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Schuster L, Essig F, Daneshkhah N, Herm J, Hellwig S, Endres M, Dirnagl U, Hoffmann F, Michalski D, Pfeilschifter W, Urbanek C, Petzold GC, Rizos T, Kraft A, Haeusler KG. Ability of patients with acute ischemic stroke to recall given information on intravenous thrombolysis: Results of a prospective multicenter study. Eur Stroke J 2023; 8:241-250. [PMID: 37021170 PMCID: PMC10069168 DOI: 10.1177/23969873221143856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/20/2022] [Indexed: 01/09/2023] Open
Abstract
Introduction: Intravenous thrombolysis (IVT) is an on label treatment for selected patients with acute ischemic stroke (AIS). As major bleeding or allergic shock may occur, the need to ensure patients’ informed consent for IVT is a matter of debate. Patients and methods: Prospective investigator-initiated multi-center observational study to assess the ability of AIS patients to recall information, provided by a physician during a standardized educational talk (SET) on IVT use. The recall of 20 pre-defined items was assessed in AIS after 60–90 min ( n = 93) or 23–25 h ( n = 40) after SET. About 40 patients with subacute stroke, 40 non-stroke patients, and 23 relatives of AIS patients served as controls, and were surveyed 60–90 min after SET. Results: Within 60–90 min after SET, AIS patients (median age 70 years, 31% female, median NIHSS score on admission 3 points) who were considered capable to provide informed consent recalled 55% (IQR 40%–66.7%) of the provided SET items. In multivariable linear regression analysis recapitulation by AIS patients was associated with their educational level (β = 6.497, p < 0.001), self-reported excitement level (β = 1.879, p = 0.011) and NIHSS score on admission (β = −1.186, p = 0.001). Patients with subacute stroke (70 years, 40% female, median NIHSS = 2) recalled 70% (IQR 55.7%–83.6%), non-stroke patients (75 years, 40% female) 70% (IQR 60%–78.7%), and AIS relatives (58 years, 83% female) 70% (IQR 60%–85%). Compared to subacute stroke patients, AIS patients less often recalled the frequency of IVT-related bleeding (21% vs 43%), allergic shock (15% vs 39%), and bleeding-related morbidity and mortality (44% vs 78%). AIS patients recalled 50% (IQR 42.3%–67.5%) of the provided items 23–25 h after SET. Conclusion: AIS patients eligible for IVT remember about half of all SET-items after 60–90 min or 23–25 h, respectively. The fact that the recapitulation of IVT-associated risks is particularly poor should be given special consideration.
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Affiliation(s)
- Luzie Schuster
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Fabian Essig
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Naeimeh Daneshkhah
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Juliane Herm
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Germany
| | - Simon Hellwig
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany
| | - Ulrich Dirnagl
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- QUEST Center, Berlin Institute of Health (BIH), Berlin, Germany
| | - Frank Hoffmann
- Department of Neurology, Martha-Maria Hospital, Halle/Saale, Germany
| | | | - Waltraud Pfeilschifter
- Department of Neurology, University of Frankfurt, Frankfurt/Main, Germany
- Department of Neurology, Hospital Lüneburg, Lüneburg, Germany
| | - Christian Urbanek
- Department of Neurology, Hospital Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University of Bonn, Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Timolaos Rizos
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Andrea Kraft
- Department of Neurology, Martha-Maria Hospital, Halle/Saale, Germany
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Abstract
Although stroke declined from the third to fifth most common cause of death in the United States, the annual incidence and overall prevalence continue to increase. Since the available US Food and Drug Administration-approved treatment options are time dependent, improving early stroke care may have more of a public health impact than any other phase of care. Timely and efficient stroke treatment should be a priority for emergency department and prehospital providers. This article discusses currently available and emerging treatment options in acute ischemic stroke focusing on the preservation of salvageable brain tissue, minimizing complications, and secondary prevention.
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Affiliation(s)
- Matthew S Siket
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 55 Claverick Street, 2nd Floor, Providence, RI 02903, USA.
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Rincon F, Lee K. Ethical considerations in consenting critically ill patients for bedside clinical care and research. J Intensive Care Med 2013; 30:141-50. [PMID: 24019298 DOI: 10.1177/0885066613503279] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Care of critically ill patients, as in any other field, demands the exercise of ethical principles related to respect of patient's autonomy, beneficence, nonmaleficence, and distributive justice. Professional duty and the common law require doctors to obtain consent before giving treatment or for requesting participation in clinical research. A procedure or research study must be adequately explained, and the patient must have the capacity to consent. If a patient does not have decision-making capacity, treatment must be given using alternative forms of consent or using principles of implied consent in emergency or life-threatening situations. In the case of clinical research, informed consent must always be sought. Exemptions to this rule are morally justified in circumstances related to research in life-threatening conditions or life-saving interventions in which the investigator departs from sound principles of equipoise. This usually implies the imposition of safeguards such as consultation with the community in which the study were to take place, oversight in patient screening and recruitment process by institutional review boards, special study designs, retrospective and prospective consent processes, and independent safety monitoring.
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Affiliation(s)
- Fred Rincon
- Divisions of Critical Care and Neurotrauma, Department of Neurology and Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kiwon Lee
- Department of Neurology and Neurosurgery, The Mischer Neuroscience Institute, Memorial Hermann of Texas Medical Center, Houston, TX, USA
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Thomas L, Viswanathan A, Cochrane TI, Johnson J, O'Brien J, McMahon M, Santimauro JM, Schwamm LH. Variability in the Perception of Informed Consent for IV-tPA during Telestroke Consultation. Front Neurol 2012; 3:128. [PMID: 23015805 PMCID: PMC3449489 DOI: 10.3389/fneur.2012.00128] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 08/04/2012] [Indexed: 11/25/2022] Open
Abstract
Objective: To study the perception of informed consent among various raters for thrombolysis in acute ischemic stroke patients receiving intravenous tissue plasminogen activator (IV-tPA). Methods: Twenty randomly selected videotaped telestroke consultations of acute stroke patients administered IV-tPA were retrospectively reviewed. Adequacy of informed consent was reviewed by five raters: a neurologist and emergency physician who routinely treat stroke, a medical risk management paralegal, a bioethicist, and a lay person. Raters assessed the quality of the informed consent presentation by the treating physician and the degree of understanding demonstrated by the patient/family authorizing consent. Factors associated with adequacy of consent were analyzed. Results: Consent was rated as adequately understood by the patient-family in 78.6% cases. Agreement between all five raters with regard to the patient-family understanding of consent was poor and also between the subgroups of non-physician and physician (all k < 0.20). Similarly, the quality of the physician consent process was poor for agreement between all five raters (k = 0.07) or between the subgroup of the three non-physician raters (k = −0.06) and fair between the two physician raters (k = 0.24). The legal reviewer and the bioethicist rated the physician consent process as being of lower quality than did the two physicians and the layperson. Conclusion: Despite high variability in the perception of informed consent among raters in this time-sensitive clinical situation, almost 80% of patients were rated by all reviewers as having adequate understanding of risks and benefits of tPA. This suggests the need for a standardized but brief tPA consent process that includes patient/family demonstration of understanding.
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Affiliation(s)
- Lisa Thomas
- Department of Emergency Medicine, Mount Auburn Hospital Cambridge, MA, USA
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Abstract
The physician must explain the treatment or procedure in detail including risks, benefits, and alternative options; the patient's choice must be voluntary; the patient must demonstrate his or her ability to understand the risks and benefits of their choice; and the patient must be able to manipulate information in a logical way. These criteria must be met in order for the process of informed consent to be valid.
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Affiliation(s)
- Teresa Lim
- Department of Psychiatry, Mount Sinai School of Medicine, 1 Gustave L Levy Place, Box 1230, New York, NY 10029, USA
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Chenaud C, Merlani P, Luyasu S, Ricou B. Informed consent for research obtained during the intensive care unit stay. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:R170. [PMID: 17156444 PMCID: PMC1794486 DOI: 10.1186/cc5120] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Revised: 09/08/2006] [Accepted: 12/08/2006] [Indexed: 01/31/2023]
Abstract
Introduction Patients in the intensive care unit (ICU) may be in an inadequate condition to give their informed consent for research. The aim of this study was to analyse the ability to recall participation in a clinical trial for which ICU patients had given their consent. Methods The data presented are a two-step observational study: first, a protocolled informed consent procedure was conducted then the informed consent was given by the patient, and second, a patient interview was held 10 ± 2 days later by the same investigator. The primary endpoints were the ability to recall their participation in the clinical trial, as well as its purpose and related risks. As secondary endpoints, we investigated whether asking questions about the clinical trial or reading the informative leaflet was related to the recall. To be included in the study, the patient had to have a Glasgow Coma Scale score of 15, be fully oriented and free of mechanical ventilation, and be judged competent by both the investigator and the attending physician. Patients admitted to the ICU after major surgery or trauma were eligible. However, patients who refused to participate, or those whose next-of-kin gave consent, were excluded. Results Of the 44 patients, 35 (80%) recognized, 10 to 12 days after informed consent had been obtained, that they had participated in the clinical trial, but only 14 out of 44 (32%) could recall the clinical trial purpose and its related risks. More patients with complete recall had read the informative leaflet or asked at least one question before signing the informed consent. Asking at least one question was associated with complete recall. Conclusion Our results confirm that obtaining informed consent for research during an ICU stay is associated with poor patient recall of participation in a clinical trial and its components (purpose and risk). Whether encouraging reading the informative leaflet and asking questions about the clinical trial improves the informed consent procedure remains to be fully investigated.
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Affiliation(s)
- Catherine Chenaud
- Service of Intensive Care, Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Rue Micheli-du-Crest 24, 1211 Geneva 14, Switzerland
| | - Paolo Merlani
- Service of Intensive Care, Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Rue Micheli-du-Crest 24, 1211 Geneva 14, Switzerland
| | - Samuel Luyasu
- Service of Intensive Care, Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Rue Micheli-du-Crest 24, 1211 Geneva 14, Switzerland
| | - Bara Ricou
- Service of Intensive Care, Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Rue Micheli-du-Crest 24, 1211 Geneva 14, Switzerland
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Abstract
Thrombolysis with intravenous alteplase for acute ischaemic stroke, which is already in clinical use in the USA and Canada, has recently been approved in the European Union. Until now, the use of alteplase has been limited to research or "off label" therapy in most of Europe. Despite the growing importance of this therapy and the many guidelines for use and comments on its effects, there is a lack of information about informed consent. The process of obtaining informed consent in the therapeutic decision process allows the patients to express their point of view on the risk-to-benefit ratio of thrombolytic therapy, on the different outcomes of stroke, and on the effect of thrombolysis. The discussion between the clinician and the patient or patient's family, during the process of obtaining consent to thrombolysis, can be problematic because therapy has to be given with extreme urgency. In this article, I highlight the importance of obtaining informed consent, help set out the process, and analyse the situations in which obtaining consent to thrombolysis may be legally and ethically avoided.
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Affiliation(s)
- Alfonso Ciccone
- Stroke Unit, Department of Neurosciences, Niguarda Hospital, Milan, Italy.
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