A waiver of consent for intensive care research?

Exceptions to the rule of informed consent for research with an intervention

BACKGROUND

In specific situations it may be necessary to make an exception to the general rule of informed consent for scientific research with an intervention. Earlier reviews only described subsets of arguments for exceptions to waive consent.

METHODS

Here, we provide a more extensive literature review of possible exceptions to the rule of informed consent and the accompanying arguments based on literature from 1997 onwards, using both Pubmed and PsycINFO in our search strategy.

RESULTS

We identified three main categories of arguments for the acceptability of a consent waiver: data validity and quality, major practical problems, and distress or confusion of participants. Approval by a medical ethical review board always needs to be obtained. Further, we provide examples of specific conditions under which consent waiving might be allowed, such as additional privacy protection measures.

CONCLUSIONS

The reasons legitimized by the authors of the papers in this overview can be used by researchers to form their own opinion about requesting an exception to the rule of informed consent for their own study. Importantly, rules and guidelines applicable in their country, institute and research field should be followed. Moreover, researchers should also take the conditions under which they feel an exception is legitimized under consideration. After discussions with relevant stakeholders, a formal request should be sent to an IRB.

Protecting participants of clinical trials conducted in the intensive care unit

Research in the intensive care unit (ICU) raises a number of scientific and ethical challenges. Potential participants in critical care studies are likely to be considered particularly vulnerable-they may lack sufficient capacity to make informed decisions about trial participation, their health care proxies may lack legal authority to enroll them in research trials or may not know their true intent, and the life-threatening nature of the illness may make them or their surrogates more susceptible to therapeutic misconception. Because of this, critical care investigators must exercise extreme caution when designing and conducting studies in the ICU. In this article, we review the key literature addressing the various scientific and ethical issues raised by critical care research, including questions of equipoise and the selection of control groups, informed consent, therapeutic misconception, conflict of interest, and quality improvement projects. We also describe the current status of key policy or regulatory initiatives designed to address these issues, particularly in light of recent controversies involving critical care studies like the ARDSNet trial.

International resuscitation research, exception from informed consent, and the European Union Directive 2001/20/EC

BACKGROUND

United States regulations allow a narrow exception from informed consent for a subset of resuscitation research. Such an exception is also allowed under the Declaration of Helsinki. In 2001, a European Union (EU) Directive was passed, which, if enforced literally, could prohibit resuscitation research. The purpose of this study is to assess the knowledge and attitudes of healthcare workers, specifically emergency physicians, with regard to the EU Directive as it applies to resuscitation research and informed consent.

METHODS

A closed-response survey was distributed in six languages at the Third Mediterranean Emergency Medicine Congress in Nice, France, and to a sample of emergency physicians using a directed approach. Descriptive and bivariate statistics, with a weighting adjustment to account for a disproportionately large number of responses from one country, are reported.

RESULTS

Two hundred and thirty-two surveys (111 using a weighted analysis) were returned from 26 countries. Sixty-seven percent of EU respondents and 70% of non-EU respondents stated that their country adhered to the Declaration of Helsinki, but only 44% of EU and 43% of non-EU respondents, were aware the Declaration allowed a waiver for resuscitation research. Among EU respondents, 49% were unaware of the EU Directive and another 15%, although aware of the Directive, were unaware of its implications for resuscitation research.

CONCLUSION

The international regulatory status of consent in resuscitation research is in flux; yet, most emergency physicians are unaware of the potential implications of the EU Directive or the provisions in the Declaration of Helsinki allowing an exemption from informed consent for resuscitation research.

Clinical research 4: qualitative data collection and analysis

This six-part research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasise the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

Clinical research 2: Legal and ethical issues in research

This research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

Informed consent in clinical trials in critical care: experience from the PAC-Man Study

OBJECTIVES

To identify the proportion of critically ill patients able to consent to participation in a randomised controlled trial (RCT) and to assess to what extent patient consent and relative assent processes could be conducted according to ethics committee permission.

DESIGN

Descriptive study nested in an RCT.

SETTING

Fifty-six UK intensive care units participating in the PAC-Man trial.

PATIENTS AND PARTICIPANTS

First 500 patients consecutively enrolled into PAC-Man.

MEASUREMENT AND RESULTS

The outcome measures were patient consent and/or relative assent. Of the 498 patients included, 13 (2.6%) provided consent before randomisation. Of the remaining 485 patients, relative assent was obtained for 394 patients (81.2%), and refused post-randomisation for 3 patients (0.6%). No relatives were available for 15 patients (3.1%), and it was unclear from documentation whether relative assent had been obtained for 73 patients (15.1%). Of the 482 patients who did not provide consent prior to randomisation, 188 (39%) survived. Of these, 175 (93.1%) gave retrospective informed consent, six (3.2%) refused, and seven (3.7%) did not regain mental competency.

CONCLUSIONS

A very small proportion of patients were able to give consent before randomisation. Due to the high in-hospital mortality (60.6%), only around one third of the remaining patients could provide consent retrospectively. This study demonstrates difficulties experienced in obtaining consent from critically ill patients to participate in medical research and raises important issues about the ethical basis of the consent process in critical care.

Informed consent for research in ICU obtained before ICU admission

OBJECTIVE

To analyze the procedure of the informed consent for ICU research obtained before ICU admission.

DESIGN

Prospective, open, observational study.

SETTING

20-bed surgical ICU of a tertiary teaching university hospital and the ward before and after ICU.

PATIENTS

Patients, scheduled for elective cardiac surgery, who accepted to participate in a coagulation study.

INTERVENTIONS

Patients underwent the same informed consent procedure, including an oral presentation of the coagulation study and an informative leaflet the day before surgery on the ward.

MEASUREMENTS AND RESULTS

Between January and August 2001, we included 38 patients; 36 survived ICU. Ten to 12 days after surgery, 8/36 (22%) patients did not know they had participated in a study, and 9/36 (25%) could not recall the study purpose and the related risk. Patients with incomplete recall stayed longer in ICU [median (range): 4 (3-6) vs 3 (1-5) days; p = 0.004]. None of these patients (0/9 vs 10/27; p < 0.04) had read the informative leaflet AND asked at least one question during the informed consent procedure.

CONCLUSIONS

Even when the informed consent is obtained in the most optimal conditions for ICU research, its ethical value remains questionable. Indeed, a substantial number of patients were unaware of their study participation, or of the related purpose and risks. When the ICU stay is prolonged, we should at least repeatedly and actively (re)-inform patients about their study participation.

Informed consent of incapable (ICU) patients in Europe: existing laws and the EU Directive

PURPOSE OF THE REVIEW

The new European legislation on good clinical practice in the conduct of clinical trials on drugs has raised serious concern that potentially lifesaving studies cannot be carried out in critically ill patients in Europe anymore after May 2004. The requirement of nominating a legal representative for obtaining informed consent before inclusion will deprive current and future patients of participation in research. The new legislation does not differentiate between patients who are incompetent because of a psychiatric illness or dementia and patients who are incapacitated owing to an emergency situation. All those patients may be enrolled in a clinical trial only after informed consent has been granted by a legal representative.

RELEVANT FINDINGS

Recent publications regarding the new European legislation manifest an outcry by intensive care specialists, emergency medicine specialists, traumatologists, and specialists of other related disciplines concerned about the proposed active withholding of potentially beneficial therapies for this very unfortunate group of patients. Many authors, although acknowledging the ethical principle of autonomy, express that in the field of emergency medicine not all criteria of autonomy may be met. The Declaration of Helsinki requires that even the best prophylactic, diagnostic, and therapeutic methods must continuously be challenged through research. There is agreement among the authors that critically ill patients should not be deprived from the benefits of research.

SUMMARY

Many groundbreaking therapies will not be scientifically evaluated anymore, and thus beneficial treatments in fatal diseases will be prevented. The European legislation is asked to adapt the Directive to promote research in critically ill patients.

Clinical research 4: qualitative data collection and analysis

This six-part research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process. A couple of points: 1. It is artificial to describe research as qualitative or quantitative. Studies often include both dimensions (for example, Evangelista LS, Doering L, Dracup K. Meaning and life purpose: the perspectives of post-transplant women. Heart Lung 2003;32(4):250-7; Fitzsimmons D, Parahoo K, Richardson SG, Stringer M. Patient anxiety while on a waiting list for coronary artery bypass surgery: a qualitative and quantitative analysis. Heart Lung 2003;32(1):23-31). However, for the purposes of this paper/series, this distinction is drawn for clarity of writing. 2. It is common practice for quantitative studies to refer to study 'subjects' and qualitative studies to refer to study 'participants'. For ease of reading, the latter term will be used throughout this series.