Impact of Using a Precompleted Consent Form for Procedural Sedation in the Pediatric Emergency Department

OBJECTIVES

This study aimed to compare elements discussed during the consent process for procedural sedation in the pediatric emergency department to documentation and parental recall before and after implementation of a standardized consent form.

METHODS

This is a mixed-methods study combining retrospective electronic record review and cross-sectional surveys of providers and parents after consent for procedural sedation. Surveys were obtained before and after implementation of a precompleted consent form. Providers' survey responses were compared with consent documentation. Recall of consent elements discussed by linked parent-provider dyads were compared.

RESULTS

Six hundred fifty-five encounters were reviewed. Pediatric emergency medicine fellows and pediatric emergency department-based pediatricians were more likely to document any benefit (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.0-2.4) or alternative (OR, 2.7; 95% CI, 1.8-3.9) compared with PEM attendings. Providers were more likely to report discussion of failure to complete the procedure (OR, 7.3; 95% CI, 2.3-23.3) and parents were more likely to recall discussion of this risk (OR, 5.3; 95% CI, 1.0-27.8) in the postintervention group. Based on provider recall, using the precompleted consent form was associated with providers discussing at least 2 of the 3 benefits (84.0% vs 97.2%, P < 0.01), 5 of the 5 risks (31% vs 67.7%, P < 0.01), and improved parental recall of risks (5.7% vs 22.9%, P = 0.03). More providers reported taking less than 1 minute to complete the form in the postimplementation group (12.0% vs 43.7%, P < 0.01).

CONCLUSIONS

Implementing a precompleted consent form for procedural sedation was associated with providers reporting decreased time spent completing the consent form and better alignment of key consent elements between reported provider discussion and parental recall.

Surgeon Information-Sharing, Parent Verbal Engagement, and Parent Knowledge of Pediatric Adenotonsillectomy

OBJECTIVE

We characterize clinician information-sharing and parent verbal engagement during pediatric adenotonsillectomy consultations and evaluate whether these behaviors relate to disease-specific knowledge for parents of children with obstructive sleep-disordered breathing (OSDB).

STUDY DESIGN

Mixed-methods sequential explanatory analysis.

SETTING

Outpatient otolaryngology clinics.

METHODS

We analyzed audio-recorded communication during outpatient encounters for children undergoing initial evaluation for adenotonsillectomy. We identified discrete triadic instances of clinician discussion of individual risks and benefits, parent verbal responses coded as passive ("Right") or active ("Would that repeat the recovery time?"), and corresponding parent answer (correct or incorrect) on a postconsult knowledge questionnaire. Primary outcomes included parent knowledge and decisional conflict. We qualitatively analyzed substantive questions asked by parents during the encounter.

RESULTS

In 30 consults, clinicians (n = 8) provided 156 instances of discussion (101 risk, 55 benefit), to which parents provided 34% active responses. Clinician discussion of risks and benefits was associated with greater parent knowledge (odds ratio [OR] = 3.70, 95% confidence interval [CI]: 2.25-6.09; P < .001), however parent active engagement was not associated with greater parent knowledge (OR = 1.04, 95% CI: 0.42-2.58, P = .93). Parents demonstrated greater knowledge of benefits than risks (χ2  = 23.16, V = 1.13; P < .001). Parents who responded actively (OR = 0.26, 95% CI: 0.09-0.72; P = .010) or had greater knowledge (OR = 0.41, 95% CI: 0.21-0.81; P = .010) had less decisional conflict.

CONCLUSION

Clinician information-sharing was associated with greater parent knowledge about OSDB treatment. Greater parent engagement and knowledge were independently associated with less decisional conflict. These findings may inform clinicians' approaches to counseling and engaging parents in decisions for surgery.

Does the standard medical procedure consent process meet the criteria required for informed consent? - A concept analysis

BACKGROUND

Informed consent is a complex process that is legally required before any surgical procedure.

PURPOSE

The purpose of this manuscript was to perform a concept analysis of the informed consent process.

METHODS

The use of dimensional analysis identified three separate yet related perspectives of the informed consent process: legal, health care, and patients. A database search using the Cumulative Index to Nursing and Allied Health Literature and PubMed were performed.

FINDINGS

A total of 27 publications were reviewed. The legal perspective addresses the requirement of informed consent, which starts with the discussion between the health care provider and the patient undergoing the surgical procedure and ends with a signature on a piece of paper. The health care perspective also addresses the legal requirement but incorporates the goals and objectives of the individual initiating the informed consent discussion. The patients' perspectives also incorporate goals and objectives; however, they differ from that of the health care provider in that they go beyond what happens in the operating room or during hospitalization.

DISCUSSION

Viewing informed consent through these different yet related perspectives provides insight into this complex process and may enhance the researcher's ability to understand and improve the informed consent process.

Family risk communication preferences in pediatric surgery: A scoping review

BACKGROUND

Effective patient-surgeon communication is vital in pediatric surgical practice. However, family (including child) preferences for the format and content of risk communication information are largely unknown. In order to optimize the shared-decision making process, this scoping review explored the family-preferred methods for risk communication in pediatric surgery.

METHODS

A search was conducted in 7 databases from inception until June 2020 to identify family risk communication preferences in pediatric surgical patients, with language restricted to English and French. Two independent reviewers completed the screening in Rayyan software following PRISMA protocol. Included publications were reviewed for data extraction, analyzed, and assessed for risk of bias using standardized instruments.

RESULTS

A total of 6370 publications were retrieved, out of which 70 were included. Studies were predominantly from ENT (30.0%), general surgery (15.7%), and urology (11.4%). Family-preferred risk communication methods were classified as visual, verbal, technology-based, written, decision aids or other. Technological (32.4%) and written tools (29.7%) were most commonly chosen by families as their preferred risk communication methods. Written tools were frequently used in general surgery and urology, while technology-based tools were widely used in ENT. Most studies were cross-sectional and had a significant risk of bias.

CONCLUSION

Eliciting families' preferences for risk communication methods is critical for the implementation of shared decision-making. Different risk communication media appear to be preferred within specific surgical domains. To further improve shared-decision making in pediatric surgery, the development and usage of robust, validated risk communication tools are necessary.

LEVEL OF EVIDENCE

Level IV (Scoping Review).

Understanding the effectiveness of consent processes and conversations in pediatric surgery: A systematic-scoping review

BACKGROUND

The consent conversation in pediatric surgery is an essential part of pre-operative care which, when inadequate, can lead to significant adverse consequences for the child, parents, surgeon, other healthcare workers and the healthcare system. We reviewed the published literature on what key stakeholders perceive are the components of effective and ineffective consenting processes in pediatric surgery.

METHODS

A medical librarian searched seven databases to retrieve articles looking at the informed consenting process in surgical care for the pediatric population. Two independent reviewers screened all publications and categorized them by stakeholder perspectives (patient/family, surgical team, other healthcare team, and hospital administration or policy maker). General study characteristics, interventions to improve consent and features of effective and ineffective consent conversations were extracted.

RESULTS

5079 titles and abstracts were screened, resulting in 88 full-text studies and 43 articles included in the final review. Most publications (51%) discussed informed consent only from the patient/family perspective, while 21% added surgeon's perspective. No study approached the consenting process from the perspective of all stakeholder groups. Effective consent components identified included use of multimedia, presence of multiple conversations prior to surgery, and individualized communication catered to unique family knowledge and needs. In contrast, ineffective conversations did not include a clear assessment of parental understanding, delivered too much information, and did not address parental anxiety.

CONCLUSIONS

The literature on the consenting process in pediatric surgery is narrow in stakeholder perspectives. Our findings highlight gaps in the literature and opportunities to improve the informed consent processes prior to pediatric surgery.

Parental Decision-Making for Surgery and Anesthesia in Young Children

Millions of young children undergo surgery and anesthesia each year, yet there is a lack of scientific consensus about the safety of anesthesia exposure for the developing brain. Also poorly understood is parental anesthesia-related decision-making and how neurotoxicity information influences their choices. The theoretical model of parental decision-making generated in this research explicates this process. Interviews with 24 mothers yielded a theoretical framework based on their narratives developed using a qualitative grounded theory analysis. Five major themes emerged from these interviews: emotional processing, cognitive processing, relationships as resources, the mother/child dyad, and the health care context. Mothers described a non-linear, iterative process; they moved fluidly through emotional and cognitive processing supported by relationships as resources and influenced by the health care context. A key element was the subtheme of the medical translator, an individual who provided context and information. The mother/child dyad grounded the model in the relationship with the child.

Establishment of resilience in a challenging recovery at home after pediatric tonsil surgery-Children's and caregivers' perspectives

The objective of this study was to explore children's and caregivers’ experiences and management of postoperative recovery at home after tonsil surgery. The study had an explorative qualitative design with an inductive approach. Twenty children (5‐12 years of age) undergoing tonsillectomy or tonsillotomy with or without adenoidectomy participated along with their caregivers in semi‐structured interviews at a mean time of 28 days after surgery. The interviews were analyzed with content analysis. One main category emerged from the interviews: children and caregivers struggle to establish resilience in a challenging recovery. The families’ resilience relied on their situational awareness and capacity to act, which in turn formed a basis for the ability to return to normal daily life. Children and caregivers described the recovery as an evident interruption of daily life which had an impact on the children's physical and psychological well‐being. Both children and caregivers described the pain as a central concern. The families used different pharmacological and complementary strategies to manage the pain, which in some cases were complex. Some families said that the analgesics were insufficient in preventing breakthrough pain, and spoke about a lack of support as well as inadequate and contradictory information from healthcare staff. Caregivers also expressed uncertainty, ambivalence, or anxiety about the responsibility associated with their child's recovery. To optimize and support the recovery after tonsil surgery, it is crucial to obtain knowledge of children's and caregivers’ perspectives of postoperative recovery at home. The results indicate that the postoperative period included several troublesome experiences for which neither the children nor the caregivers were informed or prepared. The experience of pain was significant, and often complex to manage. To increase families’ resilience, the information provided by healthcare professionals needs to be broadened. Multidisciplinary teamwork is necessary to achieve this goal.

The role of explanatory models of breast cancer in breast cancer prevention behaviors among Arab-Israeli physicians and laywomen

Background:

‘Explanatory Models’ (EMs) are frameworks through which individuals and groups understand diseases, are influenced by cultural and religious perceptions of health and illness, and influence both physicians and patients’ behaviors.

Aims:

To examine the role of EMs of illness (cancer-related perceptions) in physicians’ and laywomen’s behaviors (decision to recommend undergoing regular mammography, adhering to mammography) in the context of a traditional-religious society, that is, the Arab society in Israel.

Methods:

Two combined samples were drawn: a representative sample of 146 Arab physicians who serve the Arab population and a sample composed of 290 Arab women, aged 50–70 years, representative of the main Arab groups residing in the north and center of Israel (Muslims, Christians) were each randomly sampled (cluster sampling). All respondents completed a closed-ended questionnaire.

Results:

Women held more cultural cancer-related beliefs and fatalistic beliefs than physicians. Physicians attributed more access barriers to screening as well as fear of radiation to women patients and lower social barriers to screening, compared with the women’s community sample. Higher fatalistic beliefs among women hindered the probability of adherence to mammography; physicians with higher fatalistic beliefs were less likely to recommend mammography.

Conclusions:

The role of cultural perceptions needs to be particularly emphasized. In addition to understanding the patients’ perceptions of illness, physicians must also reflect on the social, cultural, and psychological factors that shape their decision to recommend undergoing regular mammography.

Access to an online video enhances the consent process, increases knowledge, and decreases anxiety of caregivers with children scheduled for inguinal hernia repair: A randomized controlled study

BACKGROUND

There is limited time within the clinical workflow of most pediatric surgeons to obtain a comprehensive, well informed consent. This study evaluates whether ad-lib access to an online video on the consent dialogue enhances the consent process for inguinal hernia repair (IHR) in children.

METHODS

The study was approved by the state ethics board. A 6-min video of a consent speech on IHR was produced and uploaded to a nonpublic online channel, explaining the condition, procedure, complications, and postoperative expectations. A total of 50 families were randomized to conventional, face-to-face consenting in clinic either with (intervention) or without (control) access to the online video. During their child's IHR, the parents were asked to complete the State-Trait-Anxiety Inventory (STAI), a modified Friedlander questionnaire on assessing knowledge sufficient to provide informed consent, and a validated satisfaction survey. Scores of the intervention and control group were statistically compared.

RESULTS

The intervention group demonstrated significantly decreased anxiety measured with the STAI (p = 0,026) and increased knowledge (p = 0,016) compared to controls. There was no difference in satisfaction (p = 0,557).

CONCLUSION

Preoperatively providing access to an online consent video regarding IHR reduces anxiety and enhances knowledge without altering satisfaction level. Adjunct online videos are a useful tool to enhance the consent process.

TYPE OF STUDY

Prospective randomized controlled trial.

LEVEL OF EVIDENCE

Level I.

Health Literacy in the Inpatient Setting: Implications for Patient Care and Patient Safety

Health literacy plays a role in the events leading up to children's hospitalizations, during hospital admission, and after discharge. Hospitals and providers should use a universal precautions approach and routinely incorporate health-literacy-informed strategies in communicating with all patients and families to ensure that they can understand health information, follow medical instructions, participate actively in their own/their child's care, and successfully navigate the health care system. Interventions that incorporate health-literacy-informed strategies and that target patients/families and health care systems should be implemented to improve patient outcomes and patient-centered and family-centered care.

Evaluation of Parental Perspectives and Concerns About Pediatric Tonsillectomy in Social Media

Importance

Tonsillectomy is common in children, but little is known about parental preferences and values concerning this surgical procedure. Twitter offers an opportunity to evaluate parental understanding and experience of tonsillectomy care.

Objective

To identify parental perspectives about tonsillectomy in children that may not be apparent in a routine clinical encounter.

Design, Setting, and Participants

In this qualitative study, social media platform Twitter was searched for posts (tweets) published between January 1, 2008, and December 31, 2017, by US-based parents about their child's tonsillectomy. Modified grounded theory was applied to develop a coding taxonomy to classify the tweets. Tweets were assessed for thematic synthesis and classification, and descriptive statistics were obtained for each theme.

Main Outcomes and Measures

Themes of parental experiences and perspectives about their child's tonsillectomy.

Results

Of the 5801 total tweets retrieved, 782 (13.5%) satisfied the inclusion criteria. Tweets were categorized under 2 overarching themes: procedural concerns (549 tweets [70.2%]) and attitudes or experiences (498 [63.7%]). Common tweets under procedural concerns mentioned surgical indication for tonsillectomy (55 tweets [7.0%]); eg, "strep-I think it's tonsil removing time…") and recovery (227 tweets [29.0%]), including child's attitude (89 tweets [11.4%]; eg, "so hard to get my daughter to eat") and parental experience (87 tweets [11.1%]; eg, "tonsillectomy recovery sucks for the parent as much as the kid!"). Common tweets regarding attitudes or experiences included the tenor of overall care (225 tweets [28.6%]; eg, "Tonsillectomy is a bear") and fears or apprehensions (209 tweets [26.6%]).

Conclusions and Relevance

These social media findings may be used to guide clinicians in educating and counseling parents as well as further engaging parents and children in shared decision making for tonsillectomy.

The Effect of Written Information on Recall of Surgical Risks of Primary Cleft Palate Repair: A Randomized Controlled Study

OBJECTIVE

To investigate parents' understanding of the risks of primary cleft palate surgery after counseling with and without the use of a written informational aid.

DESIGN

Prospective, randomized, single-blind trial.

SETTING

Academic tertiary care center.

PARTICIPANTS

Parents of children undergoing primary cleft palate surgery.

INTERVENTIONS

Parents were randomized to receive a standard informed consent discussion with or without provision of a written informational aid in the form of a pamphlet.

MAIN OUTCOMES MEASURE

Parents' recall of 9 specific surgical risks 3 weeks after informed consent discussion.

RESULTS

Forty parents enrolled in and completed the study (20 participants each in the control and intervention groups). There were no statistically significant differences between groups in terms of baseline demographics. The mean number of risks recalled were 3.7 (1.6) for the control group and 4.2 (1.9) for the intervention group (P = .37). The most commonly recalled risks were fistula formation and bleeding, while the least frequent were facial growth restriction and need for further surgery. No differences in risk recall were observed based on participant's gender, level of education, or income.

CONCLUSION

Parents of children undergoing primary cleft palate surgery recall less than 50% of counseled risks. The use of a written aid in the form of a pamphlet did not significantly improve recall in this sample. These results demonstrate that surgeons should implement additional measures to improve comprehension of surgical risks.

Parents' experiences managing their child's complicated postoperative recovery

OBJECTIVE

Tonsillectomy is commonly performed as same-day surgery and parents are heavily relied upon for management of children's postoperative recovery. The objective of this study was to provide an in-depth description of the experiences parents face when managing their child's complicated postoperative recoveries at home.

METHODS

An exploratory qualitative study at an academic pediatric hospital in Eastern Canada was performed. Participants included 12 parents of children aged 3-6 years who underwent adeno/tonsillectomy and experienced unexpected outcomes or complications during the postoperative recovery period. Parents participated in semi-structured interviews within 6 months of their child's surgery. Interviews were transcribed verbatim and thematic analysis was used to identify themes in the parents' experiences.

RESULTS

Parents described struggling to make the decision to come back to hospital, that adequate information does not prevent emotional difficulties, and feeling somewhat responsible for the unexpected outcome or complicated course of recovery. Communication with healthcare providers was considered very important in helping with the recovery process.

CONCLUSION

This research helps to inform healthcare professionals about how they might better support families during complicated recovery processes. Areas of action may include clear communication, setting expectations, and psychosocial support.

Informed consent in pediatric anesthesiology

BACKGROUND

Informed consent for pediatric anesthesia is unique because it is (1) obtained from surrogates (ie, parents) rather than from the patient and (2) sought after parents have authorized the surgical intervention. There are limited data on how pediatric anesthesia informed and consent discussions are conducted. The purpose of this study was to characterize the content of preanesthesia informed consent discussions and assess their impact on parent recall and understanding.

METHODS

We conducted a cross-sectional observational study at a tertiary pediatric hospital. We audio-recorded and transcribed preanesthesia consent discussions between pediatric anesthesia providers and parents of children undergoing elective surgery. Parents were recruited on the day of surgery and completed a survey postdiscussion to assess their recall and perceived understanding. We used directed content analysis to identify 7 informed consent elements: (i) description of the plan; mention of (ii) alternatives, (iii) risks, and (iv) benefits; (v) discussion of uncertainties; (vi) assessment of comprehension; and (vii) solicitation of a decision. We used multivariable logistic regression to explore the association between discussions that included 3 informed consent elements (description of plan, mention of risks, and mention of benefits) and parent recall and understanding of these elements.

RESULTS

We analyzed 97 discussions involving 41 different anesthesia providers. The element most frequently included in preanesthesia discussions was a description of the plan (100%); the least frequently included was decision solicitation (18%). Seventy-one percent of discussions included ≥5 informed consent elements and 70% included a description of the plan, mention of risks, and mention of benefits. Parental recall of these 3 informed consent elements was associated with their inclusion in the preanesthesia discussion (75% vs 34%), and more parents understood all 3 elements if they had reported (vs not reported) recall of all 3 elements (97% vs 53%).

CONCLUSION

Most pediatric preanesthesia discussions include ≥5 informed consent elements and describe the plan, mention risks, and mention benefits. Inclusion of these latter 3 consent elements was associated with parental recall of these elements but not understanding.