Informed Consent: A Monthly Review

January 2021

This digest aggregates and distills key content addressing informed consent from a broad spectrum of peer-reviewed journals and grey literature, and from various practice domains and organization types including international agencies, INGOs, governments, academic and research institutions, consortiums and collaborations, foundations, and commercial organizations. We acknowledge that this scope yields an indicative and not an exhaustive digest product.

Informed Consent: A Monthly Review is a service of the Center for Informed Consent Integrity, a program of the GE2P2 Global Foundation. The Foundation is solely responsible for its content. Comments and suggestions should be directed to:

Paige Fitzsimmons, MA
Associate Director, Center for Informed Consent Integrity
GE2P2 Global Foundation
PDF Version: GE2P2 Global_Informed Consent – A Monthly Review_January 2021

Editor’s Note:
The latest webinar in the Center’s continuing series was held on December 16th 2020 and included a presentation titled COVID-19 Immunization under Emergency Use:: Consent/Refusal, Mandates, Certificates. Foundation President & CEO David Curry led the discussion, which included a rich exchange with call participants. Full information and the webinar recording can be found here on the Center for Informed Consent Integrity website.

Further to this webinar theme, the Foundation recently released An Informed Choice/Consent/Right-to-Refuse Imperative :: Statement on Immunization Involving COVID-19 Vaccines Under Emergency Use Authorization/Listing [EUA/L]. This statement argues that immunization involving COVID-19 vaccines available under emergency use mechanisms or expanded access/compassionate use triggers an imperative to assure that individuals receive the information required to support free exercise of meaningful informed choice/consent, with a right to refuse such vaccination for any reason or no reason. Visit the statement website to read the full text and to consider adding your endorsement.

Informed Consent for Surgery at Resumption of Elective Activity After the First Wave of COVID-19

Informed Consent for Surgery at Resumption of Elective Activity After the First Wave of COVID-19
Nourelhuda M. Darwish, Muhammad Rafaih Iqbal, Adeel Abbas Dhahri, Neville Jacob, Jennifer
Jebamani, Amy Easthope, Vardhini Vijay
Cureus, 11 December 2020; 12(11)
Open Access
The coronavirus disease 2019 (COVID-19) pandemic has changed the dynamics of healthcare, and the elective surgical consent process has also evolved. The Royal College of Surgeons of England published guidance on consent during COVID-19. Through this study, we aimed to assess our local consent adherence to these guidelines on the resumption of elective activity after the first wave of COVID-19.
This prospective review of consecutive elective surgical consent forms was conducted from 20 July 2020 to 16 August 2020 at the Princess Alexandra Hospital NHS Trust, England. The primary outcome was evidence of COVID-19 risk documentation on the consent forms.
A total of 116 patients’ consent forms were reviewed. Most patients were American Society of Anaesthesiologists (ASA) grade 2 (n=70; 60.34%). Only 25 consent forms (21.55%) had COVID -19 and its associated risks documented, with registrars being the most compliant (19/46; 41.3%) followed by consultants (6/51; 11.7%). With regards to the surgical sub-specialities, general surgery, orthopaedics and ENT had the highest compliance with the guidance.
As the elective activity resumes, peri-operative risks of COVID-19 should be weighted in during the informed consent process, as mentioned in the latest international guidelines on consent to avoid litigation and negligence claims.

Ethical Challenges in Health Care Policy during COVID-19 Pandemic in Italy

Ethical Challenges in Health Care Policy during COVID-19 Pandemic in Italy
Davide Ferorelli, Gabriele Mandarelli, Biagio Solarino
Medicina, 11 December 2020
Open Access
Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, Italy has proven to be one of the countries with the highest coronavirus-linked death rate. To reduce the impact of SARS-CoV-2 coronavirus, the Italian Government decision-makers issued a series of law decrees that imposed measures limiting social contacts, stopped non-essential production activities, and restructured public health care in order to privilege assistance to patients infected with SARS-CoV-2. Health care services were substantially limited including planned hospitalization and elective surgeries. These substantial measures were criticized due to their impact on individual rights including freedom and autonomy, but were justified by the awareness that hospitals would have been unable to cope with the surge of infected people who needed treatment for COVID-19. The imbalance between the need to guarantee ordinary care and to deal with the pandemic, in a context of limited health resources, raises ethical concerns as well as clinical management issues. The emergency scenario caused by the COVID-19 pandemic, especially in the lockdown phase, led the Government and health care decision-makers to prioritize community safety above the individuals’ rights. This new community-centered approach to clinical care has created tension among the practitioners and exposed health workers to malpractice claims. Reducing the morbidity and mortality rates of the COVID-19 pandemic is the priority of every government, but the legitimate question remains whether the policy that supports this measure could be less harmful for the health care system.

Integrating Shared Decision Making into Trial Consent: A Nested, Cluster-Randomized Trial

Integrating Shared Decision Making into Trial Consent: A Nested, Cluster-Randomized Trial
Ellen A. Lipstein, Maggie Breslin, Cassandra M. Dodds, Michael D. Kappelman, Nicholas J. Ollberding, Peter Margolis, Yingying Xu, William B. Brinkman
Patient Education and Counseling, 25 December 2020
Using a nested, cluster-randomized trial, we tested the hypothesis that a shared decision-making intervention, as part of consent, would improve study-related knowledge.
We developed a shared decision-making intervention then randomized sites in a clinical trial to intervention or control (standard consent). We collected participants’ knowledge (primary outcome) and decisional support data. Other data came from a clinical registry and research coordinator surveys. We compared outcomes between study arms using generalized estimating equation models, accounting for clustering. We used qualitative description to understand variation in intervention use.
265 individuals, from 34 sites, enrolled in the parent trial during our study period. Of those, 241 participants completed our survey. There was no knowledge difference between arms (mean difference = 0.56 (95%CI: -3.8, 4.9)). Both groups had a considerable number of participants with misunderstandings. We also found no difference for decisional support (mean difference = 1.5 (95%CI: -1.8, 4.8)) or enrollment rate between arms. Clinician use of the intervention varied between sites.
We found no differences in outcomes but demonstrated the feasibility and acceptability of incorporating a shared decision-making intervention into consent.
Practice implications
Future work should consider adapting our intervention to other trials and more robust measurement strategies.

Development, Piloting and Evaluation of an evidence-based informed consent form for total knee arthroplasty (EvAb-Pilot): A protocol for a mixed methods study

Development, Piloting and Evaluation of an evidence-based informed consent form for total knee arthroplasty (EvAb-Pilot): A protocol for a mixed methods study
Alina Weise, Julia Lühnen, Stefanie Bühn, Felicia Steffen, Sandro Zacher, Lauberger Julia, Deha Murat Ates, Andreas Böhmer, Henning Rosenau, Anke Steckelberg, Tim Mathes
Research Square, 15 December 2020
Open Access
Practitioners frequently use informed consent forms to support the physician-patient communication and the informed consent process. Informed consent for surgery often focuses on risk centered information due to high liability risks for treatment errors. This may affect patients’ anxiety of adverse events and the nocebo effect. This study focuses on the optimization of pre-surgical information on risks and complications, and at the same time reconcile these information with legal requirements.
The development, piloting and evaluation of evidence-based informed consent forms for total knee arthroplasty (TKA) and related anesthesia procedures will follow the UK MRC Framework for developing and evaluating complex interventions. Conducting different sub-studies, we will (I) qualitatively explore the information acquisition and decision making processes, (II) develop and pilot test evidence-based informed consent forms on the example of TKA and related anesthesia procedures, (III) conduct a monocentric interrupted time series (ITS) pilot study to evaluate the effects of evidence-based informed consent forms in comparison with standard consent forms and (IV) perform a process evaluation to identify barriers and facilitators to the implementation of the intervention and to analyze mechanisms of impact.
The evidence-based and understandable presentation of risks in informed consent forms aims at avoiding distorted risk depiction and strengthening the patients’ competences to correctly assess the risks of undergoing surgery. This might reduce negative expectations and anxiety of adverse events, which in turn might reduce the nocebo effect. At the same time, the practitioners’ acceptance of evidence-based informed consent forms meeting legal requirements could be increased.

Framing a Consent Form to Improve Consent Understanding and Determine How This Affects Willingness to Participate in HIV Cure Research: An Experimental Survey Study

Framing a Consent Form to Improve Consent Understanding and Determine How This Affects Willingness to Participate in HIV Cure Research: An Experimental Survey Study
Research Article
John A. Sauceda, Karine Dubé, Brandon Brown, Ashley E. Pérez, Catherine E. Rivas, David Evans, Celia B. Fisher
Journal of Empirical Research on Human Research Ethics, 14 December 2020
HIV cure research carries serious risks and negligible benefits. We investigated how participants understand these risks and what influences their willingness to participate. Through internet-based and in-person convenience sampling, 86 HIV+ participants completed an experimental survey. Participants were randomized to read a standard consent form describing a hypothetical HIV cure study or one adapted using Fuzzy Trace Theory—a decision-making model to facilitate complex information processing. We measured consent understanding and cognitive (e.g., safe/harmful) and affective (e.g., concerning, satisfying) evaluations of HIV cure research. Participants who read the adapted consent form had improved consent understanding, but only positive affective evaluations were associated with a willingness to participate. Consent processes can use decision-making theories to facilitate comprehension of study information.

Assessment of the All of Us research program’s informed consent process

Assessment of the All of Us research program’s informed consent process
Megan Doerr, Sarah Moore, Vanessa Barone, Scott Sutherland, Brian M. Bot, Christine Suver, John Wilbanks
American Journal of Bioethics, 4 December 2020
Open Access
Informed consent is the gateway to research participation. We report on the results of the formative evaluation that follows the electronic informed consent process for the All of Us Research Program. Of the nearly 250,000 participants included in this analysis, more than 95% could correctly answer questions distinguishing the program from medical care, the voluntary nature of participation, and the right to withdraw; comparatively, participants were less sure of privacy risk of the program. We also report on a small mixed-methods study of the experience of persons of very low health literacy with All of Us informed consent materials. Of note, many of the words commonly employed in the consent process were unfamiliar to or differently defined by informants. In combination, these analyses may inform participant-centered development and highlight areas for refinement of informed consent materials for the All of Us Research Program and similar studies.

Simulation Training to Improve Informed Consent and Pharmacokinetic/ Pharmacodynamic Sampling in Pediatric Trials

Simulation Training to Improve Informed Consent and Pharmacokinetic/ Pharmacodynamic Sampling in Pediatric Trials
Bjoern B. Burckhardt, Agnes Maria Ciplea, Anna Laven, László Ablonczy, Ingrid Klingmann, Stephanie Läer, Karl Kleine, Michiel Dalinghaus, Milan Ðukic, Johannes M. P. J. Breur, Marijke van der Meulen, Vanessa Swoboda, Holger Schwender, Florian B. Lagler
Frontiers of Pharmacology, December 2020; 11
Open Access
Paediatric trials to add missing data for evidence-based pharmacotherapy are still scarce. A tailored training concept appears to be a promising tool to cope with critical and complex situations before enrolling the very first patient and subsequently to ensure high-quality study conduct. The aim was to facilitate study success by optimizing the preparedness of the study staff shift.
An interdisciplinary faculty developed a simulation training focusing on the communication within the informed consent procedure and the conduct of the complex pharmacokinetic/pharmacodynamic (PK/PD) sampling within a simulation facility. Scenarios were video-debriefed by an audio-video system and manikins with artificial blood simulating patients were used. The training was evaluated by participants’ self-assessment before and during trial recruitment.
The simulation training identified different optimization potentials for improved informed consent process and study conduct. It facilitated the reduction of avoidable errors, especially in the early phase of a clinical study. The knowledge gained through the intervention was used to train the study teams, improve the team composition and optimize the on-ward setting for the FP-7 funded “LENA” project (grant agreement no. 602295). Selfperceived ability to communicate core elements of the trial as well as its correct performance of sample preparation increased significantly (mean, 95% CI, p ≤ 0.0001) from 3 (2.5–3.5) to four points (4.0–4.5), and from 2 (1.5–2.5) to five points (4.0–5.0).
An innovative training concept to optimize the informed consent process and study conduct was successfully developed and enabled high-quality conduct of the pediatric trials as of the very first patient visit.

Recruitment and Consent in an observational study

Recruitment and Consent in an observational study
M Goodwin, W Whittaker, T Walsh, R Emsley, M Sutton, M Tickle
Community Dental Health, 30 November 2020; 37(4) pp 287-292
The study sought to explore the consent rate and associated potential bias across a cohort in a large longitudinal population based study.
Research design
Data were taken from a study designed to examine the effects of the reintroduction of community water fluoridation on children’s oral health over a five-year period. Children were recruited from a fluoridated and non-fluoridated area in Cumbria, referred to as Group 1 and Group 2.
Data were available for 3138 individuals. The consent rate was 12.91 percentage points lower in Group 2 than Group 1 (95% CI -16.27 to -9.56, p<0.001). The population in Group 2 was more deprived than Group 1 before consent was taken. Consent was not associated with deprivation in either group.
The cohort appeared to be unaffected by IMD-related non-consent. However there was a difference in consent rate between the two groups. With the population in Group 1 being more deprived than Group 2, it will be important to incorporate these differences into the analysis at the end of this longitudinal study.

Informed consent for neonatal trials: practical points to consider and a check list

Informed consent for neonatal trials: practical points to consider and a check list
Beate Aurich, Eric Vermeulen, Valéry Elie, Mariette H E Driessens, Christine Kubiak, Donato Bonifazi, Evelyne Jacqz-Aigrain
BMJ Pediatrics, 29 November 2020
Open Access
Obtaining informed consent from parents of critically ill neonates can be challenging. The parental decision making process is influenced by the severity of the child’s condition, the benefit–risk balance, their emotional state and the quality of the relationship with the clinical team. Independent of local legislation, parents may prefer that consent is sought from both. Misconceptions about the absence of risks or unrealistic expectations about benefits should be openly addressed to avoid misunderstandings which may harm the relationship with the clinical team. Continuous consent can be sought where it is unclear whether the free choice of parental consent has been compromised. Obtaining informed consent is a dynamic process building on trusting relationships. It should include open and honest discussions about benefits and risks. Investigators may benefit from training in effective communication. Finally, involving parents in neonatal research including the development of the informed consent form and the process of obtaining consent should be considered standard practice.