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D'Souza RS, Dunn L. In Response. Anesth Analg 2024; 138:e4-e5. [PMID: 38100812 DOI: 10.1213/ane.0000000000006771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, Minnesota,
| | - Lauren Dunn
- Departments of Anesthesiology and Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Everett SM, Triantafyllou K, Hassan C, Mergener K, Tham TC, Almeida N, Antonelli G, Axon A, Bisschops R, Bretthauer M, Costil V, Foroutan F, Gauci J, Hritz I, Messmann H, Pellisé M, Roelandt P, Seicean A, Tziatzios G, Voiosu A, Gralnek IM. Informed consent for endoscopic procedures: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2023; 55:952-966. [PMID: 37557899 DOI: 10.1055/a-2133-3365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
All endoscopic procedures are invasive and carry risk. Accordingly, all endoscopists should involve the patient in the decision-making process about the most appropriate endoscopic procedure for that individual, in keeping with a patient's right to self-determination and autonomy. Recognition of this has led to detailed guidelines on informed consent for endoscopy in some countries, but in many no such guidance exists; this may lead to variations in care and exposure to risk of litigation. In this document, the European Society of Gastrointestinal Endoscopy (ESGE) sets out a series of statements that cover best practice in informed consent for endoscopy. These statements should be seen as a minimum standard of practice, but practitioners must be aware of and adhere to the law in their own country. 1: Patients should give informed consent for all gastrointestinal endoscopic procedures for which they have capacity to do so. 2: The healthcare professional seeking consent for an endoscopic procedure should ensure that the patient has the capacity to consent to that procedure. 3: For patients who lack capacity, healthcare personnel should at all times try to engage with people close to the patient, such as family, friends, or caregivers, to achieve consensus on the appropriateness of performing the procedure. 4: Where a patient lacks capacity to provide informed consent, the best interest decision should be clearly documented in the medical record. This should include information about the capacity assessment, reason(s) that the decision cannot be delayed for capacity recovery (or if recovery is not expected), who has been consulted, and where relevant the form of authority for the decision. 5: There should be a systematic and transparent disclosure of the expected benefits and harms that may reasonably affect patient choice on whether or not to undergo any diagnostic or interventional endoscopic procedure. Information about possible alternatives, as well as the consequences of doing nothing, should also be provided when relevant. 6: The information provided on the benefit and harms of an endoscopic procedure should be adapted to the procedure and patient-specific risk factors, and the preferences of the patient should be central to the consent process. 7: The consent discussion should be undertaken by an individual who is familiar with the procedure and its risks, and is able to discuss these in the context of the individual patient. 8: Patients should confirm consent to an endoscopic procedure in a private, unrushed, and non-coercive environment. 9: If a patient requests that an endoscopic procedure be discontinued, the procedure should be paused and the patient's capacity for decision making assessed. If a competent patient continues to object to the procedure, or if a conclusive determination of capacity is not feasible, the examination should be terminated as soon as it is safe to do so. 10: Informed consent should be sufficiently detailed to cover all findings that can be reasonably anticipated during an endoscopic examination. The scope of this consent should not be expanded, nor a patient's implicit consent for additional interventions assumed, unless failure to proceed with such interventions would result in immediate and predictable harm to the patient.
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Affiliation(s)
- Simon M Everett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland
| | - Nuno Almeida
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Giulio Antonelli
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
- Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli Hospital, Ariccia, Rome, Italy
| | | | - Raf Bisschops
- Department of Gastroenterology and Hepatology, UZ Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Diseases (TARGID), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Michael Bretthauer
- Clinical Effectiveness Group, Department of Transplantation Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Farid Foroutan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- MAGIC Evidence Ecosystem Foundation
| | - James Gauci
- Department of Gastroenterology, Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Istvan Hritz
- Department of Surgery, Transplantation and Gastroenterology, Center for Therapeutic Endoscopy, Semmelweis University, Budapest, Hungary
| | - Helmut Messmann
- Department of Gastroenterology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Maria Pellisé
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Philip Roelandt
- Department of Gastroenterology and Hepatology, UZ Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Diseases (TARGID), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Andrada Seicean
- Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, Cluj-Napoca, Romania
- University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj-Napoca, Cluj-Napoca, Romania
| | - Georgios Tziatzios
- Department of Gastroenterology, "Konstantopoulio-Patision" General Hospital, Athens, Greece
| | - Andrei Voiosu
- Gastroenterology and Hepatology Department, Colentina Clinical Hospital and Internal Medicine and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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Kituuka O, Munabi IG, Mwaka ES, Galukande M, Harris M, Sewankambo N. Informed consent process for emergency surgery: A scoping review of stakeholders' perspectives, challenges, ethical concepts, and policies. SAGE Open Med 2023; 11:20503121231176666. [PMID: 37362612 PMCID: PMC10285587 DOI: 10.1177/20503121231176666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/02/2023] [Indexed: 06/28/2023] Open
Abstract
Background A scoping review of literature about the informed consent process for emergency surgery from the perspectives of the patients, next of kin, emergency staff, and available guiding policies. Objectives To provide an overview of the informed consent process for emergency surgery; the challenges that arise from the perspectives of the patients, emergency staff, and next of kin; policies that guide informed consent for emergency surgery; and to identify any knowledge gaps that could guide further inquiry in this area. Methods We searched Google Scholar, PubMed/MEDLINE databases as well as Sheridan Libraries and Welch Medical Library from 1990 to 2021. We included journal articles published in English and excluded non-peer-reviewed journal articles, unpublished manuscripts, and conference abstracts. The themes explored were emergency surgery consent, ethical and theoretical concepts, stakeholders' perceptions, challenges, and policies on emergency surgery. Articles were reviewed by three independent reviewers for relevance. Results Of the 65 articles retrieved, 18 articles were included. Of the 18 articles reviewed, 5 addressed emergency informed consent, 9 stakeholders' perspectives, 7 the challenges of emergency informed consent, 3 ethical and theoretical concepts of emergency informed consent, and 3 articles addressed policies of emergency surgery informed consent. Conclusion There is poor satisfaction in the informed consent process in emergency surgery. Impaired capacity to consent and limited time are a challenge. Policies recommend that informed consent should not delay life-saving emergency care and patient's best interests must be upheld.
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Affiliation(s)
- Olivia Kituuka
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - Moses Galukande
- Makerere University College of Health Sciences, Kampala, Uganda
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4
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Dhellemmes O, Mouton J, Auquit-Auckbur I. Hand emergencies: patient information is often neglected. J Hand Surg Eur Vol 2023; 48:153-154. [PMID: 36324199 DOI: 10.1177/17531934221132638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Octave Dhellemmes
- Plastic and Hand Surgery Department, Rouen University Hospital, Rouen, France
| | - Jordane Mouton
- Hand Surgery Department, Clinique de l'Europe, Rouen, France
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Carr JA, NeCamp T. Results of emergency colectomy in nonagenarians and octogenarians previously labeled as prohibitive surgical risk. Eur J Trauma Emerg Surg 2022; 48:4927-4933. [PMID: 35759007 DOI: 10.1007/s00068-022-02030-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/30/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE There are no standardized criteria for what constitutes prohibitive risk for emergency abdominal surgery. METHODS A retrospective review was performed comparing two groups of patients having emergent colectomy. One group had previously been labeled as being prohibitive surgical risk and the other was a contemporary, non-prohibitive risk group also requiring emergency colectomy. All operations were performed by a single surgeon. RESULTS There were 27 prohibitive risk patients and 81 non-prohibitive risk (control group) patients. The average age of the prohibitive risk group was 85 years (range 78-99) compared to the control group mean age of 52 years (18-79, p < 0.00001). Prohibitive risk was due to extremes of age combined with congestive heart failure in 44%, followed by chronic obstructive pulmonary disease combined with heart failure in 19%. The groups were closely matched by the type of colectomy performed. The total complication rate was much higher in the prohibitive risk group compared to the non-prohibitive risk patients (81% versus 48%, p 0.005). But the 30-day mortality rate was similar between groups (7% versus 4%, p 0.6). CONCLUSION Patients who are labeled as prohibitive surgical risk may be inaccurately assessed in the majority of cases. Additional research will need to be performed to evaluate the presence of quantifiable high-risk physiological conditions, and not just comorbidities, that place a patient at high risk of death after abdominal surgery. Until then, elderly patients should not be denied colectomy based upon comorbidities alone.
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Affiliation(s)
- John Alfred Carr
- ProMedica Health System, 100 Madison Avenue, Toledo, OH, 43606, USA.
| | - Timothy NeCamp
- Data Bloom Statistical Consultants, 104 Fieldstone Drive, Terrace Park, OH, 45174, USA
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Piscitello GM, Bermea RS, Stokes JW, Gannon WD, Kanelidis AJ, Konopka M, Shappell C, Frye LK, Lyons PG, Siegler M, Parker WF. Clinician Ethical Perspectives on Extracorporeal Membrane Oxygenation in Practice. Am J Hosp Palliat Care 2022; 39:659-666. [PMID: 34414798 PMCID: PMC8858336 DOI: 10.1177/10499091211041079] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Extracorporeal membrane oxygenation (ECMO) is an expensive and scarce life sustaining treatment provided to certain critically ill patients. Little is known about the informed consent process for ECMO or clinician viewpoints on ethical complexities related to ECMO in practice. METHODS We sent a cross-sectional survey to all departments providing ECMO within 7 United States hospitals in January 2021. One clinician from each department completed the 42-item survey representing their department. RESULTS Fourteen departments within 7 hospitals responded (response rate 78%, N = 14/18). The mean time spent consenting patients or surrogate decision-makers for ECMO varied, from 7.5 minutes (95% CI 5-10) for unstable patients to 20 minutes (95% CI 15-30) for stable patients (p = 0.0001). Few clinician respondents (29%) report patients or surrogate decision-makers always possess informed consent for ECMO. Most departments (92%) have absolute exclusion criteria for ECMO such as older age (43%, cutoffs ranging from 60-75 years), active malignancy (36%), and elevated body mass index (29%). A significant minority of departments (29%) do not always offer the option to withdraw ECMO to patients or surrogate decision-makers. For patients who cannot be liberated from ECMO and are ineligible for heart or lung transplant, 36% of departments would recommend the patient be removed from ECMO and 64% would continue ECMO support. CONCLUSION Adequate informed consent for ECMO is a major ethical challenge, and the content of these discussions varies. Use of categorical exclusion criteria and withdrawal of ECMO if a patient cannot be liberated from it differ among departments and institutions.
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Affiliation(s)
| | - Rene S. Bermea
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - John W. Stokes
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Whitney D. Gannon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Megan Konopka
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Claire Shappell
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Laura K. Frye
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin, Madison, WI, USA
| | - Patrick G. Lyons
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis, MO, USA
| | - Mark Siegler
- Department of Medicine, University of Chicago, IL, USA
- MacLean Center for Clinical Medical Ethics, University of Chicago, IL, USA
| | - William F. Parker
- MacLean Center for Clinical Medical Ethics, University of Chicago, IL, USA
- Section of Pulmonary and Critical Care, University of Chicago, IL, USA
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Tang S, Anderson NE, Faasse K, Adams WP, Newby JM. A Qualitative Study on the Experiences of Women With Breast Implant Illness. Aesthet Surg J 2022; 42:381-393. [PMID: 33904898 DOI: 10.1093/asj/sjab204] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Breast implant illness (BII) is a term used to describe physical and psychological symptoms experienced by some women following breast implant surgery. Few studies have examined the experiences of women with BII-a poorly understood condition with no clear cause or treatment. OBJECTIVES The aim of this study was to explore women's experiences of BII, including symptoms, healthcare encounters, social media, and explant surgery. METHODS Employing an exploratory qualitative methodology, researchers undertook semistructured interviews with 29 women who self-identified as having BII. Interviews were audio-recorded and transcribed verbatim. Data were analyzed by inductive thematic analysis. RESULTS Thematic analysis of the interviews identified 6 themes: (1) symptoms without explanation; (2) invalidation and invisibility; (3) making the BII connection; (4) implant toxicity; (5) explant surgery: solution to suffering?; and (6) concealed information. BII was described as distressing and debilitating across multiple domains including relationships, work, identity, and physical and mental health, and symptoms were attributed to implant toxicity and immune system rejection of foreign objects. When their experience was not validated by healthcare professionals, many looked to social media for information, support, and understanding, and saw explant as their only chance of recovery. CONCLUSIONS BII is disabling mentally and physically. Women with BII require support, understanding, and validation, and proactive treatment to prevent disability. With unclear pathophysiology, future research should examine how biopsychosocial approaches can be used to guide treatment, and how to best support women with BII, focusing on early detection and evidence-based education and intervention. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Samantha Tang
- Dr Tang is a research assistant and Dr Faasse is a senior lecturer, School of Psychology, Faculty of Science, UNSW Sydney, Sydney, New South Wales, Australia
| | - Natalie E Anderson
- Dr Anderson is a professional teaching fellow, Department of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Kate Faasse
- Dr Tang is a research assistant and Dr Faasse is a senior lecturer, School of Psychology, Faculty of Science, UNSW Sydney, Sydney, New South Wales, Australia
| | - William P Adams
- Dr Adams is a program director, UT Southwestern Aesthetic Surgery Fellowship and associate professor, UT Southwestern Department of Plastic Surgery, TX, USA
| | - Jill M Newby
- Dr Newby is an associate professor, Black Dog Institute, Faculty of Medicine and School of Psychology, Faculty of Science, UNSW Sydney, Sydney, New South Wales, Australia
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Utilizing the "teach-back" method to improve surgical informed consent and shared decision-making: a review. Patient Saf Surg 2022; 16:12. [PMID: 35248126 PMCID: PMC8897923 DOI: 10.1186/s13037-022-00322-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/19/2022] [Indexed: 11/10/2022] Open
Abstract
The teach-back method is a valuable communication tool that can be employed to improve patient safety and shared decision-making. Its utility in patient care has been studied extensively in many areas of clinical medicine. However, the literature on the use of teach-back in surgical patient education and informed consent is limited. Additionally, there is some ambiguity about the functional definition and performance of the teach-back method in the literature, consequently rendering this valuable tool an enigma. This review examines the current standards and ethics of preoperative informed consent and provides a concise, actionable definition of teach-back. The manner in which teach-back has been implemented in medicine and surgery is then examined in detail. Studies analyzing the use of teach-back in medicine have demonstrated its effectiveness and benefit to patient care. Further study on the use of teach-back to improve preoperative informed consent is supported by the few preliminary trials showing a positive effect after implementing the teach-back method in critical patient interactions.
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Storm AC, Fishman DS, Buxbaum JL, Coelho-Prabhu N, Al-Haddad MA, Amateau SK, Calderwood AH, DiMaio CJ, Elhanafi SE, Forbes N, Fujii-Lau LL, Jue TL, Kohli DR, Kwon RS, Law JK, Pawa S, Thosani NC, Wani S, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on informed consent for GI endoscopic procedures. Gastrointest Endosc 2022; 95:207-215.e2. [PMID: 34998575 DOI: 10.1016/j.gie.2021.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 12/11/2022]
Abstract
Informed consent is the cornerstone of the ethical practice of procedures and treatments in medicine. The purpose of this document from the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee is to provide an update on best practice of the informed consent process and other issues around informed consent and shared decision-making for endoscopic procedures. The principles of informed consent are based on longstanding legal doctrine. Several new concepts and clinical trials addressing the best practice of informed consent will help guide practitioners of the burgeoning field of GI endoscopic procedures. After a literature review and an iterative discussion and voting process by the ASGE Standards of Practice Committee, this document was produced to update our guidance on informed consent for the practicing endoscopist. Because this document was designed by considering the laws and broad practice of endoscopy in the United States, legal requirements may differ by state and region, and it is the responsibility of the endoscopist, practice managers, and other healthcare organizations to be aware of local laws. Our recommendations are designed to improve the informed consent experience for both physicians and patients as they work together to diagnose and treat GI diseases with endoscopy.
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Affiliation(s)
- Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | | | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Christopher J DiMaio
- Department of Gastroenterology, Mount Sinai School of Medicine, New York, New York, USA
| | - Sherif E Elhanafi
- Department of Gastroenterology, Texas Tech University, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Larissa L Fujii-Lau
- Department of Gastroenterology, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Terry L Jue
- Department of Gastroenterology, The Permanente Medical Group, San Francisco, California, USA
| | - Divyanshoo R Kohli
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Joanna K Law
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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Cook E, Scantlebury A, Booth A, Turner E, Ranganathan A, Khan A, Ahuja S, May P, Rangan A, Roche J, Coleman E, Hilton C, Corbacho B, Hewitt C, Adamson J, Torgerson D, McDaid C. Surgery versus conservative management of stable thoracolumbar fracture: the PRESTO feasibility RCT. Health Technol Assess 2021; 25:1-126. [PMID: 34780323 DOI: 10.3310/hta25620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There is informal consensus that simple compression fractures of the body of the thoracolumbar vertebrae between the 10th thoracic vertebra and the second lumbar vertebra without neurological complications can be managed conservatively and that obvious unstable fractures require surgical fixation. However, there is a zone of uncertainty about whether surgical or conservative management is best for stable fractures. OBJECTIVES To assess the feasibility of a definitive randomised controlled trial comparing surgical fixation with initial conservative management of stable thoracolumbar fractures without spinal cord injury. DESIGN External randomised feasibility study, qualitative study and national survey. SETTING Three NHS hospitals. METHODS A feasibility randomised controlled trial using block randomisation, stratified by centre and type of injury (high- or low-energy trauma) to allocate participants 1 : 1 to surgery or conservative treatment; a costing analysis; a national survey of spine surgeons; and a qualitative study with clinicians, recruiting staff and patients. PARTICIPANTS Adults aged ≥ 16 years with a high- or low-energy fracture of the body of a thoracolumbar vertebra between the 10th thoracic vertebra and the second lumbar vertebra, confirmed by radiography, computerised tomography or magnetic resonance imaging, with at least one of the following: kyphotic angle > 20° on weight-bearing radiographs or > 15° on a supine radiograph or on computerised tomography; reduction in vertebral body height of 25%; a fracture line propagating through the posterior wall of the vertebra; involvement of two contiguous vertebrae; or injury to the posterior longitudinal ligament or annulus in addition to the body fracture. INTERVENTIONS Surgical fixation: open spinal surgery (with or without spinal fusion) or minimally invasive stabilisation surgery. Conservative management: mobilisation with or without a brace. MAIN OUTCOME MEASURE Recruitment rate (proportion of eligible participants randomised). RESULTS Twelve patients were randomised (surgery, n = 8; conservative, n = 4). The proportion of eligible patients recruited was 0.43 (95% confidence interval 0.24 to 0.63) over a combined total of 30.7 recruitment months. Of 211 patients screened, 28 (13.3%) fulfilled the eligibility criteria. Patients in the qualitative study (n = 5) expressed strong preferences for surgical treatment, and identified provision of information about treatment and recovery and when and how they are approached for consent as important. Nineteen surgeons and site staff participated in the qualitative study. Key themes were the lack of clinical consensus regarding the implementation of the eligibility criteria in practice and what constitutes a stable fracture, alongside lack of equipoise regarding treatment. Based on the feasibility study eligibility criteria, 77% (50/65) and 70% (46/66) of surgeons participating in the survey were willing to randomise for high- and low-energy fractures, respectively. LIMITATIONS Owing to the small number of participants, there is substantial uncertainty around the recruitment rate. CONCLUSIONS A definitive trial is unlikely to be feasible currently, mainly because of the small number of patients meeting the eligibility criteria. The recruitment and follow-up rates were slightly lower than anticipated; however, there is room to increase these based on information gathered and the support within the surgical community for a future trial. FUTURE WORK Development of consensus regarding the population of interest for a trial. TRIAL REGISTRATION Current Controlled Trials ISRCTN12094890. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 62. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Elizabeth Cook
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Alison Booth
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Emma Turner
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Almas Khan
- Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
| | - Sashin Ahuja
- Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Peter May
- Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Jenny Roche
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Elizabeth Coleman
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Belén Corbacho
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Joy Adamson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
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12
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Maher DI, Serpell JW, Ayton D, Lee JC. Patient Reported Experience on Consenting for Surgery - Elective Versus Emergency Patients. J Surg Res 2021; 265:114-121. [PMID: 33901840 DOI: 10.1016/j.jss.2021.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Informed consent for surgery is a medical and legal requirement, but completing these does not necessarily translate to high patient satisfaction. This patient-reported experience study aimed to examine the surgical consent process, comparing the patients' experience in elective and emergency settings. METHODS Over a 6-mo period, postoperative patients at The Alfred Hospital Breast and Endocrine Surgical Unit were invited to participate in a survey on the surgical consent process - including perceived priorities, information provided and overall experience. Standard statistical techniques were used, with a significant P-value of < 0.05. RESULTS A total of 412 patients were invited, with 130 (32%) responses. More patients underwent elective surgery (N= 90, 69%) than emergency surgery (N = 40, 31%). Emergency patients were more likely to sign the consent form regardless of its contents (93% versus 39%, P < 0.001) and more likely to be influenced by external pressures (63% versus 1%, P < 0.001). Elective patients were more likely to want to discuss their surgery with a senior surgeon (74% versus 23%, P < 0.001) and more likely to seek advice from external sources (83% versus 10%, P < 0.001). Both groups highly valued the opportunity to ask questions (67% versus 63%, P = 0.65). CONCLUSION This study shows patients have a range of different priorities in preparation for surgery. Therefore, each consent process should be patient-specific, and focus on providing the patient with quality resources that inform decision-making.
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Affiliation(s)
- Dominic I Maher
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jonathan W Serpell
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Darshini Ayton
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - James C Lee
- Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University, Melbourne, Victoria, Australia.
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Stewart C, Biegler P, Brunero S, Lamont S, Tomossy GF. Mental Capacity Assessments for COVID-19 Patients: Emergency Admissions and the CARD Approach. JOURNAL OF BIOETHICAL INQUIRY 2020; 17:803-808. [PMID: 33169263 PMCID: PMC7651828 DOI: 10.1007/s11673-020-10055-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/23/2020] [Indexed: 06/11/2023]
Abstract
The doctrine of consent (or informed consent, as it is called in North America) is built upon presumptions of mental capacity. Those presumptions must be tested according to legal rules that may be difficult to apply to COVID-19 patients during emergency presentations. We examine the principles of mental capacity and make recommendations on how to assess the capacity of COVID-19 patients to consent to emergency medical treatment. We term this the CARD approach (Comprehend, Appreciate, Reason, and Decide).
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Affiliation(s)
- Cameron Stewart
- Sydney Law School, University of Sydney, NSW, 2006, Australia.
| | - Paul Biegler
- Monash Bioethics Centre, Monash University, Clayton, VIC, 3800, Australia
| | - Scott Brunero
- School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, 2751, Australia
- School of Health and Human Sciences, Southern Cross University, Lismore, NSW, 2480, Australia
- Mental Health Liaison Nursing, Prince of Wales Hospital, Randwick, NSW, 2034, Australia
| | - Scott Lamont
- School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, 2751, Australia
- School of Health and Human Sciences, Southern Cross University, Lismore, NSW, 2480, Australia
- Mental Health Liaison Nursing, Prince of Wales Hospital, Randwick, NSW, 2034, Australia
| | - George F Tomossy
- Macquarie Law School, Macquarie University, NSW, 2154, Australia
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14
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D'Souza RS, D'Souza S, Sharpe EE. YouTube as a source of medical information about epidural analgesia for labor pain. Int J Obstet Anesth 2020; 45:133-137. [PMID: 33339713 DOI: 10.1016/j.ijoa.2020.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/22/2020] [Accepted: 11/09/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Large gaps remain in our understanding of the role of social media platforms in the dissemination of medical information. This cross-sectional study quantitatively assessed the accuracy and quality of information on YouTube regarding epidural labor analgesia. METHODS YouTube was searched on May 23, 2020 using keywords 'epidural,' 'epidural for labor,' 'epidural for pregnancy,' 'epidural experience,' and 'epidural risks,' and the top 50 viewed videos from each search were screened. Primary outcomes included the proportion of videos containing non-factual information, and video quality analyzed using the modified DISCERN (mDISCERN) score. RESULTS Thirteen of 60 (21.7%) videos included non-factual information about epidural analgesia; these videos were viewed more than 16.5 million times (60% of total viewership of the videos analyzed). Mean (standard deviation) mDISCERN score for all included videos was 1.9 (1.3), which is below the threshold for high video-quality. Videos from medical sources (hospitals, medical practices, physicians, other medical professionals) had a higher mDISCERN score compared with videos by non-medical sources (P <0.001). Educational videos from professional societies of obstetrics or obstetric anesthesiology were not captured. CONCLUSION YouTube is an accessible platform for medical information on epidural labor analgesia, although a significant proportion of videos studied contained non-factual information and presented low video quality. Increased efforts by reputable sources including hospitals, physicians, other medical professionals, and professional societies, to disseminate accurate information, are warranted.
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Affiliation(s)
- R S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic Hospital, Rochester, MN, USA.
| | - S D'Souza
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - E E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
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15
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Langford B, Hooten WM, D'Souza S, Moeschler S, D'Souza RS. YouTube as a Source of Medical Information About Spinal Cord Stimulation. Neuromodulation 2020; 24:156-161. [PMID: 33137842 DOI: 10.1111/ner.13303] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Social media platforms may play an important role in the dissemination of medical information on interventional pain procedures. This cross-sectional study quantitatively assessed the reliability and quality of information from YouTube regarding spinal cord stimulation. MATERIALS AND METHODS YouTube was queried on May 20, 2020 using keywords "spinal cord stimulator," "spinal cord stimulation experience," and "spinal cord stimulation risks." The top 50 viewed videos from each search were analyzed. The primary outcome was video quality, which was analyzed using the modified DISCERN (mDISCERN) criteria. RESULTS Seventy-nine of 103 (77%) videos were classified as useful. Fifteen of 103 (14%) videos were classified as misleading and contained nonfactual information on spinal cord stimulation. Hospitals, group practices, or physicians produced a greater proportion of useful videos compared to misleading videos (63.3% vs. 26.7%, p = 0.008). Nonmedical independent users produced a greater proportion of misleading videos compared to useful videos (73.3% vs. 16.4%, p < 0.001). Useful videos had significantly higher mDISCERN scores compared to misleading videos (2.6 vs. 1.9, p = 0.009). Nonmedical independent users produced a greater proportion of low-quality videos (mDISCERN score < 3) than high-quality videos (mDISCERN score ≥ 3; 50.8% vs. 2.4%, respectively, p < 0.001). Educational videos from professional pain medicine societies were not captured. CONCLUSION YouTube is an accessible platform for medical information on spinal cord stimulation, yet a significant amount of nonfactual information is present. As social media platforms continue to gain prominence in health care, future efforts to appraise the quality of medical content delivered to the public are warranted. In addition, reputable sources including professional pain medicine societies should consider collaborating with producers to disseminate high-quality video content that reaches a wider audience.
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Affiliation(s)
- Brendan Langford
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - William Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Shawn D'Souza
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Susan Moeschler
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
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Eyuboglu TF, Gonenc FI. The effect of pain intensity levels and clinical symptoms on the treatment preferences of patients with endodontically involved teeth: A preliminary cross-sectional study. Eur Oral Res 2020; 54:142-147. [PMID: 33543120 PMCID: PMC7837708 DOI: 10.26650/eor.20200043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: This study aimed to evaluate the effect of pain intensity levels and clinical symptoms
on the treatment preferences of patients with endodontically involved teeth in a
local Turkish population. Subjects and methods: A total of 30 patients with symptomatic teeth requiring non-surgical root canal
treatment were included in the study. The patients’ demographic (age, gender,
and education level) and diagnostic data (tooth type, pain intensity, response to
percussion and palpation, presence of referred pain, and diagnosis) were analyzed.
Data on the patients’ explicit preferences (requested treatment, whether they are
willing to accept a proposed extraction, choice of treatment if an anterior tooth was
involved, and choice of treatment if the pain was not severe) as well as previous root
canal treatment experiences were also analyzed. Pain intensity levels were evaluated
using the Visual Analog Scale. Results: Pain intensity levels had a significant effect on the treatment requested by the
patient (p=0.001). Among the patients who requested extraction upon referral to
the clinic, the rate of those who reported that they would not accept extraction
if the pain was located in an anterior tooth was significantly lower than that of
patients stating that they would refuse (p=0.039). The presence of referred pain also
had a significant effect on the requested treatment (p=0.001). Conclusion: The intensity of pain and the presence of referred pain influence patients’ treatment
preferences.
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Affiliation(s)
- Tan Firat Eyuboglu
- Department of Endodontics, Istanbul Medipol University,Faculty of Dentistry, Istanbul,Turkey
| | - Fulya Ilcin Gonenc
- Department of Endodontics, Istanbul Medipol University,Faculty of Dentistry, Istanbul,Turkey
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Wilson EH, Burkle CM. The Meaning of Consent and Its Implications for Anesthesiologists. Adv Anesth 2020; 38:1-22. [PMID: 34106829 DOI: 10.1016/j.aan.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Elizabeth H Wilson
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, B6/319 CSC, 600 Highland Avenue, Madison, WI 53792-3272, USA
| | - Christopher M Burkle
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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