Accounts of consent: Orienting to self-other relations regarding motivations to participate in cancer bio-banking

Physicians' use of plain language during discussions of prostate cancer clinical trials with patients

OBJECTIVE

This study described physicians' use of plain language during patient-physician cancer clinical trial discussions.

METHODS

Video-recorded clinical interactions and accompanying transcripts were taken from a larger study of communication and clinical trials (PACCT). Interactions (n = 25) were selected if they included invitations to participate in a clinical trial. We used descriptive, qualitative discourse analysis, a method that identifies language patterns at or above the sentence level. We first excerpted discussions of clinical trials, then identified instances of plain language within those discussions. Finally, we inductively coded those instances to describe physicians' plain language practices.

RESULTS

The analysis identified four plain language practices. Lexical simplification replaced medical terminology with simpler words. Patient-centered definition named, categorized, and explained complex medical terminology. Metaphor explained medical terminology by comparing it with known concepts. Finally, experience-focused description replaced medical terminology with descriptions of patients' potential physical experiences.

CONCLUSION

These plain language practices hold promise as part of effective information exchange in discussions of cancer clinical trials. Testing is needed to identify patient preferences and the extent to which these practices address patient health literacy needs.

PRACTICE IMPLICATIONS

Pending further testing, these plain language practices may be integrated into physician clinical trial and other communication training.

Elicitation of children's understanding of information in pediatric genetic counseling encounters: A discourse-oriented perspective

Affirmation of children's understanding of information provided in genetic counseling encounters is crucial to obtaining children's informed consent/assent in pediatric genetic counseling encounters. It is also important for the proper management of a genetic condition. Currently, there is a relative scarcity of research on how understanding of complex genetic information by children is elicited in the process of pediatric genetic counseling. In this study, we apply theme-oriented discourse analysis to examine 23 video/audio-recorded genetic counseling encounters in Hong Kong. The encounters involve children aged between 3 and 17 years old who are suspected to have or diagnosed with Sudden Arrhythmic Death Syndrome (SADS). Specifically, we examine a range of communicative strategies that genetic professionals employ to elicit children's understanding of information in this genetic counseling setting. We also examine how children's epistemic status is negotiated between genetic professionals, parents, and children. The study reveals that genetic professionals typically use direct questioning (e.g., "do you understand?" or "do you have any questions?"). Less typical are examples where genetic professionals explore children's epistemic access and invite children to recall information after they deliver it. The study reveals two discourse strategies that genetic professionals and parents employ to justify a child's low epistemic status: (1) construction of "current ignorance" and "future competence" in children and (2) association with a child's character. In the examined counseling encounters, genetic professionals and parents tend to construct a low epistemic status in younger children and allocate the responsibility for understanding relevant information to the parents and the "future" competent children. The study highlights the impact of genetic professionals' and parents' assumptions on children's knowledge and comprehensibility at different ages, and the role that children themselves play in conforming or contesting these assumptions.

Diagnostic uncertainties, ethical tensions, and accounts of role responsibilities in genetic counseling communication

Diagnostic uncertainties are intricately associated with genomic testing-especially concerning new technologies such as exome sequencing-with test results being either inconclusive or generating secondary findings or showing variants of uncertain significance. In the process of genetic counseling, diagnostic uncertainties have to be managed even when test results for an individual client are either positive or negative because of differential implications for family members. Previous studies have investigated diagnostic uncertainties in relation to clients wanting to know or not know the test results; here, we extend this line of research by addressing how genetic counselors and clients account for the management of diagnostic uncertainties vis-à-vis the attendant ethical tensions in the complex communicative environment in the clinic setting. Our dataset from the Norwegian context is longitudinal, consisting of ten audio-recorded pre-test genetic counseling sessions. It involves one extended family with a high burden of colorectal cancer. Through theme-oriented discourse analysis, we demonstrate how diagnostic uncertainties give rise to tensions concerning risks and benefits of knowing in both professional and familial spheres, which then map onto accounts of various role responsibilities. For instance, in looking for certainty via advanced genomic testing to reduce diagnostic uncertainty for clients, genetic counselors are confronted with tensions regarding what can be communicated and made known because of their role responsibilities toward what may be regarded as scientific others and clinical others. Likewise, clients are faced with tensions concerning wanting to know/not know, which invokes various familial others and may align or not align with genetic counselors' preferences, especially relating to management of diagnostic uncertainties and secondary findings.

Ethics in genetic counselling

Difficult ethical issues arise for patients and professionals in medical genetics, and often relate to the patient's family or their social context. Tackling these issues requires sensitivity to nuances of communication and a commitment to clarity and consistency. It also benefits from an awareness of different approaches to ethical theory. Many of the ethical problems encountered in genetics relate to tensions between the wishes or interests of different people, sometimes even people who do not (yet) exist or exist as embryos, either in an established pregnancy or in vitro. Concern for the long-term welfare of a child or young person, or possible future children, or for other members of the family, may lead to tensions felt by the patient (client) in genetic counselling. Differences in perspective may also arise between the patient and professional when the latter recommends disclosure of information to relatives and the patient finds that too difficult, or when the professional considers the genetic testing of a child, sought by parents, to be inappropriate. The expectations of a patient's community may also lead to the differences in perspective between patient and counsellor. Recent developments of genetic technology permit genome-wide investigations. These have generated additional and more complex data that amplify and exacerbate some pre-existing ethical problems, including those presented by incidental (additional sought and secondary) findings and the recognition of variants currently of uncertain significance, so that reports of genomic investigations may often be provisional rather than definitive. Experience is being gained with these problems but substantial challenges are likely to persist in the long term.