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Nagy M, Sisk B, Lai A, Kodish E. Will artificial intelligence widen the therapeutic gap between children and adults? Pediatr Investig 2024; 8:1-6. [PMID: 38516139 PMCID: PMC10951493 DOI: 10.1002/ped4.12407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/31/2023] [Indexed: 03/23/2024] Open
Affiliation(s)
- Matthew Nagy
- Cleveland Clinic Lerner College of MedicineCase Western Reserve UniversityClevelandOhioUSA
| | - Bryan Sisk
- Department of PediatricsDivision of Hematology/OncologyWashington University School of MedicineSt. LouisMissouriUSA
- Department of MedicineBioethics Research CenterWashington University School of MedicineSt. LouisMissouriUSA
| | - Albert Lai
- Institute for InformaticsWashington University School of MedicineSt. LouisMissouriUSA
| | - Eric Kodish
- Cleveland Clinic Lerner College of MedicineCase Western Reserve UniversityClevelandOhioUSA
- Department of Pediatric Hematology Oncology and Blood and Marrow TransplantationCleveland Clinic Children'sClevelandOhioUSA
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2
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Bjelac J, Shaker M, Greenhawt M, Kodish E. Viewing Pediatric Food Oral Immunotherapy Through an Ethical Lens-A Narrative Systematic Review. J Allergy Clin Immunol Pract 2023; 11:1914-1925. [PMID: 36965706 DOI: 10.1016/j.jaip.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/31/2023] [Accepted: 03/11/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Food allergy remains a common problem and a lifelong condition for many children. In recent years, food allergy management has increasingly involved conversations about food oral immunotherapy (OIT). Although ethical considerations of autonomy, beneficence, nonmaleficence, and justice implicitly inform these conversations, applying these principles can be complex, particularly in young children. Families of young children assume a role of surrogate decision-maker and must balance immediate risks with the hope of longer-term benefits. OBJECTIVE To explore implementation of OIT in children through an ethical lens. METHODS To evaluate OIT through an ethical lens, we conducted a literature search to explore currently published frameworks in this area. RESULTS Evaluation of the harm principle, the basic interest principle, and the best interest principle of parental decision-making can be informative. Shared decision-making continues to be central to the process of engaging with patient-family units to individualize the best care, at the right time, and minimize decisional discord. Although OIT is well-positioned to promote health and well-being, challenges to equity, sustainability, and organizational support must be considered to improve access for appropriate patients. CONCLUSIONS Whereas approaches to food OIT may be tailored to the individual context of each patient-family unit, ethical principles must guide decisions to initiate and continue therapy. Traditional ethical principles of autonomy, beneficence, nonmaleficence, and justice remain cornerstones when considering the ethical context of OIT.
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Affiliation(s)
- Jaclyn Bjelac
- Food Allergy Center of Excellence, Center for Pediatric Allergy and Immunology, Cleveland Clinic, Cleveland, Ohio.
| | - Marcus Shaker
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Eric Kodish
- Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic Children's and Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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3
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Benedetti DJ, Marron JM, Thomas SM, Brown AEC, Pyke-Grimm KA, Johnson LM, Unguru Y, Kodish E. The role of ethicists in pediatric hematology/oncology: Current status and future needs. Pediatr Blood Cancer 2023; 70:e30132. [PMID: 36495529 DOI: 10.1002/pbc.30132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/09/2022] [Accepted: 11/12/2022] [Indexed: 12/14/2022]
Abstract
As pediatric hematology/oncology (PHO) becomes more complex and sub-subspecialized, dedicated PHO ethicists have emerged as sub-subspecialists focused on addressing ethical issues encountered in clinical and research practices. PHO physicians and other clinicians with advanced training in bioethics contribute to the field through ethics research, education, and ethics consultation services. Furthermore, there exists a newer generation of PHO trainees interested in bioethics. This review details the experiences of current PHO ethicists, providing a blueprint for future educational, research and service activities to strengthen the trajectory of the burgeoning sub-subspecialty of PHO ethics. Creating an American Society of Pediatric Hematology/Oncology (ASPHO) ethics Special Interest Group, enhancing clinical ethics education for pediatric hematologists/oncologists (PHOs), developing multi-institutional research collaborations, and increasing attention to ethical issues germane to nonmalignant hematology will serve the interests of the entire field of PHO, enhancing the care of PHO patients and careers of PHOs.
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Affiliation(s)
- Daniel J Benedetti
- Division of Pediatric Hematology/Oncology, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan M Marron
- Division of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, and Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
| | - Stefanie M Thomas
- Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Amy E Caruso Brown
- Division of Pediatric Hematology/Oncology, and Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Kimberly A Pyke-Grimm
- Department of Nursing Research and Evidence-Based Practice, Stanford Children's Health and Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Liza-Marie Johnson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Yoram Unguru
- Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, Maryland, USA.,Johns Hopkins University Berman Institute of Bioethics, Baltimore, Maryland, USA
| | - Eric Kodish
- Departments of Pediatrics, Oncology, and Bioethics, Cleveland Clinic Children's and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio, USA
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Benedetti DJ, Marron JM, Thomas SM, Caruso Brown AE, Pyke-Grimm KA, Johnson LM, Kodish E, Unguru Y. Words Matter. J Clin Oncol 2023; 41:706-707. [PMID: 36150097 DOI: 10.1200/jco.22.01056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Daniel J Benedetti
- Daniel J. Benedetti, MD, MA, Division of Pediatric Hematology/Oncology, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN; Jonathan M. Marron, MD, MPH, Division of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, and Center for Bioethics, Harvard Medical School, Boston, MA; Stefanie M. Thomas, MD, MS, Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Cleveland Clinic, Cleveland, OH; Amy E. Caruso Brown, MD, MSc, MSCS, Division of Pediatric Hematology/Oncology, and Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, NY; Kimberly A. Pyke-Grimm, PhD, Department of Nursing Research and Evidence-Based Practice, Stanford Children's Health and Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Palo Alto, CA; Liza-Marie Johnson, MD, MPH, MSB, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN; Eric Kodish, MD, Departments of Pediatrics, Oncology, and Bioethics, Cleveland Clinic Children's and Case Western Reserve University, Cleveland, OH; and Yoram Unguru, MD, MS, MA, Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, MD, Johns Hopkins University Berman Institute of Bioethics, Baltimore, MD
| | - Jonathan M Marron
- Daniel J. Benedetti, MD, MA, Division of Pediatric Hematology/Oncology, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN; Jonathan M. Marron, MD, MPH, Division of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, and Center for Bioethics, Harvard Medical School, Boston, MA; Stefanie M. Thomas, MD, MS, Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Cleveland Clinic, Cleveland, OH; Amy E. Caruso Brown, MD, MSc, MSCS, Division of Pediatric Hematology/Oncology, and Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, NY; Kimberly A. Pyke-Grimm, PhD, Department of Nursing Research and Evidence-Based Practice, Stanford Children's Health and Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Palo Alto, CA; Liza-Marie Johnson, MD, MPH, MSB, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN; Eric Kodish, MD, Departments of Pediatrics, Oncology, and Bioethics, Cleveland Clinic Children's and Case Western Reserve University, Cleveland, OH; and Yoram Unguru, MD, MS, MA, Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, MD, Johns Hopkins University Berman Institute of Bioethics, Baltimore, MD
| | - Stefanie M Thomas
- Daniel J. Benedetti, MD, MA, Division of Pediatric Hematology/Oncology, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN; Jonathan M. Marron, MD, MPH, Division of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, and Center for Bioethics, Harvard Medical School, Boston, MA; Stefanie M. Thomas, MD, MS, Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Cleveland Clinic, Cleveland, OH; Amy E. Caruso Brown, MD, MSc, MSCS, Division of Pediatric Hematology/Oncology, and Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, NY; Kimberly A. Pyke-Grimm, PhD, Department of Nursing Research and Evidence-Based Practice, Stanford Children's Health and Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Palo Alto, CA; Liza-Marie Johnson, MD, MPH, MSB, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN; Eric Kodish, MD, Departments of Pediatrics, Oncology, and Bioethics, Cleveland Clinic Children's and Case Western Reserve University, Cleveland, OH; and Yoram Unguru, MD, MS, MA, Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, MD, Johns Hopkins University Berman Institute of Bioethics, Baltimore, MD
| | | | | | - Liza-Marie Johnson
- Daniel J. Benedetti, MD, MA, Division of Pediatric Hematology/Oncology, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN; Jonathan M. Marron, MD, MPH, Division of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, and Center for Bioethics, Harvard Medical School, Boston, MA; Stefanie M. Thomas, MD, MS, Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Cleveland Clinic, Cleveland, OH; Amy E. Caruso Brown, MD, MSc, MSCS, Division of Pediatric Hematology/Oncology, and Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, NY; Kimberly A. Pyke-Grimm, PhD, Department of Nursing Research and Evidence-Based Practice, Stanford Children's Health and Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Palo Alto, CA; Liza-Marie Johnson, MD, MPH, MSB, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN; Eric Kodish, MD, Departments of Pediatrics, Oncology, and Bioethics, Cleveland Clinic Children's and Case Western Reserve University, Cleveland, OH; and Yoram Unguru, MD, MS, MA, Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, MD, Johns Hopkins University Berman Institute of Bioethics, Baltimore, MD
| | - Eric Kodish
- Daniel J. Benedetti, MD, MA, Division of Pediatric Hematology/Oncology, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN; Jonathan M. Marron, MD, MPH, Division of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, and Center for Bioethics, Harvard Medical School, Boston, MA; Stefanie M. Thomas, MD, MS, Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Cleveland Clinic, Cleveland, OH; Amy E. Caruso Brown, MD, MSc, MSCS, Division of Pediatric Hematology/Oncology, and Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, NY; Kimberly A. Pyke-Grimm, PhD, Department of Nursing Research and Evidence-Based Practice, Stanford Children's Health and Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Palo Alto, CA; Liza-Marie Johnson, MD, MPH, MSB, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN; Eric Kodish, MD, Departments of Pediatrics, Oncology, and Bioethics, Cleveland Clinic Children's and Case Western Reserve University, Cleveland, OH; and Yoram Unguru, MD, MS, MA, Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, MD, Johns Hopkins University Berman Institute of Bioethics, Baltimore, MD
| | - Yoram Unguru
- Daniel J. Benedetti, MD, MA, Division of Pediatric Hematology/Oncology, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN; Jonathan M. Marron, MD, MPH, Division of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, and Center for Bioethics, Harvard Medical School, Boston, MA; Stefanie M. Thomas, MD, MS, Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Cleveland Clinic, Cleveland, OH; Amy E. Caruso Brown, MD, MSc, MSCS, Division of Pediatric Hematology/Oncology, and Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, NY; Kimberly A. Pyke-Grimm, PhD, Department of Nursing Research and Evidence-Based Practice, Stanford Children's Health and Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Palo Alto, CA; Liza-Marie Johnson, MD, MPH, MSB, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN; Eric Kodish, MD, Departments of Pediatrics, Oncology, and Bioethics, Cleveland Clinic Children's and Case Western Reserve University, Cleveland, OH; and Yoram Unguru, MD, MS, MA, Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, MD, Johns Hopkins University Berman Institute of Bioethics, Baltimore, MD
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5
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Culbert AA, Bribriesco A, O'Connor MS, Kodish E. Navigating Informed Consent and Patient Safety in Surgery: Lessons for Medical Students and Junior Trainees. J Clin Ethics 2023; 34:278-281. [PMID: 37831648 DOI: 10.1086/726816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
AbstractIn the operating room, patient safety is of paramount importance. Medical students and junior trainees, despite their primary role as students, may play active roles in assessing patient safety and reporting suspected errors. Active consent is one layer of patient safety that is continuously assessed by several team members. This article examines an instance where patient consent may have been violated. Through the lens of trainee and senior perspectives, we discuss the ethical principles at stake and provide recommendations for medical student and junior trainee involvement in patient care when an error is suspected.
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6
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Kurowski JA, Bewtra M, Kodish E, Lashner B. Reducing the Spread of Internet Misinformation in IBD: Ethics and Responsibility. Inflamm Bowel Dis 2021; 27:960-962. [PMID: 33399199 DOI: 10.1093/ibd/izaa335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Indexed: 12/09/2022]
Affiliation(s)
- Jacob A Kurowski
- Pediatric Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, United States
| | - Meenakshi Bewtra
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Eric Kodish
- Pediatric Hematology & Oncology, Cleveland Clinic and Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio, United States
| | - Bret Lashner
- Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, United States
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7
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Porter AS, O'Callaghan J, Englund KA, Lorenz RR, Kodish E. Problems with the problem list: challenges of transparency in an era of patient curation. J Am Med Inform Assoc 2021; 27:981-984. [PMID: 32346726 DOI: 10.1093/jamia/ocaa040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/17/2020] [Accepted: 03/30/2020] [Indexed: 11/14/2022] Open
Abstract
In recent years, the OpenNotes movement and other changes in healthcare have driven institutions to make medical records increasingly transparent. As patients have begun to question and request changes to their Problem Lists, clinicians have come to face the ever more frequent challenge of discerning which changes to make and which to refuse. Now clinicians and patients together choose the list of problems that represent the patient's current state of health and illness. As the physician's role slides closer to consultant and the medical paternalism of the twentieth century falls further into the background of our technology-infused present, who holds the power of delineating a patient's clinical identity? This paper examines the ethical and practical dimensions of this question and proposes a research agenda that aims to answer it. Such explorations are essential to ensuring that the physician remains relevant to patient's notions of health, illness, intervention, and healing.
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Affiliation(s)
- Amy S Porter
- Center for Comprehensive Care, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | | | - Kristin A Englund
- Department of Infectious Disease, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Eric Kodish
- Pediatrics Institute, Cleveland Clinic Children's Hospital, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio, USA
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Abstract
The scientific purpose of phase I trials is to determine the maximum tolerated dose and/or optimal biological dose of experimental agents. Yet most participants in phase I oncology trials enroll hoping for direct medical benefit. The most common phase I trial designs use low starting doses and escalate cautiously in a "risk-escalation" model focused on minimizing risk for each participant. This approach ensures that a proportion of subjects will likely not receive any benefit, even if the intervention proves to be successful at appropriate doses. In this article, we propose that trial designs should employ dosing strategies that increase chances of providing benefit if the investigational agent should prove to be successful while limiting risk to reasonable levels. We then describe how adaptive trial designs can facilitate refined dose optimization based on both therapeutic benefit and toxicity, which can simultaneously decrease the risk of harm while increasing the chances of benefit.
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Affiliation(s)
- Bryan Anthony Sisk
- Clinical fellow in pediatric hematology/oncology in the Department of Pediatrics at Washington University School of Medicine
| | - James Dubois
- Professor in the Department of Medicine at Washington University School of Medicine
| | - Brian P Hobbs
- Associate staff member in the Department of Quantitative Health Sciences in the Lerner Research Institute at the Cleveland Clinic
| | - Eric Kodish
- Professor of pediatrics, oncology, and bioethics at Case Western Reserve and Cleveland Clinic Lerner College of Medicine
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9
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Khera N, Deeg HJ, Kodish E, Rondelli D, Majhail N. Allogeneic Hematopoietic Cell Transplantation and Other Expensive Cellular Therapies: A Miracle for the Few but Off Limits to Many? J Clin Oncol 2019; 38:1268-1272. [PMID: 31730388 DOI: 10.1200/jco.19.02232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Abstract
Informed consent for pediatric anesthesia challenges practitioners to navigate complex ethical, medical, and legal ambiguities. A patient's status as a minor does not negate the importance of his or her participation in the decision-making process but, rather, necessitates a nuanced evaluation of age and development to involve the patient to an appropriate extent. Given the complexities involved with pediatric informed consent in anesthesia practice and research, it is important to understand the experience of key stakeholders involved. For this review, we searched Medline, the Cochrane database, PROSPERO, and Clinicaltrials.gov for studies involving pediatric anesthesia informed consent. Inclusion and exclusion criteria were designed to select for studies that included issues related to informed consent as primary outcomes. The following data were extracted from included studies: title, authors, date of publication, study type, intervention, data collection method, participant type (ie, parent, pediatric patient, anesthesia provider), number of participants, pediatric patient age range, and primary outcome measures. Twenty-two articles were included for final review: studies of informed consent in pediatric anesthesia span many aspects of informed consent. Parental understanding has been studied most often (7/22 studies), followed by parental preferences (5/22 studies) and provider-related outcomes (5/22 studies) such as time spent interacting with patients, subjective reporting on amount of training related to informed consent, and provider satisfaction with the informed consent process. Outcomes pertaining to pediatric patients themselves constitute the smallest number of studies, including child anxiety (1/22), child understanding (1/22), and child refusal (1/22). Among the parties involved, parents have been most frequently identified as the subjects of these studies (2719/3805 subjects across all included studies, or 71% of all subjects). Pediatric patients are the least frequently involved subjects of studies that investigate informed consent in pediatric anesthesia (493/3805, or 13% of all subjects). Anesthesia providers and investigators have been study subjects (593/3805, or 16% of all subjects) for a range of topics including time spent interacting with patient, nature of informed consent conversation in relation to trainee status, satisfaction with informed consent process, and priorities for informed consent content. The aim of the present narrative review is to summarize the work that has been done on informed consent for pediatric anesthesia.
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Affiliation(s)
- Max M Feinstein
- From the School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Anthony E Pannunzio
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samuel Lobell
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Eric Kodish
- Department of Pediatric Hematology-Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, Ohio
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Abstract
Patient enrollment is increasingly recognized as a major limiting factor to inflammatory bowel disease (IBD) clinical trial completion. Many IBD trials will fail to enroll enough patients to adequately power their study. This has led to a renewed multifaceted effort to encourage more patients to enroll in clinical trials. Although this is of clear importance, it is also important to ensure that all efforts to enroll patients in clinical trials do not compromise the quality and validity of the patient's/study participant's informed consent. Informed consent has 4 components: disclosure, voluntariness, understanding, and capacity. The application of informed consent to IBD clinical trials for biologic agents has not been previously studied. Yet the nature of clinical trials for biologics in IBD creates certain challenges to properly fulfilling the requirements of informed consent in the recruitment process that should be examined. In the following commentary, the components of informed consent are reviewed, challenges to their fulfillment in IBD trials are reviewed, and practical advice is offered.
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Affiliation(s)
- Michael Kurin
- Division of Gastroenterology and Liver Diseases, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jeffry Katz
- Division of Gastroenterology and Liver Diseases, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Eric Kodish
- Pediatrics Institute and Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Bret Lashner
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Mahat U, Talati R, Kodish E. Comment on: Use of thrombopoietin receptor agonist (romiplostim) in neonatal autoimmune thrombocytopenia due to maternal immune thrombocytopenia. Pediatr Blood Cancer 2019; 66:e27706. [PMID: 30854752 DOI: 10.1002/pbc.27706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 02/27/2019] [Accepted: 02/28/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Upendra Mahat
- Pediatric Hematology Oncology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Ravi Talati
- Pediatric Hematology Oncology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Eric Kodish
- Pediatric Hematology Oncology, Cleveland Clinic Children's, Cleveland, Ohio
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Bester J, Kodish E. Cardiopulmonary Resuscitation, Informed Consent, and Rescue: What Provides Moral Justification for the Provision of CPR? The Journal of Clinical Ethics 2019. [DOI: 10.1086/jce2019301073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Bester J, Kodish E. Cardiopulmonary Resuscitation, Informed Consent, and Rescue: What Provides Moral Justification for the Provision of CPR? J Clin Ethics 2019; 30:67-73. [PMID: 30896446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Questions related to end-of-life decision making are common in clinical ethics and may be exceedingly difficult. Chief among these are the provision of cardiopulmonary resuscitation (CPR) and do-not-resuscitate orders (DNRs). To better address such questions, clarity is needed on the values of medical ethics that underlie CPR and the relevant moral framework for making treatment decisions. An informed consent model is insufficient to provide justification for CPR. Instead, ethical justification for CPR rests on the rule of rescue and on substituted interest judgments. Patients' known wishes and values are relevant, particularly in protecting them from unwanted CPR. Clinicians should rescue patients with the means at their disposal, as a prima facie moral imperative, unless there are compelling reasons to refrain. We present a moral framework for making decisions regarding CPR and DNR.
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Affiliation(s)
- Johan Bester
- DUniversity of Nevada, Las Vegas School of Medicine, Las Vegas, Nevada USA.
| | - Eric Kodish
- Lerner College of Medicine, Case Western Reserve University in Cleveland, Ohio USA.
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Abstract
Recent genomic discoveries have improved our understanding of many hematologic diseases and led to novel therapeutic options for many patients. The rapid decrease in the cost of genomic testing has enabled widespread use of clinical genomic testing. However, these advances are accompanied by concomitant challenging ethical concerns. In pediatrics, issues of informed consent for genomic testing, assent, and permission vary significantly by patient age and comprehension. Broader testing strategies, such as whole-exome or whole-genome sequencing, are more likely to yield incidental findings unrelated to the reason for the initial test, and plans to deal with these results when they occur are increasingly important. The lines of clinical care and research are becoming more blurry in the era of precision medicine in which approaches to individual genetic mutations (as opposed to disease phenotypes) occur with increased frequency. Finally, because justice is a fundamental ethical consideration, access to genomic testing and a rigorous approach to utility are critical to individual patients and the field of hematology. In this review, we use 3 cases of genomic testing in pediatric hematology to illustrate core ethical concerns and explore potential solutions.
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Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Eric Kodish
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, OH
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16
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Sisk BA, Kodish E. Reasons Don't Matter. Am J Bioeth 2018; 18:59-60. [PMID: 30133399 DOI: 10.1080/15265161.2018.1485776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
| | - Eric Kodish
- b Pediatrics Institute, Lerner College of Medicine, Cleveland Clinic
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Affiliation(s)
- Bryan A. Sisk
- Washington University School of Medicine; Department of Pediatrics
| | - Eric Kodish
- Lerner College of Medicine in the Cleveland Clinic; Pediatrics Institute
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Sisk BA, Kodish E. Therapeutic Misperceptions in Early-Phase Cancer Trials: From Categorical to Continuous. IRB 2018; 40:13-20. [PMID: 30387976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Appropriate enrollment in early-phase clinical trials demands that potential research participants understand and appreciate critical study-related information, because discrepancies in understanding or appreciation can potentially invalidate informed consent to participate in research. Four terms were previously developed to categorize these discrepancies: therapeutic "misconception," "therapeutic misestimation," "therapeutic optimism," and "unrealistic optimism." In this article, we propose a continuous framework of therapeutic misperceptions, rather than discrete categorical concepts. One end of this continuum contains discrepancies in understanding, and at the other end are discrepancies in appreciation. Categorical terminologies represent points along this continuum. Discrepancies in understanding and appreciation each lead to unique ethical concerns and likely require different interventions. This framework highlights the dearth of empirical work on the appreciation end of the continuum, especially related to navigating persistent discrepancies in appreciation. Employing a continuous framework of therapeutic misperceptions supports a nuanced approach to the unique circumstances of each research subject, aiding researchers in supporting truly informed consent.
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Affiliation(s)
- Max M Feinstein
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Eric Kodish
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
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Porter AS, Kodish E. The Ethics of Using Complementary Medicine in Pediatric Oncology Trials: Reconciling Challenges. J Law Med Ethics 2018; 46:64-71. [PMID: 30026655 PMCID: PMC6047750 DOI: 10.1177/1073110518766018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Medication reconciliation for pediatric oncology patientparticipants enrolled in clinical trials often reveals the use of chemical complementary medicine alongside protocol therapeutic agents. Considering the blurry delineation between clinical ethics and research ethics, this paper demonstrates how complementary medicine-related protocol violations introduce ethical questions of who should be included and excluded from clinical trials and offers recommendations on how to manage physician-patient-family interactions around these challenging issues.
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Affiliation(s)
- Amy S Porter
- Currently a Pediatrics Resident at the Cleveland Clinic planning to pursue a career in Pediatric Palliative Medicine. She received her M.D. and Ph.D. in Clinical Medicine and Anthropology from Harvard University
| | - Eric Kodish
- Professor of Pediatrics and Bioethics at Cleveland Clinic Lerner College of Medicine and Program Director of the Fellowship in Pediatric Hematology/Oncology at Cleveland Clinic
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Kodish E. "What's in a name?" CAR-T Gene Therapy. Hastings Cent Rep 2017; 47:inside back cover. [PMID: 29171056 DOI: 10.1002/hast.786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Bester J, Kodish E. Children Are Not the Property of Their Parents: The Need for a Clear Statement of Ethical Obligations and Boundaries. Am J Bioeth 2017; 17:17-19. [PMID: 29111927 DOI: 10.1080/15265161.2017.1378768] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Johan Bester
- a University of Nevada Las Vegas School of Medicine
| | - Eric Kodish
- b The Cleveland Clinic Foundation and the Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University
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Lie DA, Fu JB, Schmitt P, Kodish E, Mukherjee D. Cultural Factors in Ethics Consultations. PM R 2017; 9:1030-1037. [DOI: 10.1016/j.pmrj.2017.08.446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 08/30/2017] [Indexed: 10/18/2022]
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Abstract
Policies to remove parents' ability to opt-out from school immunization requirements on the basis of religious or personal beliefs (ie, nonmedical exemptions) may be a useful strategy to increase immunization rates and prevent outbreaks of vaccine-preventable disease. However, there is uncertainty about the effectiveness of this strategy and the range of possible outcomes. We advocate for a more deliberative process through which a broad range of outcomes is scrutinized and the balance of values underlying the policy decision to eliminate nonmedical exemptions is clearly articulated. We identify 3 outcomes that require particular consideration before policies to eliminate nonmedical exemptions are implemented widely and outline a process for making the values underlying such policies more explicit.
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Affiliation(s)
- Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Jason L Schwartz
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Saad B Omer
- Departments of Epidemiology and Global Health, Emory University School of Public Health, Atlanta, Georgia.,Emory Vaccine Center, Atlanta, Georgia
| | - Ross Silverman
- Department of Health Policy and Management, Indiana University Fairbanks School of Public Health, Indianapolis.,Indiana University McKinney School of Law, Indianapolis
| | - Jeff Duchin
- Public Health-Seattle and King County, Seattle, Washington.,Department of Epidemiology, University of Washington School of Public Health, Seattle.,Department of Medicine, University of Washington School of Medicine, Seattle
| | - Eric Kodish
- Pediatric Institute and Department of Bioethics, Cleveland Clinic, Cleveland, Ohio
| | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Edgar K Marcuse
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Walt Orenstein
- Emory Vaccine Center, Atlanta, Georgia.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Abstract
Decisions about continuing or terminating a pregnancy touch on profound, individualized questions about bodily integrity, reproductive autonomy, deeply held values regarding one's capacity for parenthood, and, in the case of a high-risk pregnancy, the risks one is willing to take to have a baby. So far as possible, reproductive decisions are made between a patient, in some cases her partner, and her medical provider. However, this standard framework cannot be applied if the patient lacks decision-making capacity. In this essay, we discuss one such case that came before our clinical ethics team. We describe the challenges of respecting a patient's reproductive preferences when the patient cannot share what those preferences are, and we argue that decisions regarding reproductive health care should not be treated with exceptionalism. Rather, they should proceed under the normal processes of surrogate decision-making, including the application of substituted judgment. This approach enables us to take the patient's values into account when considering the questions implicated in reproductive health care, just as we do for other kinds of health care decisions in which a patient's deeply held values are salient.
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Sisk BA, DuBois J, Kodish E, Wolfe J, Feudtner C. Navigating Decisional Discord: The Pediatrician's Role When Child and Parents Disagree. Pediatrics 2017; 139:peds.2017-0234. [PMID: 28562285 PMCID: PMC5470498 DOI: 10.1542/peds.2017-0234] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2017] [Indexed: 11/24/2022] Open
Abstract
From the time when children enter the preteen years onward, pediatric medical decision-making can entail a complex interaction between child, parents, and pediatrician. When the child and parents disagree regarding medical decisions, the pediatrician has the challenging task of guiding the family to a final decision. Unresolved discord can affect family cohesiveness, patient adherence, and patient self-management. In this article, we outline 3 models for the pediatrician's role in the setting of decisional discord: deference, advocative, and arbitrative. In the deference model, the pediatrician prioritizes parental decision-making authority. In the advocative model, the pediatrician advocates for the child's preference in decision-making so long as the child's decision is medically reasonable. In the arbitrative model, the pediatrician works to resolve the conflict in a balanced fashion. Although each model has advantages and disadvantages, the arbitrative model should serve as the initial model in nearly all settings. The arbitrative model is likely to reach the most beneficial decision in a manner that maintains family cohesiveness by respecting the authority of parents and the developing autonomy of children. We also highlight, however, occasions when the deference or advocative models may be more appropriate. Physicians should keep all 3 models available in their professional toolkit and develop the wisdom to deploy the right model for each particular clinical situation.
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Affiliation(s)
- Bryan A. Sisk
- Department of Pediatrics, St Louis Children’s Hospital, St Louis, Missouri
| | - James DuBois
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Eric Kodish
- Pediatrics Institute and Department of Bioethics, Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts; and
| | - Chris Feudtner
- Department of Medical Ethics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Statler A, Radivoyevitch T, Siebenaller C, Gerds AT, Kalaycio M, Kodish E, Mukherjee S, Cheng C, Sekeres MA. The relationship between eligibility criteria and adverse events in randomized controlled trials of hematologic malignancies. Leukemia 2016; 31:1808-1815. [DOI: 10.1038/leu.2016.374] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/20/2016] [Accepted: 11/02/2016] [Indexed: 12/21/2022]
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Abstract
In this paper, we examine the limits of informed consent with particular focus on ways in which various factors can overwhelm decision-making capacity. We introduce overwhelm as a phenomenon commonly experienced by patients in clinical settings and distinguish between emotional overwhelm and informational overload. We argue that in these situations, a clinician's primary duty is prevention of harm and suggest ways in which clinicians can discharge this obligation. To illustrate our argument, we consider the clinical application of genetic sequencing testing, which involves scientific and technical information that can compromise the understanding and decisional capacity of most patients. Finally, we consider and rebut objections that this could lead to paternalism.
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Affiliation(s)
- Johan Bester
- Member of the professional staff of the Department of Bioethics at the Cleveland Clinic in Cleveland, Ohio
| | - Cristie M Cole
- Professional staff as a regional bioethicist in the Department of Bioethics at the Cleveland Clinic in Cleveland, Ohio, and the acting ethics liaison for Cleveland Clinic's Genomic Medicine Institute
| | - Eric Kodish
- Inaugural director of Cleveland Clinic's Center for Ethics, Humanities and Spiritual Care in Cleveland, Ohio, where he also serves as the F. J. O'Neill Professor and chairman of the Department of Bioethics, and the executive director of the Cleveland Fellowship in Advanced Bioethics and a professor of pediatrics at the Lerner College of Medicine of Case Western Reserve University
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Hazen R, Greenley RN, Drotar D, Kodish E. Recommending Randomized Trials for Pediatric Leukemia: Observer and Physician Report of Recommendations. J Empir Res Hum Res Ethics 2016; 2:49-56. [DOI: 10.1525/jer.2007.2.2.49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Physicians' presentation of treatment options in a non-coercive manner is critical for informed consent for participation in randomized clinical trials (RCTs). This study examined discrepancies between observer and physician report of treatment recommendations for pediatric leukemia RCTs. This study also assessed relationships between recommendations and decisions to participate in RCTs. Participants were 104 parents of children with leukemia and the treating physicians. Measures included observations of informed consent conferences (ICCs), physician report of treatment recommendations, and parent report of trial participation. Observation revealed that physicians recommended RCTs in 38% of ICCs, while physicians reported recommending RCTs in 73% of ICCs. Treatment recommendations were unrelated to decisions to participate in RCTs. Results highlight the importance of enhancing parent-physician communication regarding RCT participation.
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Affiliation(s)
| | | | | | - Eric Kodish
- Cleveland Clinic Department of Bioethics (USA)
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Abstract
This secondary qualitative analysis of extant focus group data was performed to develop an understanding of suboptimal adherence to 6-mercaptopurine therapy in adolescents with acute lymphoblastic leukemia. Six participants, aged 16 to 23 years at the time of data collection, were interviewed about their adherence to oral maintenance chemotherapy during their treatment for acute lymphoblastic leukemia. The primary aim of the study was to understand the role of adolescent development in adolescents' perception of adherence to therapy. The secondary aim was to understand how factors other than development, including the features of the disease such as its chronic nature and family involvement, can affect treatment adherence to 6-mercaptopurine. Four broad themes emerged as critical elements in adolescent adherence to oral maintenance therapy: a desire for normalcy, egocentrism, concrete thinking, and parental involvement. Incorporation of these themes into clinical practice with adolescents may help increase adherence and improve clinical outcomes.
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Affiliation(s)
- Tara Malbasa
- Department of Pediatric Hematology/Oncology at Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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Abstract
Transparency has become an ethical cornerstone of American medicine. Today, patients have the right to know their health information, and physicians are obliged to provide it. It is expected that patients will be informed of their medical condition regardless of the severity or prognosis. This ethos of transparency is ingrained in modern trainees from the first day of medical school onward. However, for most of American history, the intentional withholding of information was the accepted norm in medical practice. It was not until 1979 that a majority of physicians reported disclosing cancer diagnoses to their patients. To appreciate the current state of the physician-patient relationship, it is important to understand how physician-patient communication has developed over time and the forces that led to these changes. In this article, we trace the ethics and associated practices of truth-telling during the past two centuries, and outline the many pressures that influenced physician behavior during that time period. We conclude that the history of disclosure is not yet finished, as physicians still struggle to find the best way to share difficult information without causing undue harm to their patients.
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Affiliation(s)
- Bryan Sisk
- Pediatrics Resident at the St Louis Children's Hospital in MO.
| | - Richard Frankel
- Professor of Medicine and Geriatrics at the Indiana University School of Medicine Education Institute in Indianapolis.
| | - Eric Kodish
- Director of the Center for Ethics, Humanities and Spiritual Care at the Cleveland Clinic in OH.
| | - J Harry Isaacson
- Director of Clinical Education at the Cleveland Clinic Lerner College of Medicine and an Internist in the Department of General Internal Medicine at the Cleveland Clinic in OH.
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Opel DJ, Kronman MP, Diekema DS, Marcuse EK, Duchin JS, Kodish E. Childhood Vaccine Exemption Policy: The Case for a Less Restrictive Alternative. Pediatrics 2016; 137:peds.2015-4230. [PMID: 26993127 PMCID: PMC4811320 DOI: 10.1542/peds.2015-4230] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2016] [Indexed: 11/24/2022] Open
Affiliation(s)
- Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, and Departments of Pediatrics and
| | | | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, and Departments of Pediatrics and Departments of Health Services and
| | | | - Jeffrey S Duchin
- Medicine, University of Washington School of Medicine, Seattle, Washington; Epidemiology, University of Washington School of Public Health, Seattle, Washington; Communicable Disease Epidemiology and Immunization Section, Public Health-Seattle and King County, Seattle, Washington; and
| | - Eric Kodish
- Department of Bioethics, Center for Ethics, Humanities and Spiritual Care, Cleveland Clinic, Cleveland, Ohio
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Smith ML, Kodish E. The ethics of ICDs: History and future directions. Cleve Clin J Med 2016; 83:99-100. [DOI: 10.3949/ccjm.83a.15122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Fins JJ, Kodish E, Cohn F, Danis M, Derse AR, Dubler NN, Goulden B, Kuczewski M, Mercer MB, Pearlman RA, Smith ML, Tarzian A, Youngner SJ. A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants. Am J Bioeth 2016; 16:15-24. [PMID: 26913652 DOI: 10.1080/15265161.2015.1134705] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step on the pathway to an eventual certification process for clinical ethics consultants.
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Affiliation(s)
- Joseph J Fins
- a New York Presbyterian Hospital-Weill Cornell Center
| | | | - Felicia Cohn
- c Kaiser Permanente Orange County and American Society for Bioethics and Humanities
| | | | | | | | | | | | | | - Robert A Pearlman
- h National Center for Ethics in Health Care, Department of Veterans Affairs
| | | | - Anita Tarzian
- i University of Maryland School of Nursing and School of Law
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Dekking SAS, van der Graaf R, de Vries MC, Bierings MB, van Delden JJM, Kodish E, Lantos JD. Is a New Protocol for Acute Lymphoblastic Leukemia Research or Standard Therapy? Pediatrics 2015; 136:566-70. [PMID: 26283776 PMCID: PMC4893943 DOI: 10.1542/peds.2014-2327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 11/24/2022] Open
Abstract
In the United States, doctors generally develop new cancer chemotherapy for children by testing innovative chemotherapy protocols against existing protocols in prospective randomized trials. In the Netherlands, children with leukemia are treated by protocols that are agreed upon by the Dutch Childhood Oncology Group. Periodically, the Dutch Childhood Oncology Group revises its protocols. Sometimes, these revisions are categorized as research, sometimes as treatment. In this Ethics Rounds, we analyze whether enrollment in a new protocol ought to be considered research and, if so, we discuss the implications of that designation. Our discussion highlights the different ways different countries approach complex issues of research ethics.
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Affiliation(s)
- Sara A. S. Dekking
- Julius Center for Health Sciences and Primary Care, Department of Medical Humanities and
| | - Rieke van der Graaf
- Julius Center for Health Sciences and Primary Care, Department of Medical Humanities and
| | - Martine C. de Vries
- Leiden University Medical Center, Department of Pediatrics, Leiden, Netherlands
| | - Marc B. Bierings
- Wilhelmina Children’s Hospital, Department of Pediatric Hematology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Eric Kodish
- Center for Ethics, Humanities and Spiritual Care, Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio; and
| | - John D. Lantos
- Children’s Mercy Hospital, Kansas City, Missouri,Address correspondence to John D. Lantos, MD, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108. E-mail:
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Rose SL, Sanghani RM, Schmidt C, Karafa MT, Kodish E, Chisolm GM. Gender Differences in Physicians' Financial Ties to Industry: A Study of National Disclosure Data. PLoS One 2015; 10:e0129197. [PMID: 26067810 PMCID: PMC4466034 DOI: 10.1371/journal.pone.0129197] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 05/07/2015] [Indexed: 11/18/2022] Open
Abstract
Background Academic literature extensively documents gender disparities in the medical profession with regard to salary, promotion, and government funded research. However, gender differences in the value of financial ties to industry have not been adequately studied despite industry’s increasing contribution to income and research funding to physicians in the U.S. Methods & Findings We analyzed publicly reported financial relationships among 747,603 physicians and 432 pharmaceutical, device and biomaterials companies. Demographic and payment information were analyzed using hierarchical regression models to determine if statistically significant gender differences exist in physician-industry interactions regarding financial ties, controlling for key covariates. In 2011, 432 biomedical companies made an excess of $17,991,000 in payments to 220,908 physicians. Of these physicians, 75.1% were male. Female physicians, on average, received fewer total dollars (-$3,598.63, p<0.001) per person than men. Additionally, female physicians received significantly lower amounts for meals (-$41.80, p<0.001), education (-$1,893.14, p<0.001), speaker fees (-$2,898.44, p<0.001), and sponsored research (-$15,049.62, p=0.05). For total dollars, an interaction between gender and institutional reputation was statistically significant, implying that the differences between women and men differed based on industry’s preference for an institution, with larger differences at higher reputation institutions. Conclusions Female physicians receive significantly lower compensation for similarly described activities than their male counterparts after controlling for key covariates. As regulations lead to increased transparency regarding these relationships, efforts to standardize compensation should be considered to promote equitable opportunities for all physicians.
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Affiliation(s)
- Susannah L. Rose
- Department of Bioethics, Cleveland Clinic, Cleveland, Ohio, United States of America
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, United States of America
- * E-mail:
| | - Ruchi M. Sanghani
- Department of Bioethics, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Cory Schmidt
- Innovation Management and Conflict of Interest Program, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Matthew T. Karafa
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Eric Kodish
- Department of Bioethics, Cleveland Clinic, Cleveland, Ohio, United States of America
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Guy M. Chisolm
- Innovation Management and Conflict of Interest Program, Cleveland Clinic, Cleveland, Ohio, United States of America
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Affiliation(s)
- Martin Kohn
- Director of the Cleveland Clinic's Program in Medical Humanities within the Center for Ethics, Humanities and Spiritual Care and an associate professor in the Lerner College of Medicine at Case Western Reserve University in Cleveland, Ohio
| | - Eric Kodish
- Director of the Center for Ethics, Humanities and Spiritual Care at the Cleveland Clinic in Cleveland, Ohio, where he is also the F. J. O'Neill Professor and chairman of the Department of Bioethics and executive director of the Cleveland Fellowship in Advanced Bioethics
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Thomas SM, Ford PJ, Weise KL, Worley S, Kodish E. Not just little adults: a review of 102 paediatric ethics consultations. Acta Paediatr 2015; 104:529-34. [PMID: 25611088 DOI: 10.1111/apa.12940] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 12/30/2014] [Accepted: 01/19/2015] [Indexed: 11/27/2022]
Abstract
AIM The American Academy of Pediatrics statement on institutional ethics committees highlights the importance of paediatric ethics consultation. However, little has been published on actual experience with ethics consultation in paediatrics. The objective of this study was to review and describe topics covered by a large retrospective sample of clinical ethics consultations in paediatric medicine. METHODS We reviewed ethics consultations involving patients of <18 years of age from January 2005 to July 2013 at one institution. Descriptive statistics of the patient population, the reason for the ethics consultation and the consultant's perceived contribution to the case were generated. Subgroups of patients were compared based on demographic and clinical characteristics using Wilcoxon's rank sum tests, chi-square tests and logistic regression models. RESULTS Most of the 102 eligible consultations originated from intensive care units and were requested by attending physicians. The most frequent topic leading to consultation was end-of-life issues. Both younger age and male sex were associated with consults for end-of-life issues (p < 0.001 and p = 0.010). CONCLUSION This analysis provides important information describing the type of consults requested in paediatric medicine, which is necessary given the movement towards professionalising clinical ethics consultation. Further empirical research is needed on ethics consultation in paediatrics.
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Affiliation(s)
- Stefanie M. Thomas
- Department of Pediatric Hematology/Oncology and Blood and Marrow Transplantation; Cleveland Clinic Children's; Cleveland OH USA
| | - Paul J. Ford
- Center for Ethics, Humanities and Spiritual Care; Cleveland Clinic Foundation; Cleveland OH USA
| | - Kathryn L. Weise
- Center for Ethics, Humanities and Spiritual Care; Cleveland Clinic Foundation; Cleveland OH USA
| | - Sarah Worley
- Department of Quantitative Health Sciences; Cleveland Clinic Foundation; Cleveland OH USA
| | - Eric Kodish
- Center for Ethics, Humanities and Spiritual Care; Cleveland Clinic Foundation; Cleveland OH USA
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Hazen RA, Zyzanski S, Baker JN, Drotar D, Kodish E. Communication about the risks and benefits of phase I pediatric oncology trials. Contemp Clin Trials 2015; 41:139-45. [PMID: 25638751 PMCID: PMC4404031 DOI: 10.1016/j.cct.2015.01.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 11/16/2022]
Abstract
Introduction Phase 1 pediatric oncology trials offer only a small chance of direct benefit and may have significant risks and an impact on quality of life. To date, research has not examined discussions of risks and benefits during informed consent conferences for phase 1 pediatric oncology trials. The objective of the current study was to examine clinician and family communication about risks, benefits, and quality of life during informed consent conferences for phase 1 pediatric oncology trials. Methods Participants included clinician investigators, parents, and children recruited from 6 sites conducting phase 1 pediatric oncology trials. Eighty-five informed consent conferences were observed and audiotaped. Trained coders assessed discussions of risks, benefits, and quality of life. Types of risks discussed were coded (e.g., unanticipated risks, digestive system risks, death). Types of benefits were categorized as therapeutic (e.g. discussion of how participation may or may not directly benefit child), psychological, bridge to future trial, and altruism. Results Risks and benefits were discussed in 95% and 88% of informed consent conferences, respectively. Therapeutic benefit was the most frequently discussed benefit. The impact of trial participation on quality of life was discussed in the majority (88%) of informed consent conferences. Conclusion Therapeutic benefit, risks, and quality of life were frequently discussed. The range of information discussed during informed consent conferences suggests the need for considering a staged process of informed consent for phase 1 pediatric oncology trials.
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Affiliation(s)
- Rebecca A Hazen
- Department of Pediatrics, Case Western Reserve University and Rainbow Babies and Children's Hospital, 10524 Euclid Ave, Cleveland, OH 44106, USA.
| | - Stephen Zyzanski
- Department of Family Medicine, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106, USA.
| | - Justin N Baker
- St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678, USA.
| | - Dennis Drotar
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH 45229-3026, USA.
| | - Eric Kodish
- Center for Ethics, Humanities, and Spiritual Care, Cleveland Clinic, 9500 Euclid Ave JJ60, Cleveland, OH 44195, USA.
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Flamm AL, Kodish E. Empirical Bioethics Research Is a Winner, But Bioethics Mission Creep Is a False Alarm. The Journal of Clinical Ethics 2014. [DOI: 10.1086/jce201425302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Koyfman SA, Reddy CA, Hizlan S, Leek AC, Kodish E. Text, talk, and informed consent: A component analysis. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.e20558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Flamm AL, Kodish E. Empirical bioethics research is a winner, but bioethics mission creep is a false alarm. J Clin Ethics 2014; 25:189-193. [PMID: 25192342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
While we do not share Evans's view that social science research is needed to shield bioethics from competitive threat, we incorporate and engage in social science research to inform our knowledge base, our clinical practice, and our contributions to the ongoing development of the field.
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Affiliation(s)
| | - Eric Kodish
- Cleveland Clinic, JJ607, 9500 Euclid Avenue, Cleveland, Ohio 44195 USA
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Kodish E, Fins JJ, Braddock C, Cohn F, Dubler NN, Danis M, Derse AR, Pearlman RA, Smith M, Tarzian A, Youngner S, Kuczewski MG. Quality attestation for clinical ethics consultants: a two-step model from the American Society for Bioethics and Humanities. Hastings Cent Rep 2013; 43:26-36. [PMID: 24092588 DOI: 10.1002/hast.198] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Eric Kodish
- Center for Ethics, Humanities, and Spiritual Care, Department of Bioethics, Lerner College of Medicine, and Cleveland Clinic
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, and American Society for Bioethics and Humanities
| | - Clarence Braddock
- Center for Medical Education Research and Innovation, Center for Medical Ethics, and Division of General Internal Medicine, Department of Medicine, Stanford School of Medicine
| | - Felicia Cohn
- Kaiser Permanente Orange County and American Society for Bioethics and Humanities
| | - Nancy Neveloff Dubler
- The Albert Einstein College of Medicine, New York City Health and Hospitals Corporation, and NYU Langone Medical Center
| | - Marion Danis
- Section on Ethics and Health Policy, Department of Bioethics, NIH Clinical Center, National Institutes of Health
| | - Arthur R Derse
- Center for Bioethics and Medical Humanities, Institute for Health and Society, Medical College of Wisconsin
| | - Robert A Pearlman
- National Center for Ethics in Health Care, United States Department of Veteran Affairs, and University of Washington
| | - Martin Smith
- Center for Ethics, Humanities and Spiritual Care, Department of Bioethics, Cleveland Clinic
| | - Anita Tarzian
- Family and Community Health, University of Maryland School of Nursing, and Maryland Health Care Ethics Committee Network, University of Maryland School of Law
| | | | - Mark G Kuczewski
- Neiswanger Institute for Bioethics and Health Policy, Health Sciences Division, Loyola University Chicago, and American Society for Bioethics and Humanities
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Koyfman SA, Agre P, Carlisle R, Classen L, Cheatham C, Finley JP, Kuhrik N, Kuhrik M, Mangskau TK, O'Neill J, Reddy CP, Kodish E, McCabe MS. Consent form heterogeneity in cancer trials: the cooperative group and institutional review board gap. J Natl Cancer Inst 2013; 105:947-53. [PMID: 23821757 DOI: 10.1093/jnci/djt143] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cooperative group (CG) provided consent forms (CGP-CFs) undergo re-review and revision by local institutional review boards (IRB) before institutional approval. We compared the relative readability and length of IRB-approved consent forms (IRB-CFs) used at seven academic institutions with their corresponding CGP-CFs. We also assessed the variability of these metrics across our institutions. METHODS This study included 197 consent forms (CFs) from 56 CG trials that were open in at least two of the participating institutions. The Flesch Reading Ease Score (FRES), the Flesch-Kincaid Grade Level (FKGL), and document length were collected on all CFs. Unpaired t test was used to compare length and readability of CGP-CF with the IRB-CF. Analysis of variance and Bonferroni-Dunn tests were used to assess interinstitutional variability in readability for all IRB-CFs. All statistical tests were two-sided. RESULTS IRB-CFs were statistically significantly longer than CGP-CFs (mean number of pages = 17 vs 13; P < .001). Mean FKGLs were higher (10.3 vs 9.4; P < .0001) and the mean FRESs were lower (53.1 vs 57.1; P < .0001) for IRB-CFs compared with CGP-CFs. Readability varied statistically significantly between institutions for all sections of the IRB-CF (P < .0001). Finalized IRB-CFs for identical clinical trials at different institutions demonstrated substantial heterogeneity of readability and length. CONCLUSIONS As CFs progress from National Cancer Institute (NCI)-sponsored CGs to local IRBs, they seem to become longer and less readable. Interinstitutional heterogeneity in CF readability is substantial and widespread. More consistent adherence to CGP-CFs based on the newly revised NCI CF template with minimal modification by local IRBs should help simplify and standardize CFs used in cancer clinical trials.
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Affiliation(s)
- Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, USA.
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Affiliation(s)
- Cristie M Cole
- Fellow in the Cleveland Fellowship in Advanced Bioethics, a multi-institutional program administered by the Cleveland Clinic
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Wilfond BS, Magnus D, Antommaria AH, Appelbaum P, Aschner J, Barrington KJ, Beauchamp T, Boss RD, Burke W, Caplan AL, Capron AM, Cho M, Clayton EW, Cole FS, Darlow BA, Diekema D, Faden RR, Feudtner C, Fins JJ, Fost NC, Frader J, Hester DM, Janvier A, Joffe S, Kahn J, Kass NE, Kodish E, Lantos JD, McCullough L, McKinney R, Meadow W, O'Rourke PP, Powderly KE, Pursley DM, Ross LF, Sayeed S, Sharp RR, Sugarman J, Tarnow-Mordi WO, Taylor H, Tomlinson T, Truog RD, Unguru YT, Weise KL, Woodrum D, Youngner S. The OHRP and SUPPORT. N Engl J Med 2013; 368:e36. [PMID: 23738513 DOI: 10.1056/nejmc1307008] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
One of the most pressing ethical challenges facing phase I cancer research centres is the process of informed consent. Historically, most scholarship has been devoted to redressing therapeutic misconception, that is, the conflation of the nature and goals of research with those of therapy. While therapeutic misconception continues to be a major ethical concern, recent scholarship has begun to recognise that the informed consent process is more complex than merely a transfer of information and therefore cannot be evaluated only according to how well an individual understands such information. Other components of decision-making operate independently of understanding and yet still may compromise the quality of informed consent. Notable among these components is unrealistic optimism, an event-specific belief that one has a better chance of receiving benefit than others similarly situated. In this article, we consider responses to interviews with parents who had recently completed an informed consent conference for enrolling their child in a phase I cancer clinical trial to examine how this influence manifests and how investigators might address it during informed consent.
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Affiliation(s)
- Joshua Crites
- Center for Ethics, Humanities, and Spiritual Care, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
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Miller VA, Baker JN, Leek AC, Hizlan S, Rheingold SR, Yamokoski AD, Drotar D, Kodish E. Adolescent perspectives on phase I cancer research. Pediatr Blood Cancer 2013; 60:873-8. [PMID: 23034985 PMCID: PMC3538102 DOI: 10.1002/pbc.24326] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 08/21/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to examine adolescent patients' perspectives on their understanding and decision making about a pediatric phase I cancer study. PROCEDURE Participants included adolescents ages 14-21 years with cancer (N = 20), all of whom attended a phase I study consent conference. Participants responded to closed- and open-ended questions on a verbally administered structured interview, which assessed aspects of understanding and decision making about the phase I study. RESULTS All participants decided to enroll in the phase I study. The majority of participants understood that participation was voluntary, entailed risks, and that they could withdraw. Most also believed that participation in the phase I study would increase the length of their lives. The most frequent reasons for enrolling were positive clinical benefit, needing an option, impact on quality of life, and few side effects or fewer than those of current or past treatments. Eighty-five percent of participants reported that they themselves made the final decision about enrollment in the phase I study. CONCLUSIONS Most participants hoped or expected that the phase I study would provide a direct benefit (increased survival time or cure) and reported that they themselves were the final decision-maker about enrollment. Clinicians may underestimate the role of adolescents, especially if they believe that parents typically make such decisions. Future research should assess the actual participation of children and adolescents during the informed consent process and explore the role of hope in their decision making about phase I studies.
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Affiliation(s)
- Victoria A. Miller
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN
| | - Angela C. Leek
- Department of Bioethics, Cleveland Clinic, Cleveland, OH
| | - Sabahat Hizlan
- Department of Bioethics, Cleveland Clinic, Cleveland, OH
| | - Susan R. Rheingold
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Dennis Drotar
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Eric Kodish
- Center for Ethics, Humanities and Spiritual Care, Cleveland Clinic, Cleveland, OH
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