1
|
Albert M, Thonander M, Forsberg S, Lindgren F, Thuccani M, Odell A, Skoglund K, Bergh N, Hollenberg J, Ringh M, Jonsson M, Nordberg P, Lundgren P. Hospitalized patients' attitudes towards participating in a randomized control trial in case of a cardiac arrest. Resusc Plus 2024; 18:100645. [PMID: 38708065 PMCID: PMC11066544 DOI: 10.1016/j.resplu.2024.100645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background No previous study has evaluated patients attitudes towards inclusion in an ongoing cardiac arrest clinical trial. The aim of this study was to assess patientś willingness and motives to participate in the ongoing randomized controlled drug trial "Vasopressin and Steroids in addition to Adrenaline in cardiac arrest" (VAST-A trial) in case of an in-hospital cardiac arrest (IHCA). Objectives Hospitalized patients, men ≥ 18 and women ≥ 50 years, were asked for informed consent for inclusion in the VAST-A trial in case of an IHCA, the reason for approving or declining inclusion in the trial and baseline characteristics. Methods Patients admitted to hospital were asked to give informed consent of inclusion in VAST-A in case of an IHCA during their hospital stay. Patients were also asked why they approved or declined inclusion as well as baseline characteristics questions. Results 1,064 patients were asked about willingness to participate in the VAST-A trial, of these 902 (84.8%) patients approved inclusion. A subgroup of 411 patients were, except willingness, also asked about motives to participate or not and basic characteristics. The main reason for approving inclusion was to contribute to research (n = 328, 83.9%). The main reason for declining inclusion was concerns regarding testing the drug treatment (n = 6, 30%). Conclusion Among hospitalized patients the vast majority gave informed consent to inclusion in an ongoing randomized cardiac arrest drug trial. The main reason for approving inclusion was to contribute to research.
Collapse
Affiliation(s)
- Malin Albert
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Sweden
| | - Marie Thonander
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Cardiology, Gothenburg, Sweden
| | - Sune Forsberg
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Sweden
- Norrtälje Hospital, Norrtälje, Sweden
| | | | - Meena Thuccani
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Cardiology, Gothenburg, Sweden
| | - Annika Odell
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Cardiology, Gothenburg, Sweden
- Institute of Health and Care Science at University of Gothenburg, Sweden
| | - Kristofer Skoglund
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Cardiology, Gothenburg, Sweden
| | - Niklas Bergh
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Cardiology, Gothenburg, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Sweden
| | - Mattias Ringh
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Sweden
| | - Martin Jonsson
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Sweden
| | - Per Nordberg
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Sweden
| | - Peter Lundgren
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Cardiology, Gothenburg, Sweden
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, SE- 501 90 Borås, Sweden
| |
Collapse
|
2
|
Fitzpatrick A, Wood F, Shepherd V. Trials using deferred consent in the emergency setting: a systematic review and narrative synthesis of stakeholders' attitudes. Trials 2022; 23:411. [PMID: 35578362 PMCID: PMC9109432 DOI: 10.1186/s13063-022-06304-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with acute conditions often lack the capacity to provide informed consent, and narrow therapeutic windows mean there is no time to seek consent from surrogates prior to treatment being commenced. One method to enable the inclusion of this study population in emergency research is through recruitment without prior consent, often known as 'deferred consent'. However, empirical studies have shown a large disparity in stakeholders' opinions regarding this enrolment method. This systematic review aimed to understand different stakeholder groups' attitudes to deferred consent, particularly in relation to the context in which deferred consent might occur. METHODS Databases including MEDLINE, EMCare, PsychINFO, Scopus, and HMIC were searched from 1996 to January 2021. Eligible studies focussed on deferred consent processes for adults only, in the English language, and reported empirical primary research. Studies of all designs were included. Relevant data were extracted and thematically coded using a narrative approach to 'tell a story' of the findings. RESULTS Twenty-seven studies were included in the narrative synthesis. The majority examined patient views (n = 19). Data from the members of the public (n = 5) and health care professionals (n =5) were also reported. Four overarching themes were identified: level of acceptability of deferred consent, research-related factors influencing acceptability, personal characteristics influencing views on deferred consent, and data use after refusal of consent or participant death. CONCLUSIONS This review indicates that the use of deferred consent would be most acceptable to stakeholders during low-risk emergency research with a narrow therapeutic window and where there is potential for patients to benefit from their inclusion. While the use of narrative synthesis allowed assessment of the included studies, heterogeneous outcome measures meant that variations in study results could not be reliably attributed to the different trial characteristics. Future research should aim to develop guidance for research ethics committees when reviewing trials using deferred consent in emergency research and investigate more fully the views of healthcare professionals which to date have been explored less than patients and members of the public. Trial registration PROSPERO CRD42020223623.
Collapse
Affiliation(s)
| | - Fiona Wood
- Division of Population Medicine and PRIME Centre Wales, University Hospital of Wales, Cardiff University, 8th floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS Wales
| | | |
Collapse
|
3
|
de Tonnerre EJ, Smith JL, Spencer WS, Date PA, Taylor DM. Patient perceptions of participation in emergency medicine research projects. Emerg Med Australas 2020; 32:570-572. [PMID: 32043294 DOI: 10.1111/1742-6723.13455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/16/2019] [Accepted: 12/20/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if ED research reflects patient expectations. METHOD A cross-sectional ED patient survey. RESULTS Three hundred and nine (98.1%, 95% confidence interval [CI] 95.7-99.2) of 315 patients believed that ED research was important. Two hundred and twelve (68.4%, 95% CI 62.9-73.5) would welcome involvement, only 26 (8.4%, 95% CI 5.7-12.3) felt pressured to do so. Two hundred and thirty-one (75.7%, 95% CI 70.5-80.4) and 279 (91.5%, 95% CI 87.6-94.3) believed consent was necessary for observational and experimental studies, respectively. One hundred and one (32.4%, 95% CI 27.3-37.9) disagreed with medical records being accessed without consent. CONCLUSION Patient expectations are not always consistent with current practice. The expectation of consent prior to record access is worthy of further consideration.
Collapse
Affiliation(s)
- Erik J de Tonnerre
- Northern Sydney Local Health District, NSW Health, Sydney, New South Wales, Australia
| | | | | | | | - David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
4
|
Traverse JH. The Misguided Regulation of Cardiac Emergencies: The Rise of the IRB-Industrial Complex and the Increasing Risk to Cardiovascular Research and Our Patients. Circ Res 2018; 119:1063-1066. [PMID: 27789585 DOI: 10.1161/circresaha.116.309893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jay H Traverse
- From the Cardiovascular Division, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, School of Medicine, University of Minnesota.
| |
Collapse
|
5
|
Furyk J, Franklin R, Watt K, Emeto T, Dalziel S, McBain-Rigg K, Stepanov N, Babl FE. Community attitudes to emergency research without prospective informed consent: A survey of the general population. Emerg Med Australas 2018; 30:547-555. [DOI: 10.1111/1742-6723.12958] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/08/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Jeremy Furyk
- Emergency Department; The Townsville Hospital; Townsville Queensland Australia
- School of Public Health, Tropical Medicine and Rehabilitation Sciences; James Cook University; Brisbane Queensland Australia
- Public Health and Tropical Medicine; James Cook University; Brisbane Queensland Australia
| | - Richard Franklin
- School of Public Health, Tropical Medicine and Rehabilitation Sciences; James Cook University; Brisbane Queensland Australia
| | - Kerrianne Watt
- School of Public Health, Tropical Medicine and Rehabilitation Sciences; James Cook University; Brisbane Queensland Australia
| | - Theopilus Emeto
- School of Public Health, Tropical Medicine and Rehabilitation Sciences; James Cook University; Brisbane Queensland Australia
| | - Stuart Dalziel
- Children's Emergency Department; Starship Children's Hospital; Auckland New Zealand
| | - Kris McBain-Rigg
- School of Public Health, Tropical Medicine and Rehabilitation Sciences; James Cook University; Brisbane Queensland Australia
| | - Nikola Stepanov
- Emergency Department; The Townsville Hospital; Townsville Queensland Australia
| | - Franz E Babl
- Emergency Department; Royal Children's Hospital; Melbourne Victoria Australia
| |
Collapse
|
6
|
Furyk J, McBain-Rigg K, Watt K, Emeto TI, Franklin RC, Franklin D, Schibler A, Dalziel SR, Babl FE, Wilson C, Phillips N, Ray R. Qualitative evaluation of a deferred consent process in paediatric emergency research: a PREDICT study. BMJ Open 2017; 7:e018562. [PMID: 29146655 PMCID: PMC5695338 DOI: 10.1136/bmjopen-2017-018562] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND A challenge of conducting research in critically ill children is that the therapeutic window for the intervention may be too short to seek informed consent prior to enrolment. In specific circumstances, most international ethical guidelines allow for children to be enrolled in research with informed consent obtained later, termed deferred consent (DC) or retrospective consent. There is a paucity of data on the attitudes of parents to this method of enrolment in paediatric emergency research. OBJECTIVES To explore the attitudes of parents to the concept of DC and to expand the knowledge of the limitations to informed consent and DC in these situations. METHOD Children presenting with uncomplicated febrile seizures or bronchiolitis were identified from three separate hospital emergency department databases. Parents were invited to participate in a semistructured telephone interview exploring themes of limitations of prospective informed consent, acceptability of the DC process and the most appropriate time to seek DC. Transcripts underwent inductive thematic analysis with intercoder agreement, using Nvivo 11 software. RESULTS A total of 39 interviews were conducted. Participants comprehended the limitations of informed consent under emergency circumstances and were generally supportive of DC. However, they frequently confused concepts of clinical care and research, and support for participation was commonly linked to their belief of personal benefit. CONCLUSION Participants acknowledged the requirement for alternatives to prospective informed consent in emergency research, and were supportive of the concept of DC. Our results suggest that current research practice seems to align with community expectations.
Collapse
Affiliation(s)
- Jeremy Furyk
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Kristin McBain-Rigg
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Kerrianne Watt
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Theophilus I Emeto
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Richard C Franklin
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Donna Franklin
- Paediatric Critical Care Research Group, Lady Cilento Children’s Hospital, Brisbane, Queensland, Australia
- Mater Research Institute – The University of Queensland, Brisbane, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Lady Cilento Children’s Hospital, Brisbane, Queensland, Australia
- Mater Research Institute – The University of Queensland, Brisbane, Australia
| | - Stuart R Dalziel
- Starship Children’s Hospital, Auckland, New Zealand
- The University of Auckland, Auckland, New Zealand
| | - Franz E Babl
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia
| | - Catherine Wilson
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Natalie Phillips
- Emergency Department, Lady Cilento Children’s Hospital, Brisbane, Queensland, Australia
| | - Robin Ray
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| |
Collapse
|
7
|
Buckley JM, Irving AD, Goodacre S. How do patients feel about taking part in clinical trials in emergency care?: Table 1. Emerg Med J 2016; 33:376-80. [DOI: 10.1136/emermed-2015-205146] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 12/19/2015] [Indexed: 11/03/2022]
|
8
|
Gobat NH, Gal M, Francis NA, Hood K, Watkins A, Turner J, Moore R, Webb SAR, Butler CC, Nichol A. Key stakeholder perceptions about consent to participate in acute illness research: a rapid, systematic review to inform epi/pandemic research preparedness. Trials 2015; 16:591. [PMID: 26715077 PMCID: PMC4693405 DOI: 10.1186/s13063-015-1110-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/08/2015] [Indexed: 12/14/2022] Open
Abstract
Background A rigorous research response is required to inform clinical and public health decision-making during an epi/pandemic. However, the ethical conduct of such research, which often involves critically ill patients, may be complicated by the diminished capacity to consent and an imperative to initiate trial therapies within short time frames. Alternative approaches to taking prospective informed consent may therefore be used. We aimed to rapidly review evidence on key stakeholder (patients, their proxy decision-makers, clinicians and regulators) views concerning the acceptability of various approaches for obtaining consent relevant to pandemic-related acute illness research. Methods We conducted a rapid evidence review, using the Internet, database and hand-searching for English language empirical publications from 1996 to 2014 on stakeholder opinions of consent models (prospective informed, third-party, deferred, or waived) used in acute illness research. We excluded research on consent to treatment, screening, or other such procedures, non-emergency research and secondary studies. Papers were categorised, and data summarised using narrative synthesis. Results We screened 689 citations, reviewed 104 full-text articles and included 52. Just one paper related specifically to pandemic research. In other emergency research contexts potential research participants, clinicians and research staff found third-party, deferred, and waived consent to be acceptable as a means to feasibly conduct such research. Acceptability to potential participants was motivated by altruism, trust in the medical community, and perceived value in medical research and decreased as the perceived risks associated with participation increased. Discrepancies were observed in the acceptability of the concept and application or experience of alternative consent models. Patients accepted clinicians acting as proxy-decision makers, with preference for two decision makers as invasiveness of interventions increased. Research regulators were more cautious when approving studies conducted with alternative consent models; however, their views were generally under-represented. Conclusions Third-party, deferred, and waived consent models are broadly acceptable to potential participants, clinicians and/or researchers for emergency research. Further consultation with key stakeholders, particularly with regulators, and studies focused specifically on epi/pandemic research, are required. We highlight gaps and recommendations to inform set-up and protocol development for pandemic research and institutional review board processes. PROSPERO protocol registration number CRD42014014000 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1110-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Nina H Gobat
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
| | - Micaela Gal
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
| | - Nick A Francis
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
| | - Kerenza Hood
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, Wales, UK.
| | - Angela Watkins
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
| | | | | | | | | | | |
Collapse
|
9
|
Scotton WJ, Kolias AG, Ban VS, Crick SJ, Sinha R, Gardner A, Massey K, Minett T, Santarius T, Hutchinson PJ. Community consultation in emergency neurosurgical research: lessons from a proposed trial for patients with chronic subdural haematomas. Br J Neurosurg 2013; 27:590-4. [DOI: 10.3109/02688697.2013.793291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
10
|
Kämäräinen A, Silfvast T, Saarinen S, Virta J, Virkkunen I. Conduct of emergency research in patients unable to give consent--experiences and perceptions of patients, their consent providing next of kin, and treating physicians following a prehospital resuscitation trial. Resuscitation 2011; 83:81-5. [PMID: 21801702 DOI: 10.1016/j.resuscitation.2011.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 07/04/2011] [Accepted: 07/14/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE According to a directive of the European Parliament, informed consent is required to conduct a clinical trial also in emergencies when the patient is unable to provide consent. In these cases surrogate consent can be obtained from the patient's next of kin. There are no reports describing how patients and their next of kin perceive this policy. The perceptions of patients and their spouses involved in an emergency trial conducted under surrogate consent were surveyed. METHODS A survey was sent to survivors of prehospital cardiac arrest, to consent providers regardless of patient outcome, and to physicians who had recruited the patients. RESULTS 11 (92%) patients, 17 (68%) consent providers, and all physicians returned the survey. All held a positive attitude towards emergency research and were willing to participate without own consent in a trial approved by an institutional review board (IRB). Opinions among responding groups were similar albeit a significant difference regarding the perceived capability of the consent provider to decide upon patient's enrolment. Spouses felt able to provide consent, but physicians were sceptical of this. Patients and their spouses would have appreciated additional information regarding the index trial after the acute phase. CONCLUSIONS Emergency research was perceived positively by cardiac arrest victims and their spouses previously involved in a resuscitation trial. Possible own participation in an emergency trial without personal consent was considered acceptable. Patients and their spouses would prefer additional research information after enrolment.
Collapse
Affiliation(s)
- Antti Kämäräinen
- Critical Care Medicine Research Group, Tampere University Hospital, TAYS PL2000, Tampere, Finland.
| | | | | | | | | |
Collapse
|
11
|
Biros MH, Sargent C, Miller K. Community attitudes towards emergency research and exception from informed consent. Resuscitation 2009; 80:1382-7. [PMID: 19818546 DOI: 10.1016/j.resuscitation.2009.08.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Revised: 07/27/2009] [Accepted: 08/21/2009] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine public attitudes towards emergency research, exception from informed consent (EFIC) and a specific proposed clinical trial using EFIC. METHODS As part of a planned community consultation activity, a survey was conducted at a popular public venue. Participants answered demographic questions and then were asked their opinions on specifically described consent circumstances in emergency research, including the proposed EFIC trial. Multiple logistic and linear regression were used to determine respondent characteristics associated with specific attitudes. RESULTS 1901 surveys were completed. The majority of respondents supported emergency research (88%) and the concept of surrogate consent by a legally authorized representative (78%). The concept of EFIC was less well supported (35%) but the application of EFIC was more accepted, especially when EFIC was applied to the respondent themselves (51%). The community believed the proposed EFIC study was acceptable (82%); a minority had concerns but most were related to patient safety and not to EFIC. Respondents with less education and lower incomes were less likely to express opinions about the consent and research concepts described. CONCLUSIONS Emergency research and the proposed EFIC trial is supported in this community. The concept of EFIC is less well supported but is more acceptable when a specific trial is described or when respondents consider EFIC for themselves. Specific respondent characteristics are associated with attitudes about research; this can assist in development of meaningful community consultation activities.
Collapse
Affiliation(s)
- Michelle H Biros
- University of Minnesota, Department of Emergency Medicine, 717 Delaware Avenue, Minneapolis, MN 55415, United States.
| | | | | |
Collapse
|
12
|
Abstract
Clinical trials in traumatic brain injury have shown little success in providing an evidence base for the introduction of successful new therapies into clinical practice. In addition to the problems that are common to all such studies in critical illness, trials in traumatic brain injury are complicated by the extremely short temporal window for intervention, failure of many candidate drugs to cross the blood-brain barrier, ethical and regulatory obstacles associated with research in subjects who cannot provide consent, the tendency to use small sample sizes in anticipation of unrealistic treatment benefits, and difficulty in translating experimental success into clinical practice. This article reviews the potential causes of these problems and suggests some solutions. These include the changes in regulatory frameworks that are making waived consent an acceptable strategy once more, and an increasing trend toward appropriately large trials. Other encouraging developments include the increasing use of human experimental medicine strategies before phase III trials to assess blood-brain barrier penetration and dose ranging, and provide proof of concept and proof of mechanism. Novel approaches to trial design, such as sliding dichotomy, coupled with robust outcome prediction models, can increase statistical power and improve trial design.
Collapse
|
13
|
Dickert NW, Kass NE. Patients' perceptions of research in emergency settings: a study of survivors of sudden cardiac death. Soc Sci Med 2008; 68:183-91. [PMID: 19004536 DOI: 10.1016/j.socscimed.2008.10.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Indexed: 11/18/2022]
Abstract
Conditions such as stroke, sudden cardiac death, and major traumatic injury are major causes of morbidity and mortality, and there is a need for clinical research to improve treatment for these conditions. However, because informed consent is often impossible, research in these situations poses ethical concerns. Despite growing literature on the ethics of emergency research, little is known about the views of relevant patient populations regarding research in emergency settings conducted under an exception from informed consent (EFIC). In this qualitative study, survivors of sudden cardiac death (SCD)--recruited from an outpatient cardiology clinic in late 2005--were asked their views on scenarios representing different types of EFIC research. Patients were generally accepting of such research, more than previous studies would have predicted. Their concerns focused primarily on study risks and benefits and less on waiving consent or randomization. EFIC research is of international importance and ethical controversy. This study represents the first attempt to assess views of SCD survivors on this type of research and one of the first to assess patients' views in-depth. Findings indicate broad acceptance of EFIC research among this population and re-focus discussion on what risks are reasonable for non-autonomous subjects. The study also demonstrates potential for valuable input from patients regarding complicated and ethically challenging issues using a method that allows them to develop opinions on unfamiliar issues.
Collapse
Affiliation(s)
- Neal W Dickert
- Division of Cardiology, Emory University, EPICORE, Bldg A, Suite 1N, Mailstop 1256/001/1AR, Atlanta, GA 30322, USA.
| | | |
Collapse
|
14
|
Iwanowski P, Budaj A, Członkowska A, Wąsek W, Kozłowska-Boszko B, Olędzka U, Masełbas W. Informed consent for clinical trials in acute coronary syndromes and stroke following the European Clinical Trials Directive: investigators' experiences and attitudes. Trials 2008; 9:45. [PMID: 18644120 PMCID: PMC2517587 DOI: 10.1186/1745-6215-9-45] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2007] [Accepted: 07/21/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND During clinical trials in emergency medicine, providing appropriate oral and written information to a patient is usually a challenge. There is little published information regarding patients' opinions and competence to provide informed consent, nor on physicians' attitudes towards the process. We have investigated the problem of obtaining consent from patients in emergency-setting clinical trials (such as acute coronary syndromes (ACS) and stroke) from a physicians' perspective. METHODS A standardised anonymous 14-item questionnaire was distributed to Polish cardiac and stroke centres. RESULTS Two hundred and fourteen informative investigator responses were received. Of these investigators, 73.8% had experience with ACS and 25.2% had experience with acute stroke trials (and 1% with both fields). The complete model of informed consent (embracing all aspects required by Good Clinical Practice (GCP) and law) was used in 53.3% of cases in emergency settings, whereas the legal option of proxy consent was not used at all. While less than 15% of respondents considered written information to have been fully read by patients, 80.4% thought that the amount of information being given to emergency patients is too lengthy. Although there is no legal obligation, more than half of the investigators sought parallel consent (assent) from patients' relatives. Most investigators confirmed that they would adopt the model proposed by the GCP guidelines: abbreviated verbal and written consent in emergency conditions with obligatory "all-embracing" deferred consent to continue the trial once the patient is able to provide it. However, this model would not follow current Polish and European legislation. CONCLUSION An update of national and European regulations is required to enable implementation of the emergency trial consent model referred to in GCP guidelines.
Collapse
Affiliation(s)
- Piotr Iwanowski
- Association for Good Clinical Practice in Poland, ul. Postępu 18B (Neptun), 02-676 Warszawa, Poland
- International Centre for Therapeutic Research, Servier Poland, ul. Jana Kazimierza 10, 01-248 Warszawa, Poland
| | - Andrzej Budaj
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, ul. Grenadierów 51/59, 04-073 Warszawa, Poland
| | - Anna Członkowska
- Institute of Psychiatry and Neurology, 2nd Department of Neurology, ul. Sobieskiego 9, 02-957 Warszawa, Poland
- Department of Experimental and Clinical Pharmacology, Medical University, Warsaw, ul. Krakowskie Przedmieście 26/28, 00-325 Warszawa, Poland
| | - Wojciech Wąsek
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, ul. Grenadierów 51/59, 04-073 Warszawa, Poland
| | - Beata Kozłowska-Boszko
- Association for Good Clinical Practice in Poland, ul. Postępu 18B (Neptun), 02-676 Warszawa, Poland
- Bayer HealthCare, Medical Department, Al. Jerozolimskie 158, 02-326 Warszawa, Poland
| | - Urszula Olędzka
- Association for Good Clinical Practice in Poland, ul. Postępu 18B (Neptun), 02-676 Warszawa, Poland
- International Centre for Therapeutic Research, Servier Poland, ul. Jana Kazimierza 10, 01-248 Warszawa, Poland
| | - Wojciech Masełbas
- Association for Good Clinical Practice in Poland, ul. Postępu 18B (Neptun), 02-676 Warszawa, Poland
- PPD Development, ul. Postępu 18B (Orion), 02-676 Warszawa, Poland
| |
Collapse
|
15
|
Lecouturier J, Rodgers H, Ford GA, Rapley T, Stobbart L, Louw SJ, Murtagh MJ. Clinical research without consent in adults in the emergency setting: a review of patient and public views. BMC Med Ethics 2008; 9:9. [PMID: 18445261 PMCID: PMC2390563 DOI: 10.1186/1472-6939-9-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Accepted: 04/29/2008] [Indexed: 11/28/2022] Open
Abstract
Background In emergency research, obtaining informed consent can be problematic. Research to develop and improve treatments for patients admitted to hospital with life-threatening and debilitating conditions is much needed yet the issue of research without consent (RWC) raises concerns about unethical practices and the loss of individual autonomy. Consistent with the policy and practice turn towards greater patient and public involvement in health care decisions, in the US, Canada and EU, guidelines and legislation implemented to protect patients and facilitate acute research with adults who are unable to give consent have been developed with little involvement of the lay public. This paper reviews research examining public opinion regarding RWC for research in emergency situations, and whether the rules and regulations permitting research of this kind are in accordance with the views of those who ultimately may be the most affected. Methods Seven electronic databases were searched: Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, Philosopher's Index, Age Info, PsychInfo, Sociological Abstracts and Web of Science. Only those articles pertaining to the views of the public in the US, Canada and EU member states were included. Opinion pieces and those not published in English were excluded. Results Considering the wealth of literature on the perspectives of professionals, there was relatively little information about public attitudes. Twelve studies employing a range of research methods were identified. In five of the six questionnaire surveys around half the sample did not agree generally with RWC, though paradoxically, a higher percentage would personally take part in such a study. Unfortunately most of the studies were not designed to investigate individuals' views in any depth. There also appears to be a level of mistrust of medical research and some patients were more likely to accept an experimental treatment 'outside' of a research protocol. Conclusion There are too few data to evaluate whether the rules and regulations permitting RWC protects – or is acceptable to – the public. However, any attempts to engage the public should take place in the context of findings from further basic research to attend to the apparently paradoxical findings of some of the current surveys.
Collapse
Affiliation(s)
- Jan Lecouturier
- Institute of Health and Society, Newcastle University, The Medical School, Framlington Place, Newcastle upon Tyne, UK.
| | | | | | | | | | | | | |
Collapse
|
16
|
Mitchell AM, Kline JA. Systematic bias introduced by the informed consent process in a diagnostic research study. Acad Emerg Med 2008; 15:225-30. [PMID: 18304052 DOI: 10.1111/j.1553-2712.2008.00066.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine population characteristics, outcomes, and reasons for unsuccessful enrollment among potential study subjects approached for written, informed consent in a minimal-risk emergency department (ED) study. The authors hypothesized that the prevalence of venous thromboembolism (VTE) would be lower among study participants and that medical acuity and refusal to provide a blood sample would be the most common reasons for nonparticipation. METHODS The authors requested prospective, written, informed consent for a blood sample and follow-up from consecutive ED patients undergoing evaluation for pulmonary embolism (PE) and recorded spontaneously stated reasons for refusal. VTE was diagnosed or excluded using a combination of D-dimer testing and selective computed tomography (CT) angiography of the chest with venography of the lower extremities. The primary outcome was defined by the number of CT scans positive for VTE among ED patients evaluated for PE. RESULTS Over 16 weeks, 260 of 287 (91%, 95% confidence interval [CI] = 87 to 94%) eligible patients were approached and consent was obtained from 183 patients (64%, 95% CI = 58% to 69%). The prevalence of VTE was 6% among participants and 13% among nonparticipants (95% CI [of the difference] = 1% to 15%). The proportions of African Americans, uninsured, and Medicaid patients were significantly higher among nonparticipants. No significant differences were found in the proportions of nonparticipants who disliked or distrusted research or desired financial reimbursement, compared to those not enrolled due to medical acuity or refused a blood sample. CONCLUSIONS These data implicate the written, informed consent process as a significant source of bias on estimated disease prevalence.
Collapse
Affiliation(s)
- Alice M Mitchell
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | | |
Collapse
|
17
|
Ethical issues of recruitment and enrollment of critically ill and injured patients for research. AACN Adv Crit Care 2008; 18:352-5. [PMID: 17978608 DOI: 10.1097/01.aacn.0000298626.30406.e1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
18
|
Rózyńska J, Czarkowski M. Emergency research without consent under Polish law. SCIENCE AND ENGINEERING ETHICS 2007; 13:337-50. [PMID: 17874211 DOI: 10.1007/s11948-007-9023-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Accepted: 06/25/2007] [Indexed: 05/17/2023]
Abstract
Although Directive 2001/20/EC of the European Parliament and of Council of 4 April 2001 on the approximation of the laws regulations and administrative provisions of the Member States relating to the implementation of good clinical practice in the conduct of clinical trials on medicinal products for human use does not contain an exception for emergency situations, and requires the informed consent of a legal representative in all cases where research is conducted on legally competent individuals who are unable to give informed consent, in Poland, emergency research can be conducted without consent. Polish regulations on emergency research can hardly be treated as a result of intentional legislative policy. Our provisions arise from multiple and sophisticated interpretations of different regulations that govern medical experiments on human subjects and clinical trials. These interpretations can be summarized as follows: (1) There are two categories of medical experiments: therapeutic and non-therapeutic experiments. Emergency research without consent may be conducted in the category of therapeutic experiment only (therapeutic experiment consists of the introduction by the physician of new or only partially proven diagnostic, therapeutic or preventive methods in order to achieve direct benefit to the health of the patients, and it can be carried out when hitherto applied methods were ineffective or their effectiveness was insufficient). (2). Emergency research may be conducted without consent if there is a situation of great urgency in which the research subject's life is in danger and there is no possibility of obtaining immediate consent from the research subject him or herself, or from his or her legal representative or guardianship court, and the research subject has not refused to give consent for the participation in an emergency therapeutic experiment. The legal representative or guardianship court shall be provided with all the relevant information concerning subject's participation in an experiment as soon as possible. All projects of emergency research with intent to be done without the research subject's consent must be approved by an independent bioethics committee. Because these five requirements seem to provide insufficient protection for a subject's autonomy and rights it is necessary to add to them two other conditions: (1) the emergency research could not be conducted using other research participants capable of giving informed consent; and (2) informed consent for continued participation in the emergency research shall be obtained from either the participant him or herself or the legally authorized representative as soon as possible (requirement of obtaining deferred consent). A consolidated single Act that will govern all aspects of medical experiments on human subjects, including emergency research, should be prepared and enacted as soon as possible.
Collapse
Affiliation(s)
- Joanna Rózyńska
- Graduate School for Social Research, Institute of Philosophy and Sociology, Polish Academy of Sciences, Warsaw, Poland.
| | | |
Collapse
|
19
|
Booth MG. Informed consent in emergency research: a contradiction in terms. SCIENCE AND ENGINEERING ETHICS 2007; 13:351-359. [PMID: 18210228 DOI: 10.1007/s11948-007-9028-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 06/29/2007] [Indexed: 05/25/2023]
Abstract
Improving the treatment of life threatening emergency illness or disease requires that new or novel therapies be assessed in clinical trials. As most subjects for these trials will be incapacitated there is some controversy about they might best protected whilst still allowing research to continue. Recent European and UK clinical trials legislation, which has effectively stopped research into emergency conditions, is discussed. Possible changes to these regulations are proposed.
Collapse
Affiliation(s)
- Malcolm G Booth
- Anaesthesia and Intensive Care, Royal Infirmary, Castle Street, Glasgow, G4 0SF, UK,
| |
Collapse
|
20
|
Bibliography: current world literature. Curr Opin Anaesthesiol 2007; 20:157-63. [PMID: 17413401 DOI: 10.1097/aco.0b013e3280dd8cd1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
21
|
Harvey SE, Elbourne D, Ashcroft J, Jones CM, Rowan K. Informed consent in clinical trials in critical care: experience from the PAC-Man Study. Intensive Care Med 2006; 32:2020-5. [PMID: 17019555 DOI: 10.1007/s00134-006-0358-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2006] [Accepted: 07/26/2006] [Indexed: 10/24/2022]
Abstract
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.
Collapse
Affiliation(s)
- Sheila E Harvey
- Intensive Care National Audit & Research Centre, Tavistock House, Tavistock Square, London, UK
| | | | | | | | | |
Collapse
|