•Don’t make firm predictions
•Do what predictions you do for yourself
•Don’t communicate unless asked
•Don’t be specific
•Don’t be extreme
•Be compassionate and optimistic
Patient-Centered Communication: A Useful Clinical ReviewZackary Berger
Patient-centered communication is important because of the 5 E's: ethics, emotions, efficiency, effectiveness, and equity. This talk was originally given October 1, 2014, at the Baltimore City Medical Society.
•Don’t make firm predictions
•Do what predictions you do for yourself
•Don’t communicate unless asked
•Don’t be specific
•Don’t be extreme
•Be compassionate and optimistic
Patient-Centered Communication: A Useful Clinical ReviewZackary Berger
Patient-centered communication is important because of the 5 E's: ethics, emotions, efficiency, effectiveness, and equity. This talk was originally given October 1, 2014, at the Baltimore City Medical Society.
INFORMATION SHARING AND SHARED DECISION MAKING IN CLINICAL .pptxSuryansh Agrawal
Important of information sharing is vital to safeguarding and promoting the welfare of children, young people and adults. The decisions about how much information to share, with whom and when, can have a profound impact on individuals' lives. It could ensure that an individual receives the right services at the right time
Consumer Attitudes About Comparative EffectivenessMSL
Evidence as an essential—but insufficient—ingredient for medical decision-making. Presentation to the National Comparative Effectiveness Summit by Chuck Alston, SVP and Director of Public Affairs at MSLGROUP Washington, DC on September 16, 2013.
Discussion 1Decision-Making ProcessWith the paternalistic deVinaOconner450
Discussion 1
Decision-Making Process
With the paternalistic decision-making model, people tend to feel as though the situation they are intends to be democratic since workers are required to discuss as well as comment and their questions are responded to. Nevertheless, the decision is based on the person at the top. This form of decision-making is effective only when dealing with an individual whose freedom of choice is seriously impaired. With this model, the majority of the decisions are made with the employees’ best interests considered. The manager is provided with the power to rule from the idea that they have the ability to make decisions for the team which enhances trust as well as loyalty with the workers. However, this form of decision-making is wrong sometimes and tends to interfere with an individual’s autonomy. What do I mean by this? May exist the case in which the participants do not come to an agreement all at once, and if that’s so, the “leader” will decide for all of them attempting against the right of autonomy of those few individuals that did not agree at first. (Driever, Stiggerlbout, & Brand, 2020).
Informative decision-making
The informative decision-making model is mainly used when the choices that people have to make are related to the decision topic. It mainly involves assessing potential outcomes, benefits as well as risks related to every option. With informative decision-making, people tend to have a sense of self-confidence, reduced anxiety and feelings of conflict on one’s decision. However, this form of decision-making tends to require too much time. The decision to be made and the whole process it entails requires time to listen to all people and identify the most effective decision to make (El Miedany et al., 2019).
Shared decision-making
The shared decision-making method involves the healthcare team collaboration to decide the approach to use on the patients’ plan of care. It mainly involves selecting tests as well as treatment in regard to evidence as well as the individual’s individual preferences, beliefs as well as values. Shared decision-making mainly involves allowing evidence and patients’ preferences to be included in a consultation enhancing patient knowledge, risk perception accuracy, patient-clinician communication, and minimizing decisional conflict. However, with this type of decision-making, the majority of the patients do not wish to take part in decisions, therefore uncertainties inherent in medical care tend to be dangerous. This is not appropriate to offer information on the potential risks as well as benefits of all treatment choices. Additionally, maximizing patient involvement in decision-making may result in increased demand for inappropriate, expensive as well as dangerous procedures that might undermine the equitable allocation of healthcare resources (Driever, Stiggerlbout, & Brand, 2020).
The method that has the strongest possibility of resulting in permanent change
The informative ...
Communication: The Key to Unlocking Patient Care ImprovementMichael Peters
This presentation takes a look at the barriers and improvement opportunities that exist within Oncology and Healthcare in general to build a better patient and healthcare provider communication experience.
April 18, 2018
Decision aids can be highly-effective tools to promote shared decision making and support patients in becoming engaged participants in their healthcare. Join us for the first-ever convening with leaders behind a Washington experiment in certifying decision aids, as state officials, health systems, and on-the-ground implementation experts share lessons learned and discuss policy recommendations for national or statewide approaches to decision aid certification.
For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/decision-aids-for-patients-with-serious-illness
Course 2 the need for a careful and thorough historyNelson Hendler
The medical literature reports that 40%-80% of chronic pain patients are misdiagnosed. Clearly, misdiagnosis leads to ordering the wrong tests, and thereby obtaining an incorrect diagnosis, or overlooking a diagnosis totally, which results in mistreatment. Many reports in the medical literature indicate the best way to get an accurate diagnosis, is to obtain a complete and thorough history. However, this is a time consuming process, and most physicians don’t spend the needed time with a patient. Therefore, a team of doctors from Johns Hopkins Hospital developed a 72 question test, with 2008 possible answers, available over the Internet. When a patient completes the questionnaire, diagnoses are returned within 5 minutes. These diagnoses have a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This is the highest level of accuracy of any expert system available. The efficacy of this approach is proven by outcome studies, which prove that this approach results in a far higher return to work rate and reduced use of medication and doctors visits, when compared to other techniques. This is similar to the techniques used by Johns Hopkins Hospital to reduce their workers compensation payments by 54%.
INFORMATION SHARING AND SHARED DECISION MAKING IN CLINICAL .pptxSuryansh Agrawal
Important of information sharing is vital to safeguarding and promoting the welfare of children, young people and adults. The decisions about how much information to share, with whom and when, can have a profound impact on individuals' lives. It could ensure that an individual receives the right services at the right time
Consumer Attitudes About Comparative EffectivenessMSL
Evidence as an essential—but insufficient—ingredient for medical decision-making. Presentation to the National Comparative Effectiveness Summit by Chuck Alston, SVP and Director of Public Affairs at MSLGROUP Washington, DC on September 16, 2013.
Discussion 1Decision-Making ProcessWith the paternalistic deVinaOconner450
Discussion 1
Decision-Making Process
With the paternalistic decision-making model, people tend to feel as though the situation they are intends to be democratic since workers are required to discuss as well as comment and their questions are responded to. Nevertheless, the decision is based on the person at the top. This form of decision-making is effective only when dealing with an individual whose freedom of choice is seriously impaired. With this model, the majority of the decisions are made with the employees’ best interests considered. The manager is provided with the power to rule from the idea that they have the ability to make decisions for the team which enhances trust as well as loyalty with the workers. However, this form of decision-making is wrong sometimes and tends to interfere with an individual’s autonomy. What do I mean by this? May exist the case in which the participants do not come to an agreement all at once, and if that’s so, the “leader” will decide for all of them attempting against the right of autonomy of those few individuals that did not agree at first. (Driever, Stiggerlbout, & Brand, 2020).
Informative decision-making
The informative decision-making model is mainly used when the choices that people have to make are related to the decision topic. It mainly involves assessing potential outcomes, benefits as well as risks related to every option. With informative decision-making, people tend to have a sense of self-confidence, reduced anxiety and feelings of conflict on one’s decision. However, this form of decision-making tends to require too much time. The decision to be made and the whole process it entails requires time to listen to all people and identify the most effective decision to make (El Miedany et al., 2019).
Shared decision-making
The shared decision-making method involves the healthcare team collaboration to decide the approach to use on the patients’ plan of care. It mainly involves selecting tests as well as treatment in regard to evidence as well as the individual’s individual preferences, beliefs as well as values. Shared decision-making mainly involves allowing evidence and patients’ preferences to be included in a consultation enhancing patient knowledge, risk perception accuracy, patient-clinician communication, and minimizing decisional conflict. However, with this type of decision-making, the majority of the patients do not wish to take part in decisions, therefore uncertainties inherent in medical care tend to be dangerous. This is not appropriate to offer information on the potential risks as well as benefits of all treatment choices. Additionally, maximizing patient involvement in decision-making may result in increased demand for inappropriate, expensive as well as dangerous procedures that might undermine the equitable allocation of healthcare resources (Driever, Stiggerlbout, & Brand, 2020).
The method that has the strongest possibility of resulting in permanent change
The informative ...
Communication: The Key to Unlocking Patient Care ImprovementMichael Peters
This presentation takes a look at the barriers and improvement opportunities that exist within Oncology and Healthcare in general to build a better patient and healthcare provider communication experience.
April 18, 2018
Decision aids can be highly-effective tools to promote shared decision making and support patients in becoming engaged participants in their healthcare. Join us for the first-ever convening with leaders behind a Washington experiment in certifying decision aids, as state officials, health systems, and on-the-ground implementation experts share lessons learned and discuss policy recommendations for national or statewide approaches to decision aid certification.
For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/decision-aids-for-patients-with-serious-illness
Course 2 the need for a careful and thorough historyNelson Hendler
The medical literature reports that 40%-80% of chronic pain patients are misdiagnosed. Clearly, misdiagnosis leads to ordering the wrong tests, and thereby obtaining an incorrect diagnosis, or overlooking a diagnosis totally, which results in mistreatment. Many reports in the medical literature indicate the best way to get an accurate diagnosis, is to obtain a complete and thorough history. However, this is a time consuming process, and most physicians don’t spend the needed time with a patient. Therefore, a team of doctors from Johns Hopkins Hospital developed a 72 question test, with 2008 possible answers, available over the Internet. When a patient completes the questionnaire, diagnoses are returned within 5 minutes. These diagnoses have a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This is the highest level of accuracy of any expert system available. The efficacy of this approach is proven by outcome studies, which prove that this approach results in a far higher return to work rate and reduced use of medication and doctors visits, when compared to other techniques. This is similar to the techniques used by Johns Hopkins Hospital to reduce their workers compensation payments by 54%.
Carle Palliative Care Journal Club 1/15/2020Mike Aref
A journal club review and criticism of J Natl Cancer Inst. 2019 Dec 17. pii: djz233. doi: 10.1093/jnci/djz233 Emergency Department Visits for Opioid Overdoses Among Patients with Cancer by Jairam V, Yang DX, Yu JB, Park HS.
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
Carle General Surgery Grand Rounds presentation on palliative care symptom management, specifically pain, nausea, constipation, and malignant bowel obstruction.
The Family Meeting: The Procedure of Patient-Centered CareMike Aref
University of Illinois College of Medicine at Urbana-Champaign Internal Medicine Grand Rounds presentation on the elements, techniques, and tools of high-quality family meetings.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Immunity to Veterinary parasitic infections power point presentation
Ethical Issues of Applying Technological Solutions to the Informed Consent Process
1. Ethical Issues of Applying
Technological Solutions to the
Informed Consent Process
An Anti-Luddite Discussion
Michael Aref, MD, PhD, FACP, FHM, FAAHPM, HMDC
@PalliatorMike #CarleBioethxSeminar
2. Disclosures
• No financial disclosures.
• This presentation is my opinion and interpretation
of the literature and does not reflect any opinion
other than my own.
3. Objectives • Review concepts of informed consent,
goals of care and shared decision making.
• Discuss principlist ethical concepts of
autonomy, beneficence, non-maleficence,
and justice in terms of informed consent.
• Discuss issues of decisional capacity,
health literacy, and language as they
complicate informed consent.
• Compare and contrast video and virtual
reality technology solutions for improving
informed consent.
5. Definitions
Informed Consent
• The process in which a health care
provider educates a patient or
their healthcare decision making
surrogate about the risks, benefits,
and alternatives of a given
procedure or intervention.
• Ethically and legally required.
• In practice it is poorly performed
and does not meet the high
standards of its definition
Goals of Care
• The determination of the
endpoints of treatment that are
consistent with a patient’s values
and meaning.
• Ethically required.
Shah P, Thornton I, Turrin D, Hipskind JE. Informed consent. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2021. doi:10.1038/s41415-021-2614-y
Pope TM. Informed Consent Requires Understanding: Complete Disclosure Is Not Enough. Am J Bioeth. 2019;19(5):27-28. doi:10.1080/15265161.2019.1587549
8. Shared Decision Making
Choices regarding care that are made jointly by patients
or their proxy and their healthcare providers.
The application of relational autonomy or the selection
of a plan of care from among a clinically viable set of
options that is consistent with the patient’s goals.
Lenz M, Buhse S, Kasper J, Kupfer R, Richter T, Mühlhauser I. Decision aids for patients. Dtsch Arztebl Int. 2012;109(22-23):401-408. doi:10.3238/arztebl.2012.0401
Elwyn G, Frosch D, Thomson R, et al. Shared decision making: A model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367. doi:10.1007/s11606-012-2077-6
9. Technology and Shared
Decision Making
• Both informed consent
and goals of care are
inadequately
implemented in
practice.
• Communications training
• Scripting
• Websites
• Apps
• Videos
• Augmented and virtual
reality
Pope TM. Certified patient decision aids: Solving persistent problems with informed consent law. J Law, Med Ethics. 2017;45(1):12-40. doi:10.1177/1073110517703097
10. Process of Informed Consent
Communication between the provider and the
patient or their surrogate in which information is
exchanged.
The patient or their surrogate elect and authorize
an intervention or treatment.
Ebbesen M, Sundby M, Pederson F, Andersen S. A Philosophical Analysis of Informed Consent for Whole Genome Sequencing in Biobank Research by use of Beauchamp and Childress’ Four Principles of Biomedical Ethics. J Clin Res Bioeth. 2015;06(06). doi:10.4172/2155-9627.1000244
11. Rules of Informed Consent
• Respect the privacy of others.
• Protect confidential information.
• Obtain consent for interventions with
patients.
• When asked, help others making
important decisions.
• Telling the truth.
Beauchamp T, Childess JF. Principles of Biomedical Ethics. 7th ed. Oxford University Press; 2012.
12. Informed Consent in Terms of Ethical Principles
•The right to protection
from harm
•The right to the same
treatment regardless of
non-disease related factors
such as age, sex, gender,
sexual orientation, race,
religion, finances, or other
demographic differences
•The right to only be offered
options that are helpful
•The right of a patient to
freely choose among
offered clinical options
Autonomy Beneficence
Non-
maleficence
Justice
13. Autonomy in Informed Consent
• Autonomy is the key principle of informed consent.
• Majority of patients with serious illness would appreciate
prognostication to plan and anticipate their needs, however a
majority of physicians are hesitant to do so due to:
• lack of training in prognostication and communication regarding prognosis
• fear of causing hopelessness
• poor estimate models
Christakis NA, Lamont EB. Extent and determinants of error in physicians’ prognoses in terminally ill patients: Prospective cohort study. West J Med. 2000;172(5):310-313. doi:10.1136/ewjm.172.5.310
Ranjan P, Kumari A, Chakrawarty A. How can doctors improve their communication skills? J Clin Diagnostic Res. 2015;9(3):1-4. doi:10.7860/JCDR/2015/12072.5712
14. Beneficence in Informed Consent
• Informed consent requires the
appraisal and the disclosure of a
patient’s prognosis as well as the
interpretation of the disclosed
information.
• It is important to use evidenced-
based interventions that have
supportive evidence including
positive endpoints of conveying
information, risk analysis, and
comprehension.
• Numerical representations
presenting statistics in terms of
natural frequencies rather than
percentages.
• Avoiding linguistic representation
of risks without supporting
numerical representations.
• Graphical representations of
information.
• SPIKES model
• ”Teach-back”
Martin EJ, Widera E. Prognostication in Serious Illness. Med Clin NA. 2020;104(3):391-403. doi:10.1016/j.mcna.2019.12.002
Lenz M, Buhse S, Kasper J, Kupfer R, Richter T, Mühlhauser I. Decision aids for patients. Dtsch Arztebl Int. 2012;109(22-23):401-408. doi:10.3238/arztebl.2012.0401
Yen PH, Leasure AR. Use and Effectiveness of the Teach-Back Method in Patient Education and Health Outcomes. Fed Pract. 2019;36(6):284-289. http://www.ncbi.nlm.nih.gov/pubmed/31258322%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC6590951.
15. SPIKES
Set-up the interview
Perception of the patient/surrogate
Invitation of the patient/surrogate
Knowledge sharing
Emotional acknowledgement
Strategize and summarize
16. Teach-Back
A Priori A Posteriori
• Patient has seen a specialist or
been referred from another
physician.
• Minimum: Review documentation.
Ideally speak with other physician.
• “To make sure I provide you with
the best care, it helps me to
understand if you can tell me, in
your own words, what Dr. X, the
[specialty] doctor, explained to
you.”
• You are finishing your visit and
want to assess that the patient has
increased understanding of the
clinic situation.
• “We talked about a lot today and
sometimes I can get a little
technical. For my benefit, if you
were to explain the most important
points of today’s visit to your
family, what would you tell them?”
JBI Database System Rev Implement Rep. 2016 Jan;14(1):210-47
17. Non-Maleficence in Informed Consent
• Research has demonstrated that physicians often feel that it is the
responsibility of patients to learn about their prognosis rather than
information that is provided by the physician.
• Two in every three physicians decline providing estimates of
prognosis, particularly regarding life-expectancy.
• As a group, oncologists often use negative and aggressive metaphors
to describe the discussion of prognosis such as
• “hitting [the patient] over the head”
• “dropping a bomb”
• “ambushing [the patient]”
Gordon EJ, Daugherty CK, Gordon E.J, Daugherty C.K. “Hitting you over the head”: Oncologists’ disclosure of prognosis to advanced cancer patients. Bioethics. 2003;17(2):142-168. doi:10.1111/1467-8519.00330
Martin EJ, Widera E. Prognostication in Serious Illness. Med Clin NA. 2020;104(3):391-403. doi:10.1016/j.mcna.2019.12.002
Brennan F, Stewart C, Burgess H, et al. Time to improve informed consent for dialysis: An international perspective. Clin J Am Soc Nephrol. 2017;12(6):1001-1009. doi:10.2215/CJN.09740916
18. Non-maleficence in Informed Consent
• No clear consensus on diagrams, narratives, or inclusion of cultural
characteristics in communicating prognostication.
• No studies on layout for communicating prognostication.
• No definitive evidence regarding language complexity and level used.
• Differing prognostic estimates by different providers involved in care.
Martin EJ, Widera E. Prognostication in Serious Illness. Med Clin NA. 2020;104(3):391-403. doi:10.1016/j.mcna.2019.12.002
Siddiqui S, Zhang WW, Platzbecker K, Douglas MJ, Rock LK, Eikermann M. Ethical, legal, and communication challenges in managing goals-of-care discussions in chronically critically ill patients. J Crit Care. 2020;(2020). doi:10.1016/j.jcrc.2020.08.029
19. Justice in Informed Consent
• Informed consent is typically obtained just prior to the procedure,
often after any time of consideration of risks versus benefits.
• The time period of the duration of the informed consent is not
universally agreed upon setting up conflicts of interest when it comes
to the appropriate time to reexplore goals of care.
Nusbaum L, Douglas B, Damus K, Paasche-Orlow M, Estrella-Luna N. Communicating Risks and Benefits in Informed Consent for Research: A Qualitative Study. Glob Qual Nurs Res. 2017;4. doi:10.1177/2333393617732017
Siddiqui S, Zhang WW, Platzbecker K, Douglas MJ, Rock LK, Eikermann M. Ethical, legal, and communication challenges in managing goals-of-care discussions in chronically critically ill patients. J Crit Care. 2020;(2020). doi:10.1016/j.jcrc.2020.08.029
20. Decisional Capacity
• Capacity is the provider’s assessment that the patient’s level of
attention, cognitive processing, and language comprehension with
suitable aids that are sufficient for comprehension and processing of
medical information to reach, at worst, an informed and, at best,
rational decision
• Decisional capacity assessments are at minimum best performed by two
independent parties.
• May benefit from multiple perspectives in cases of greater complexity such as
when the patient is only partially incapacitated.
Brennan F, Stewart C, Burgess H, et al. Time to improve informed consent for dialysis: An international perspective. Clin J Am Soc Nephrol. 2017;12(6):1001-1009. doi:10.2215/CJN.09740916
Bernat JL. Ethical issues in the perioperative management of neurologic patients. Neurol Clin. 2004;22(2):457-471. doi:10.1016/j.ncl.2003.12.004
21. Decisional Capacity
Clear Incapacity
• Coma
• Severe, non-verbal, dementia
Occult Incapacity
• Verbal patients particularly those
with good “defense” mechanisms.
• Conversant but lack the executive
functioning or short-term memory to
make complex, informed, medical
decisions
• Waxing and waning cognition.
• Delirium, encephalopathy
• Acute due to emotional impact of
new diagnostic or prognostic
information.
Forte DN, Kawai F, Cohen C. A bioethical framework to guide the decision-making process in the care of seriously ill patients. BMC Med Ethics. 2018;19(1):78-78. doi:10.1186/s12910-018-0317-y
Requarth JA. Informed consent challenges in frail, delirious, demented, and do-not-resuscitate adult patients. J Vasc Interv Radiol. 2015;26(11):1647-1651. doi:10.1016/j.jvir.2015.08.011
Bernat JL. Ethical issues in the perioperative management of neurologic patients. Neurol Clin. 2004;22(2):457-471. doi:10.1016/j.ncl.2003.12.004
22. Relationships in Informed Consent
Patient
Provider
Surrogate
If patients perceive their physician as being integral
to decision-making and value their expertise, the
more likely they will accept counsel regarding their
decisions and remain adherent with
recommendations.
Separating the patient’s voice from the proxy’s wishes
Labrie NHMM, Schulz PJ. The effects of general practitioners’ use of argumentation to support their treatment advice: results of an experimental study using video-vignettes. Health Commun. 2015;30(10):951-961. doi:10.1080/10410236.2014.909276
It is appropriate to include patients with
impaired decisional capacity in informed
consent to the level of their incapacity,
proxies may not understand or accept that
the patient’s decisional capacity as impaired.
23. Health Literacy and Language in Informed
Consent
• In first world countries nearly half the population has suboptimal or
inadequate health literacy, simultaneously due to the desire to allow
for self-determination, there is a drive toward patients and their
families making choices amongst increasingly complex options in their
healthcare.
• Dichotomy between intended and received meaning likely arises from
dissimilar life experience and assumptions before, during, and after
conversations:
• literal meaning
• intended meaning
• received meaning.
Perrenoud B, Velonaki V-S, Bodenmann P, Ramelet A-S. The effectiveness of health literacy interventions on the informed consent process of health care users: a systematic review protocol. JBI database Syst Rev Implement reports. 2015;13(10):82-94. doi:10.11124/jbisrir-2015-2304
Batten JN, Wong BO, Hanks WF, Magnus DC. Treatability statements in serious illness: The gap between what is said and what is heard. Cambridge Q Healthc Ethics. 2019;28(3):394-404. doi:10.1017/S096318011900029X
24. Health Literacy and Language in Informed
Consent
Highly contextual words can impair communication:
•Treatable
•Comfort
Provider factors can further complicate communication
•provider discomfort with prognostication due to inaccurate tools
•fear of inaccurate prediction
•discomfort with disclosure of serious news
•inadequate communication skills
•fear of diminishing hope
•fear of causing distress
•fear of disrupting the clinical relationship
•fear of patient dissatisfaction
•provider guilt over not being able to provide curative treatment
Martin EJ, Widera E. Prognostication in Serious Illness. Med Clin NA. 2020;104(3):391-403. doi:10.1016/j.mcna.2019.12.002
25. Development of Technology for Informed
Consent
• Development of informed consent technology:
• systematic literature review
• establishing a theoretical framework
• assessing patient attitudes and preferences
• pilot phase
• evaluation phase
• implementation
• This is an ethical quagmire as biases carried by developers of tools to assist with informed
consent can impact the literature review, theoretical framework, and assessment of patient
preferences.
Lenz M, Buhse S, Kasper J, Kupfer R, Richter T, Mühlhauser I. Decision aids for patients. Dtsch Arztebl Int. 2012;109(22-23):401-408. doi:10.3238/arztebl.2012.0401
26. Video
Informed
Consent
Aids
• Video does show benefit in the decision-making
process, offering different modalities of patient
education beyond brochures increases patient
knowledge and satisfaction.
• For example, in the CPR-VDA study video
• appeared to be feasible
• accepted by all parties involved
• positively affected decision-making by
improving knowledge
• clarifying patient values and self-determination
• improved congruence between patient’s
choices and physician orders
• improved communication regarding CPR
• reduced uncertainty between involved parties
Rothwell E, Johnson E, Wong B, et al. Comparison of Video, App, and Standard Consent Processes on Decision-Making for Biospecimen Research: A Randomized Controlled Trial. J Empir Res Hum Res Ethics. 2020;15(4):252-260. doi:10.1177/1556264620913455
Kapell Brown C, Kryworuchko J, Martin W, Brown CK, Kryworuchko J, Martin W. Evaluation of the CPR video decision aid with patients with end stage renal disease. BMC Nephrol. 2018;19(1). doi:10.1186/s12882-018-1018-y
27. Video
Informed
Consent
Aids
Video modalities allow for standardization of the information
transmission portion of informed consent but are likely only
useful in cases where the options are relatively binary, e.g.
CPR.
Video does not allow for the option of assessing knowledge,
so even the highest-level information about prognosis will not
necessarily be understood and assessment of understanding
not obtained.
Informed consent improvement is most needed for people
with low health literacy which cannot be assessed by the
video decision making aid.
When families are integrated into conversations and
empowered to assist with shared decision making the process
is improved, particularly when a patient has impaired
decisional capacity.
Perrenoud B, Velonaki V-S, Bodenmann P, Ramelet A-S. The effectiveness of health literacy interventions on the informed consent process of health care users: a systematic review protocol. JBI database Syst Rev Implement reports. 2015;13(10):82-94. doi:10.11124/jbisrir-2015-2304
Kalocsai C, Amaral A, Piquette D, et al. “It’s better to have three brains working instead of one”: a qualitative study of building therapeutic alliance with family members of critically ill patients. BMC Health Serv Res. 2018;18(1):533-533. doi:10.1186/s12913-018-3341-1
29. Augmented
and Virtual
Reality
• Insubstantial literature on the use of augmented and
virtual reality in informed consent.
• Virtual reality would allow a patient to literally see
themselves undergo the treatment without having to
bear the burden of direct experience and allow the
highest likelihood or best and worst-case scenario’s
play out.
• Only with minimal risk procedures, such as
hemodialysis, patients can trial the intervention
before committing to treatment.
• Even with strict oversight and guidelines, the rich
presentation of suboptimal information leads to
significant ethical issues.
• Even if we could make the experience indistinguishable
from real life it would be unethical to have a patient
experience the suffering of an intervention for an
imaginary benefit just to assist them in their choices
regarding whether to pursue intervention.
Scherer JS, Holley JL. The role of time–limited trials in dialysis decision making in critically ill patients. Clin J Am Soc Nephrol. 2016;11(2):344-353. doi:10.2215/CJN.03550315
30. Augmented and Virtual Reality
• Perhaps the way forward is to make virtual reality simulations of our patients and allow
physicians to practice their conversations with these simulacra first before having to
engage the patient and their surrogates.
SPIKES takes a good deal of training to be done well. Difficult to replicate this with technology
‘Teach back” requires high level executive functioning assess effectiveness, also difficult to be done by technology
In addition, poor health literacy, innumeracy15, and early cognitive impairment in dementia16 may all be patient limiting factors in understanding and comprehension that technology cannot solve.
Given the underlying rules for informed consent it seems likely that however well-intentioned a new tool would be to assist in informed consent there is an increased risk of further removing physicians from their ethical responsibility of prognostication and communication. That stated there also remains the opportunity with both video and virtual reality aids to empower patients to ask more questions, pulling clinicians from their place of discomfort and promoting ethically responsible, patient-focused, informed consent.
Different estimates, particularly emotionally distressing information such as prognostic estimates, will impair shared decision making and with differing information make informed consent impossible. Until this divide is traversed it seems non-beneficial to add a separate opinion in the glossy packaging of a video or virtual reality to the mix.
Many of the issues regarding justice and informed consent appear to be temporal. The patient presents for the procedure or treatment and consent is signed, that is the patient is likely already committed, somewhat in a sunk cost fallacy, to proceeding and no further decision making will be made at that time. Thus, even the best technological aid to informed consent will need to be implemented in a timely fashion to optimize robust reflection on the decisions regarding an intervention well before it would begin. Furthermore, patients and their families may feel that informed consent is for a specific procedure and the time during which the patient undergoes the procedure. However, proceduralists and surgeons may view informed consent as being inclusive of the pre-, peri- post-procedural and recovery from the intervention while other members of the healthcare team will have different opinions regarding the time period for which the informed consent is valid. Clearly any technological solution to informed consent would be biased by the creators to their perceived appropriate duration of the informed consent. Use of ideological rather than scientific considerations in informed consent can derail the shared decision making required because the information provided is inaccurate. This would remain an existential threat to any technological platform to enhance informed consent unless clear standards, such as those used in evidenced-based clinical recommendations, were used.
Here, again, issues will arise with using technological aids to informed consent. Presenting more information via either video or through virtual reality to an incapacitated patient would only heighten distress for patient and family.
There are essentially three parties involved in informed consent: the patient, healthcare usually represented by the person obtaining informed consent, and the patient’s support network, e.g. their significant other, family, close friends, or caregivers, typically represented by the patient’s healthcare surrogate or power of attorney. These parties must communicate, i.e. patient-provider, provider-surrogate, and patient-surrogate, in order for informed consent to be truly obtained. There are issues with all these interactions that may potentially complicate technological adjuncts to informed consent.
Technological interventions of whatever kind may be able to help provide and frame information. Videos are well suited for providing information and basic computer or web applications may be able to assess rudimentary knowledge but are likely not able to frame information in context of individual patient goals. Short of artificial intelligence that can pass the Turing test (where an artificial intelligence’s answers are indistinguishable from a human)21, provide empathy, and translate goals into definitive clinical plans of care, technology will not be able to assist with decision making and adherence in the same way as an engaged healthcare provider.
The way that an oncologist, a palliative care physician, and a critical care physician view chemotherapy or cardiopulmonary resuscitation (CPR) is significantly different
This is a limitation of deferring or delegating informed decision making to a tool like video, apps, or virtual reality as conversation will likely suffer given baseline discomfort with prognostication and conversations about poor prognosis.
Medicine has suffered morally because of the adoption of more technological solutions when a more human one was required. Each technological advance in medicine has not improved quality of life nor decreased provider burnout and stress. When we look to technology to solve issues that we are fundamentally uncomfortable with such as fear of the unknown and of being cruel we run the risk of making the problem worse and not better. The best way forward in using technology is not by allowing it to address our weaknesses in communication and collaboration but in finding ways to make them our strengths. Perhaps the way forward is to make virtual reality simulations of our patients and allow physicians to practice their conversations with these simulacra first before having to engage the patient and their surrogates.
Medicine has suffered morally because of the adoption of more technological solutions when a more human one was required. Each technological advance in medicine has not improved quality of life nor decreased provider burnout and stress. When we look to technology to solve issues that we are fundamentally uncomfortable with such as fear of the unknown and of being cruel we run the risk of making the problem worse and not better. The best way forward in using technology is not by allowing it to address our weaknesses in communication and collaboration but in finding ways to make them our strengths. Perhaps the way forward is to make virtual reality simulations of our patients and allow physicians to practice their conversations with these simulacra first before having to engage the patient and their surrogates.