to allow patient participation if there were no direct benefits to the patient, had given less thought about the way genetic research is conducted, and were much less likely to have a person in their life who they would trust to make decisions for them if they were incapacitated.
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Affiliation(s)
| | - Brian R Clarridge
- Center for Survey Research, University of Massachusetts, Boston, MA, USA
| | - Jessica L LeBlanc
- Center for Survey Research, University of Massachusetts, Boston, MA, USA
| | - Rumel S Mahmood
- Center for Survey Research, University of Massachusetts, Boston, MA, USA
| | - Anthony M Roman
- Center for Survey Research, University of Massachusetts, Boston, MA, USA
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Berger JT. Stumbled, Fumbled, Bumbled, Grumbled, and Humbled: Looking Back at the Future History of Clinical Ethics. THE JOURNAL OF CLINICAL ETHICS 2014. [DOI: 10.1086/jce201425202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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