Advancing the cause of informed consent: moving from disclosure to understanding

Navigating ethical challenges of conducting randomized clinical trials on COVID-19

BACKGROUND

The contemporary frameworks for clinical research require informed consent for research participation that includes disclosure of material information, comprehension of disclosed information and voluntary consent to research participation. There is thus an urgent need to test, and an ethical imperative, to test, modify or refine medications or healthcare plans that could reduce patient morbidity, lower healthcare costs or strengthen healthcare systems.

METHODS

Conceptual review.

DISCUSSION

Although some allocation principles seem better than others, no single moral principle allocates interventions justly, necessitating combining the moral principles into multiprinciple allocation systems. The urgency notwithstanding, navigating ethical challenges related to conducting corona virus disease (COVID-19) clinical trials is mandatory, in order to safeguard the safety and welfare of research participants, ensure autonomy of participants, reduce possibilities for exploitation and ensure opportunities for research participation. The ethical challenges to can be categorized as challenges in allocation of resources for research; challenges of clinical equipoise in relation to the research questions; challenges of understanding disclosed information in potential participants; and challenges in obtaining informed consent.

CONCLUSION

To navigate these challenges, stakeholders need a delicate balance of moral principles during allocation of resources for research. Investigators need to apply information processing theories to aid decision-making about research participation or employ acceptable modifications to improve the informed consent process. Research and ethics committees should strengthen research review and oversight to ensure rigor, responsiveness and transparency.

Design of a randomized clinical trial of a colorectal cancer screening decision aid to promote appropriate screening in community-dwelling older adults

BACKGROUND

Appropriate colorectal cancer screening in older adults should be aligned with the likelihood of net benefit. In general, patient decision aids improve knowledge and values clarity, but in older adults, they may also help patients identify their individual likelihood of benefit and foster individualized decision-making. We report on the design of a randomized clinical trial to understand the effects of a patient decision aid on appropriate colorectal cancer screening. This report includes a description of the baseline characteristics of participants.

METHODS

English-speaking primary care patients aged 70-84 years who were not currently up to date with screening were recruited into a randomized clinical trial comparing a tailored colorectal cancer screening decision aid with an attention control. The intervention group received a decision aid that included a values clarification exercise and individualized decision-making worksheet, while the control group received an educational pamphlet on safe driving behaviors. The primary outcome was appropriate screening at 6 months based on chart review. We used a composite measure to define appropriate screening as screening for participants in good health, a discussion about screening for patients in intermediate health, and no screening for patients in poor health. Health state was objectively determined using patients' Charlson Comorbidity Index score and age.

RESULTS

A total of 14 practices in central North Carolina participated as part of a practice-based research network. In total, 424 patients were recruited to participate and completed a baseline visit. Overall, 79% of participants were White and 58% female, with a mean age of 76.8 years. Patient characteristics between groups were similar by age, gender, race, education, insurance coverage, or work status. Overall, 70% had some college education or more, 57% were married, and virtually all had Medicare insurance (90%). The three primary medical conditions among the cohort were a history of diabetes, pneumonia, and cancer (28%, 26%, and 21%, respectively).

CONCLUSION

We designed a randomized clinical trial to test a novel use of a patient decision aid to promote appropriate colorectal cancer screening and have recruited a diverse study population that seems similar between the intervention and control groups. The study should be able to determine the ability of a patient decision aid to increase individualized and appropriate colorectal cancer screening.

Supporting shared decision making when clinical evidence is low

Shared decision making (SDM) is the process of providing the patient with critical information that can support his or her informed participation in decision making. Shared decision making has become accepted as an important component of quality health care. Influenced by its foundations in law and ethics and by empirical work on its value as a tool to reduce variability in care, a perception has developed that SDM is relevant primarily to clinical situations with high-quality clinical evidence. This raises the question of the role of SDM in situations when clinical evidence is lacking or of low quality. This article posits that SDM is equally relevant and important to low-evidence situations in four ways--SDM fosters shared acceptance of uncertainty, closes the gap in knowledge between patient and physician, promotes patient empowerment, and enhances trust through transparent communication.

Informed consent in complementary and alternative medicine

The objective of this study was to examine complementary and alternative medicine (CAM) practitioners' (i) attitudes toward informed consent and (ii) to assess whether standards of practice exist with respect to informed consent, and what these standards look like. The design and setting of the study constituted face-to-face qualitative interviews with 28 non-MD, community-based providers representing 11 different CAM therapeutic modalities. It was found that there is great deal of variability with respect to the informed consent process in CAM across providers and modalities. No unique profession-based patterns were identified. The content analysis yielded five major categories related to (i) general attitude towards the informed consent process, (ii) type and amount of information exchange during that process, (iii) disclosure of risks, (iv) discussions of alternatives, and (v) potential benefits. There is a widespread lack of standards with respect to the practice of informed consent across a broad range of CAM modalities. Addressing this problem requires concerted and systematic educational, ethical and judicial remedial actions. Informed consent, which is often viewed as a pervasive obligation is medicine, must be reshaped to have therapeutic value. Acknowledging current conceptions and misconception surrounding the practice of informed consent may help to bring about this change. More translational research is needed to guide this process.

A targeted decision aid for the elderly to decide whether to undergo colorectal cancer screening: development and results of an uncontrolled trial

BACKGROUND

Competing causes of mortality in the elderly decrease the potential net benefit from colorectal cancer screening and increase the likelihood of potential harms. Individualized decision making has been recommended, so that the elderly can decide whether or not to undergo colorectal cancer (CRC) screening. The objective is to develop and test a decision aid designed to promote individualized colorectal cancer screening decision making for adults age 75 and over.

METHODS

We used formative research and cognitive testing to develop and refine the decision aid. We then tested the decision aid in an uncontrolled trial. The primary outcome was the proportion of patients who were prepared to make an individualized decision, defined a priori as having adequate knowledge (10/15 questions correct) and clear values (25 or less on values clarity subscale of decisional conflict scale). Secondary outcomes included overall score on the decisional conflict scale, and preferences for undergoing screening.

RESULTS

We enrolled 46 adults in the trial. The decision aid increased the proportion of participants with adequate knowledge from 4% to 52% (p < 0.01) and the proportion prepared to make an individualized decision from 4% to 41% (p < 0.01). The proportion that preferred to undergo CRC screening decreased from 67% to 61% (p = 0. 76); 7 participants (15%) changed screening preference (5 against screening, 2 in favor of screening)

CONCLUSION

In an uncontrolled trial, the elderly participants appeared better prepared to make an individualized decision about whether or not to undergo CRC screening after using the decision aid.

A structurational analysis of informed consent to treatment: (re)productions of contradictory sociohistorical structures in practitioners' interpretive schemes

Informed consent (IC) to treatment honors patient autonomy and bodily integrity. Yet, it is a leading reason for patient litigation, it has not been examined from discursive or theoretical perspectives, and its sociohistorical context is ignored. In a previous analysis of American IC law and the IC literature, structuration theory guided a reconceptualization of IC as unfolding amid contradictory sociohistorical structures or discursive formations-traditionalism, liability, and decision making-representing interests favoring a group's (physicians, states and administrative entities, and patients, respectively) control of IC. This study's focus groups with radiologists found them (re)producing these structures in their interpretive schemes of patients' reactions to IC, IC as protective paperwork, and IC as a patient- and relationship-centered process.

"It's not what you say ...": racial disparities in communication between orthopedic surgeons and patients

BACKGROUND

Excellent communication between surgeons and patients is critical to helping patients to make informed decisions and is a key component of both high quality of care and patient satisfaction. Understanding racial disparities in communication is essential to provide quality care to all patients.

OBJECTIVE

To examine the content and process of informed decision-making (IDM) between orthopedic surgeons and elderly white versus African American patients. To assess the association of race and patient satisfaction with surgeon communication.

RESEARCH DESIGN

Analysis of audiotape recordings of office visits between orthopedic surgeons and patients.

PARTICIPANTS

Eighty-nine orthopedic surgeons and 886 patients age 60 years or older in Chicago, Illinois.

METHODS

Tapes were analyzed by coders for content using 9 elements of IDM and for process using 4 global ratings of the relationship-building component of communication (responsiveness, respect, listening, and sharing). Ratings by race were compared using chi analysis. Patients completed a questionnaire rating satisfaction with surgeon communication and the visit overall. Logistic analysis was used to assess the effect of race on satisfaction.

RESULTS

Overall there were practically no significant differences in the content of the 9 IDM elements based on race. However, coder ratings of relationship were higher on 3 of 4 global ratings (responsiveness, respect, and listening) in visits with white patients compared with African American patients (P < 0.01). Patient ratings of communication and overall satisfaction with the visit were significantly higher for white patients.

CONCLUSIONS

The content of IDM conversations does not differ by race. Yet differences in the process of relationship building and in patient satisfaction ratings were clearly present. Efforts to enhance cultural communication competence of surgeons should emphasize the skills of building relationships with patients in addition to the content of IDM.

A structurational analysis of informed consent to treatment: societal evolution, contradiction, and reproductions in medical practice

Informed consent (IC) to treatment enables physician disclosures (e.g., risks, benefits) and shared decisions, and honors patient autonomy and bodily integrity. Unfortunately, litigation and rising physician malpractice insurance suggest a need to reexamine IC. To initiate this, problems plaguing prior studies of IC interaction--lack of discursive and theoretical perspectives, neglect of IC's sociohistorical context--must first be addressed. Structuration theory, which overcomes these problems, guided analyses of IC law, resulting in discovery of three sociohistorical systems of meaning or discourses representing interests that favor different groups' (physicians, states and administrative entities, patients) control of IC's meaning and ideal practice. The article then works toward blending IC's sociohistorical context with struggles in contemporary practice by reexamining the literature on IC interaction for (re)productions of these discourses.

Informed Consent: A Process to Facilitate Older Adults' Participation in Research

Trust is the foundation of the informed consent process. According to Kass et al., Yet only through vigilance and humility will we, as investigators, be able to live up to the trust that is placed in us; and only if that trust is deserved can the research enterprise survive (1996, p. 28). Therefore, further research should examine the effect of the informed consent process in limiting older adults' participation. Only by re-evaluating the first point of contact, implementing creative strategies to overcome barriers to the informed consent process, and validating these strategies through research will nurses facilitate the inclusion of older adults in research.

Interventions for patients, providers, and health care organizations

Clinicians and the organizations within which they practice play a major role in enabling patient participation in cancer screening and ensuring quality services. Guided by an ecologic framework, the authors summarize previous literature reviews and exemplary studies of breast, cervical, and colorectal cancer screening intervention studies conducted in health care settings. Lessons learned regarding interventions to maximize the potential of cancer screening are distilled. Four broad lessons learned emphasize that multiple levels of factors-public policy, organizational systems and practice settings, clinicians, and patients-influence cancer screening; that a diverse set of intervention strategies targeted at each of these levels can improve cancer screening rates; that the synergistic effects of multiple strategies often are most effective; and that targeting all components of the screening continuum is important. Recommendations are made for future research and practice, including priorities for intervention research specific to health care settings, the need to take research phases into consideration, the need for studies of health services delivery trends, and methods and measurement issues.