Informed Consent and Digit Replantation: Current State and Recommendations for Ethical Patient Care
Emily Gudbranson, Adnan Prsic, Ashley Pistorio, David L. Colen
The Journal of Hand Surgery, 18 April 2024
Abstract
The importance of informed consent and the value of shared decision-making in hand surgery are well-established and particularly critical in the setting of digit amputation when considering replantation. Informed consent requires an understanding of not only the immediate and long-term risks and benefits of surgery, as well as the risks and alternatives involved, but also the capacity of the patient to make a medical decision. However, patients who have acutely sustained a disfiguring trauma are often in distress and may not fully process the consent discussion. Digit replantation is an “elective emergency”—the decision must be made immediately but is not lifesaving—which poses a difficult dilemma: are surgeons acting in patients’ best interests by pursuing replantation if we engage those patients in informed consent discussions when they may not have capacity? This article explores the relevant bioethical principles associated with digit replantation, summarizes updated literature regarding informed consent and shared decision-making, and provides recommendations for patient education materials to standardize informed consent discussions for surgeons approaching patients at this unique intersection of considering revision amputation versus replantation.

Informed consent in clinical practice: Old problems, new challenges
Research Article
Isaac KS Ng
Journal of the Royal College of Physicians of Edinburgh, 14 April 2024
Abstract
Informed consent is a fundamental tenet of patient-centred clinical practice as it upholds the ethical principle of patient autonomy and promotes shared decision-making. In the medicolegal realm, failure to meet the accepted standards of consent can be considered as medical negligence which has both legal and professional implications. In general, valid consent requires three core components: (1) the presence of mental capacity – characterised by the patient’s ability to comprehend, retain information, weigh options and communicate the decision, (2) adequate information disclosure – based on the ‘reasonable physician’ or ‘reasonable patient’ standards and (3) voluntariness in decision-making. Nonetheless, in real-world clinical settings, informed consent is not always optimally achieved, due to various patient, contextual and systemic factors. In this article, I herein discuss three major challenges to informed consent in clinical practice: (1) patient literacy and sociocultural factors, (2) psychiatric illnesses and elderly patients with cognitive impairment and (3) artificial intelligence in clinical care, and sought to offer practical mitigating strategies to address these barriers.

Preparing Patients for Oral Immunotherapy (PPOINT): International Delphi consensus for procedural preparation and consent
Douglas P. Mack, Timothy E. Dribin, Paul J. Turner, Richard L. Wasserman, Mariam A. Hanna, Marcus Shaker, Mimi L.K. Tang, Pablo Rodríguez del Río, Brad Sobolewski, Elissa M. Abrams, Aikaterini Anagnostou, Stefania Arasi, Sakina Bajowala, Philippe Bégin, Scott B. Cameron, Edmond S. Chan, Sharon Chinthrajah, Andrew T. Clark, Paul Detjen, George du Toit, Matthew Greenhawt
Journal of Allergy and Clinical Immunology, 8 April 2024
Abstract

Background
Despite the promise of oral immunotherapy (OIT) to treat food allergies, this procedure is associated with potential risk. There is no current agreement about what elements should be included in the preparatory or consent process.
Objective
We developed consensus recommendations about the OIT process considerations and patient-specific factors that should be addressed before initiating OIT and developed a consensus OIT consent process and information form.
Methods
We convened a 36-member Preparing Patients for Oral Immunotherapy (PPOINT) panel of allergy experts to develop a consensus OIT patient preparation, informed consent process, and framework form. Consensus for themes and statements was reached using Delphi methodology, and the consent information form was developed.
Results
The expert panel reached consensus for 4 themes and 103 statements specific to OIT preparatory procedures, of which 76 statements reached consensus for inclusion specific to the following themes: general considerations for counseling patients about OIT; patient- and family-specific factors that should be addressed before initiating OIT and during OIT; indications for initiating OIT; and potential contraindications and precautions for OIT. The panel reached consensus on 9 OIT consent form themes: benefits, risks, outcomes, alternatives, risk mitigation, difficulties/challenges, discontinuation, office policies, and long-term management. From these themes, 219 statements were proposed, of which 189 reached consensus, and 71 were included on the consent information form.
Conclusion
We developed consensus recommendations to prepare and counsel patients for safe and effective OIT in clinical practice with evidence-based risk mitigation. Adoption of these recommendations may help standardize clinical care and improve patient outcomes and quality of life.

Valid consent in the acute hospital setting: perspectives of patients and members of the public
Original Article
Živa Kovic, Motheo Kobua, Mary Fogarty, Claire L. Donohoe, Michael E. Kelly, Gerard J. Fitzmaurice, Mella Fitzgerald, Paul Zambra, Una Geary, Marie E. Ward
Irish Journal of Medical Science, 5 April 2024
Open Access
Abstract
Background
People who interact with healthcare services have an ethical and legal right to control their own lives, to make informed decisions, and to consent to what happens to them. For consent to be considered ethically and legally valid, three key criteria must be met: consent must be given voluntarily; people must be sufficiently informed of all options; and people should have capacity to make the decision to give or withhold their consent.
Aim
This study set out to explore, through the use of surveys, the perspectives of patients and public in relation to consent.
Method
Surveys were developed for patients and the public and administered paper based (patients) and through social media (public).
Results
One hundred and forty surveys were posted to patients, with a 38% response rate; 104 responses were received from the public. Ninety-six percent of patients were satisfied that the decision they made was informed; 100% felt they had made a voluntary decision; 98% felt the clinician seemed knowledgeable about the procedure. What matters most to the public were being informed about the risks associated with the proposed procedure and being assured that whatever choice they make they will receive the best care possible.
Conclusions
The results highlight interesting similarities and differences in relation to consent between members of the public thinking about a possible treatment, surgery, or procedure and those patients who have actually been through the process in the past 12 months. Recommendations have been developed on the basis of these findings to co-design improvements in consent practices.

Standardized Informed Consent Form for Clinicians Administering Platelet-Rich Plasma
Satvik N. Pai, Naveen Jeyaraman, Ravichandran Venkatasalam, Ravi VR, Swaminathan Ramasubramanian, Sangeetha Balaji, Arulkumar Nallakumarasamy, Shilpa Sharma, Bishnu P. Patro, Madhan Jeyaraman
Cureus, 3 April 2024; 16(4)
Abstract
Introduction
When it comes to medico-legal malpractice suits, lawyers and insurers tend to focus on informed consent documentation. Unfortunately, there is no standard protocol for obtaining informed consent for the use of platelet-rich plasma (PRP) injections, which might cause problems. This study aimed to mitigate this concern through the development of a standardized informed consent document for PRP injections, grounded in evidence-based practices.
Materials and methods
An examination of databases was conducted to explore the medico-legal ramifications associated with PRP injections, as well as the broader topic of informed consent, with a particular focus on the context of PRP injections. Moreover, interviews were carried out with healthcare providers and individuals who had received PRP injections within the preceding year, utilizing a semi-structured methodology.
Results
We developed an evidence-based informed consent document tailored for PRP injections. To guarantee its legal validity, the document underwent review by a legal specialist. Subsequently, our institutions implemented the finalized form for PRP injection procedures over one year.
Conclusion
A legally valid and evidence-based informed consent form for PRP injections would ensure patient’s rights, and encourage open communication and transparency between them and the doctor. Moreover, if a lawsuit were to arise, it would serve as a critical document in the doctor’s defense and withstand scrutiny from lawyers and the judiciary.

Informed consent in endoscopy: read, understood, or just signed?
Ana Catarina Carvalho, Ricardo Cardoso, Hugo Marcelo Vieira, Américo Silva
iGIE, 2 April 2024
Abstract
Background And Study Aims
While informed consent is a requirement for all interventional procedures such as those in gastrointestinal endoscopy, its standardization is a challenge. While very thorough documents have been proposed, it is unknown whether patients actually read them. We intended to evaluate if patients read and understand informed consent forms and information leaflets for gastrointestinal endoscopy.
Patients And Methods
This single center prospective observational study was performed between April 2021 and April 2022 and included adult patients proposed for outpatient elective esophagogastroduodenoscopy and colonoscopy. Informed consent forms and information leaflets were mailed to patients, with a small text instruction added to the informed consent form. Prior to endoscopy it was assessed whether patients adequately read the informed consent form, based on patient signature, table questionnaire completion and performance of the text instruction.
Results
The study included 232 patients (50.6% males, mean age 63.8±12.76 years). Most had only basic education (78.0%) and had previously undergone gastrointestinal endoscopy (90.6%). 86.6% of patients stated they had read the form while 13.4% did not. While most signed the form (83.6%), only 24.6% adequately read and understood it. No statistically significant association between informed consent form adequate reading and any of the assessed variables was found.
Conclusions
Despite the timely provision of information, most patients do not read or adequately understand the provided documents. It is necessary to develop new strategies to enhance patients’ involvement in decision making, improving the doctor-patient relationship in obtaining informed consent.

Editor’s note: iGIE is published by Elsevier Inc. on behalf of American Society for Gastrointestinal Endoscopy.

Moral Dilemmas Regarding Physical Restraints in Intensive Care Units: Understanding Autonomy, Beneficence, Non-Maleficence and Justice in the Use of Physical Restraints
Zhou J, Qin Q, Chen S, Zhang H
Journal of Multidisciplinary Healthcare, 28 March 2024
Abstract
In intensive care units, patients are often restrained to ensure their safety, with physical restraints being the most commonly used method. However, physical restraints compromises the patient’s freedom, health and comfort, and nurses often face moral dilemmas when deciding whether to use physical restraints. This article examines physical restraints through the four universal principles of autonomy, beneficence, non-maleficence and justice. Through these principles, the authors will critically explore whether the physical restraints of patients by nurses is ethical in practice and what moral issues exist. This paper also explores conflicts and moral dilemmas for nurses in this context. Finally, suggestions are made on changes to education and clinical practice.