Background
Methods
Study design
Systematic review
Design
Eligibility criteria
Search strategy
Quality appraisal
Data screening, extraction, and analysis
Transparent expert consultation
Setting and participants
Data analysis
Median regions and IQR | Interpretation |
---|---|
7–9 | Recommendation indicated |
4–6 | Recommendation equivocal |
1–3 | Recommendation not indicated |
IQR inoneregion | Strict agreement for recommendation |
IQR inanythree-point region | Broad agreement for recommendation |
Results
Systematic review search results
Patient population of interest | Study focus on processes of consent | |||
---|---|---|---|---|
Innovating research methods (n = 37) | Applying research methods (n = 30) | Attitudes and ethical considerations (n = 22) | Total studies (n = 89)* | |
Palliative care/cancer | 16 | |||
Dementia | 1 [80] | 24 | ||
Geriatric care | 0 | 5 | ||
Parkinson’s disease | 1 [86] | 0 | 0 | 1 |
Cerebral ischaemic stroke | 0 | 1 [89] | 3 | |
Mental health | 1 [98] | 9 | ||
Delirium | 0 | 4 | ||
Intensive care | 14 | |||
General population | 0 | 0 | 13 |
Authors, country, EPOC grade | Year | Study design and aim | Setting | Sample description | Consent process for adults across the capacity spectrum | No. patients/eligible (%) | Key findings, challenges, and solutions |
---|---|---|---|---|---|---|---|
Enhanced informed consent processes | |||||||
Dobratz et al. [43], USA, B3 | 2003 | Retrospective research study with a vulnerable population to describe issues and dilemmas related to non-participation, attrition, and need for assistance in research with vulnerable home hospice participants. | Home or preferred setting of home hospice agency recipients from two metropolitan settings | Palliative care: home hospice agency recipients | Informed consent: study was explained to all participants over the phone. Participants provided ‘telephone consent’. During the study visit, participants provided informed consent. Adults with declining capacity | 97/113 (86%) | Key findings: five people who agreed to take part unable to provide informed consent due to distress; five other participants with cognitive impairment precluded informed consent. Solutions: participants require regular monitoring of their physical and psychological symptoms, oversampling to anticipate and plan for withdrawals, and cognitive assessment tool for all potential participants regardless of diagnosis (e.g. brain metastases), and careful screening of psychological behaviours to reduce distress. Participant positive feedback about the study. |
Siminoff et al. [71], the Netherlands, C1 | 2004 | Qualitative study examining the factors that were important in making research participation decisions among patients with Alzheimer’s disease (AD), cancer, critically ill children. | Unclear | Dementia: patients with Alzheimer’s disease with cognitive impairment | Informed consent: potential subjects were given information about the study by phone. During the conversation, if patients met initial eligibility criteria and expressed continued interest in participation, attended the clinic for formal informed consent procedure. The consent form was read to the subjects and questions were addressed throughout and at the end of reviewing the written consent form. Adults with declining capacity | 46 AD patients, mean age 72, 91.3% white, 61% female, 78.3% married, 63.6% more than a high school education, 65.6% income > $25,000 | Key findings: key elements of informed consent. Information—the AD (mean = 1.78) group received more information about voluntary participation than the paediatric (mean = 1.27) group (F = 4.1; p < .05). Confidentiality—were most likely discussed with the AD group (87%) versus the cancer (22%) and paediatric (9.2%) groups (χ2 = 85.24; p < .001). Discussion of ‘no treatment’ as a viable option occurred most often in the AD group (58.7%) versus the adult cancer (41.6%) and paediatric (3.9%) subjects (χ2 = 46.38; p < .001). AD subjects received the most information about voluntary participation and confidentiality, and no treatment option. Challenge: lack of discussions about confidentiality and no treatment as an option. |
Buckles et al. [59], USA, B3 | 2003 | Longitudinal study of healthy ageing and dementia to evaluate understanding of informed consent by older participants across a range of dementia severity using a brief test on the elements of informed consent for a low-risk study. | Not stated | Dementia: 415 participants, 165 without dementia, 250 with dementia | Informed consent and assessment dementia severity with Clinical Dementia Rating (CDR), MMSE Adults with declining capacity | 415 | Key findings: after adjusting for education, performance on the test varied with dementia severity in mean differences and by correlation. All non-demented and very mildly demented participants and 92% of mildly demented participants provided correct answer for at least 8 of 10 true-false items, whereas only 67% of the moderately demented participants achieved this level of accuracy. Solutions: by moderate dementia stage, involvement of a responsible caregiver in consent process should be mandatory. |
Mangset et al. [103], Norway, C1 | 2008 | Qualitative study to explore critically ill patients’ experience with the principle of informed consent in a clinical trial and their ability to give valid informed consent. | 2 Norwegian hospitals | Stroke: stroke patients who were invited to take part in an international stroke trial | Informed consent Adults with declining capacity | 11 | Key findings: the results challenge the validity of informed consent for an experimental trial obtained from critically ill patients, and the concept of the consent as a contract obtained on a rational basis between equal and autonomous parties. Challenges: most patients did not understand the purpose of randomisation or the concept of clinical equipoise. The main reasons for consent were patients’ dependency on the doctor, their need for a trustful relationship, and seeing study information as a recommendation. |
Chouliara et al. [44], UK, C1 | 2004 | Individual interviews on some ethical and methodological challenges involved in conducting research with older people with cancer by referring to researchers’ experiences in an on-going research project. | Care of the elderly wards and a cancer centre | Cancer: people with cancer > 65 years old | Informed consent: obtained after explaining the project verbally and written. Family members involved to assist patient decision-making. In instances where they felt like the patient was not understanding, they also involved. Adults with declining capacity | 37/50 (74%) | Key findings: mean age 74.3 (SD = 7.5), MMSE 24.0 (4.1)—mild dementia. Involvement of vulnerable, elderly individuals was considered ethical in a low-risk qualitative study. Challenges: Fluctuating capacity, fatigue, frailty, physical and cognitive limitations. Solutions: a semi-structured interview schedule allowed patients to talk freely. A rigorous procedure to obtain valid consent, including the viewpoints of all the parties involved. |
Mittal et al. [61], USA, B3 | 2007 | RCT comparing two processes of consent to evaluate the feasibility, acceptability, and preliminary efficacy of two enhanced consent procedures for patients with Alzheimer’s disease or mild cognitive impairment that used either a PowerPoint presentation or printed consent form. | 2 medical centres | Dementia: referred patients with possible or probable Alzheimer’s disease (MMSE ≥ 19), mild cognitive impairment | Enhanced informed consent. PowerPoint slideshow presentation (no written consent form) (SSP) or enhanced written consent procedure (researcher reads the information aloud, while the potential participant can follow from their own copy with large fonts). Followed with MacCAT-CR assessment of capacity, then repeat of either of the consent processes. MMSE ≥ 19 Adults with impaired capacity | 35 | Key findings: participants improved their understanding scores after verbal re-explanation of consent information. There were no significant differences in level of understanding among those in the SSP versus the EWCP conditions at either trial, but we found the SSP took significantly less time to administer. |
Rubright et al. [63], USA, A3 | 2010 | RCT testing whether a memory and organisational aid improves AD patient performance on measures of capacity and competency to give informed consent. | Alzheimer’s disease centre | Dementia: patients with Alzheimer’s disease | Enhanced informed consent with memory and organisational aid or standardised informed consent: intervention group received the additional aid which summarised the key elements in the drug Z-298 informed consent form. It presented information in the same sequence and header titles as presented in the informed consent form. The text simplified important points from the consent form using language at a sixth grade reading level. All participants went through a capacity assessment. | 80/112 (71%) of potential AD patients, 30/33 (91%) of cognitively normal older adults | Key findings: the intervention group was more likely to be judged competent than the control group (χ2 = 8.2, df = 1, p = 0.004) and had higher scores on MacCAT-CR measure of understanding (z = 2.86, p = 0.004). This RCT shows that a memory and organisational aid tailored to the distinctive cognitive patterns of AD patients can improve the ability of patients with very mild to early moderate AD to provide their own informed consent to enrol in an early-phase clinical trial. Challenge: this tool was designed specifically for AD patients and may not generalisable to other populations. Use of formal capacity assessments should not be treated with strict cut-off measurements. More challenging for high-risk trials. Solutions: for patients at an early phase of AD, capacity can be enhanced. |
Ford et al. [86], USA, B2 | 2008 | RCT to evaluate the effects of social support on comprehension and recall of consent form information in a study of Parkinson’s disease patients and their caregivers. | Medical centre | Parkinson’s disease: Parkinson’s disease patients (mean age 71 (SD 8.6) years) and their caregivers | Enhanced informed consent: in the social support group, patient-caregiver pair was asked to complete the consent form in the same room compared to the control group who completed the forms in separate rooms. Adults with impaired capacity | 136/143 (95%) | Key findings: 1-week follow-up, no significant differences in Quality of Informed Consent (QuIC) scores between participants receiving the social support intervention and the control group. Regardless of the group allocation, participants scored approximately 50% of the QuIC questions. But the findings showed that comprehension of consent form information was increased through the social support intervention in a ‘real-world’ clinical setting. Challenge: initial comprehension was low and remained relatively consistent within the 1-month period. Solutions: informational support provided by family caregivers. Caregivers who scored high on correct QuIC were associated with patient participants who with high QuIC scores, e.g. understanding information. |
Campbell et al. [94], South Africa, B3 | 2017 | Case-control study exploring if using iterative learning improves participants’ understanding of the research study and predictors of better understanding of the study at the initial screening. | Psychiatric hospitals and clinics | Mental health: patients with psychosis/schizophrenia | Enhanced informed consent (with iterative learning): following explanation, University of California, San Diego Brief Assessment of Capacity to Consent Questionnaire (UBACC) is administrated, if the person achieves > 14.5 demonstrating capacity to consent; informed consent is provided. Adults with impaired capacity | 1056 participants—528 matched cases and controls. (target was 181 pairs) | Key findings: before iterative learning, 55% of cases and 33% of controls were scoring lower than the cut-off point for study participation. After iterative learning, only 7% of cases and 3% of the controls were unable to consent to participate. Iterative learning process improved decisional capacity and understanding of the study in both cases and controls. This process is repeated after iterative learning. Solutions: the study recruiters play a significant role in managing the quality of the informed consent process. |
Palmer et al. [62], USA, A3 | 2018 | RCT to evaluate the efficacy of a multimedia-aided enhanced consent process incorporating corrective feedback, compared with routine consent, among individuals with mild-to-moderate Alzheimer’s disease and non-neuropsychiatric comparison (NC) subjects. | Unclear | Dementia: individuals with Alzheimer’s disease (mild to moderate) | Enhanced informed consent: the enhanced consent procedure expanded on routine consent by adding a more structured, iterative process and by incorporating multimedia tools into the consent presentation. Participants were randomised to routine consent and enhanced consent procedures for participating in a hypothetical RCT lower risk (FDA-approved medication) or a high risk (phase 2 immunotherapy). Assessment of capacity using MacCAT-CR. Adults with impaired capacity | 248—134 control, 114 Alzheimer’s disease | Key findings: regardless of whether randomised to the lower or higher risk protocol type, participants who received the enhanced consent procedure did not demonstrate significantly better decisional capacity scores compared with those who received the routine consent procedure. Findings could be due to rapid forgetting. |
Moser et al. [93], USA, B2 | 2006 | Quasi-experimental, pre-post study to determine whether a brief intervention could improve decisional capacity in people with schizophrenia. | Unclear | Mental health: individuals with schizophrenia | Enhanced informed consent: a very brief (less than 30 min), semi-individualised intervention consisting of a computerised presentation of the hypothetical study information in a bulleted, simplified format, with one key point per slide. Participants viewed the presentation and read along as the examiner read aloud each slide. Following the educational remediation, the examiner reviewed with the participant all MacCAT- CR ‘understanding’ items for which the participant did not receive maximum credit. Participants received both a standardised intervention, individualised discussion, and corrective feedback regarding the aspects of the research protocol that they found confusing. The MacCAT-CR interview was then repeated to assess participants’ decisional capacity following the educational remediation. Finally, the examiner a briefer structured interview designed to assess the adequacy of participants’ understanding of the hypothetical study. Adults with fluctuating capacity | 30 individuals with schizophrenia and 30 healthy comparison participants | Key findings: at follow-up, the schizophrenia group had improved significantly on understanding (t [27] = 2.85, p = .008) and was no longer significantly different from the comparison group on any of the four dimensions of decisional capacity on the MacCART-CR scale (p = .13–.33). Follow-up analyses also showed a significant effect of the intervention on a sub-set of the schizophrenia group who had performed most poorly at baseline, from a baseline mean of 18.0 (SD = 4.7) to 20.6 (SD = 4.9; t [7] = 2.59, p = .029). The effect size for this change is moderate in size (Cohen’s d = 0.6). Participants with schizophrenia earned significantly lower scores than those in the comparison group across multiple neuropsychological domains. Challenge: unable to determine what aspect of the intervention used was most helpful (active ingredients), as all participants in the schizophrenia group received both the standardised computer presentation and the individualised corrective feedback components. Had healthy comparisons, not other schizophrenia patients. Solutions: those individuals who initially lacked decisional capacity may benefit significantly from enhanced consent procedures. Further research is needed to unpick which components of the intervention are those causing the improvements. |
Jeste et al. [92], USA, A3 | 2009 | RCT to evaluate the effectiveness of a multimedia versus routine consent procedure (augmented with a 10-min control video presentation) to enhance understanding among adults with schizophrenia and healthy comparison subjects. | Outpatient clinics of an older mental health service | Mental health: older patients with schizophrenia | Enhanced informed consent: multimedia consent; the research assistant (RA) provided participants with the printed consent form. Subjects watched a DVD that explained the protocol. Multiple representation and contiguity principles were present throughout the DVD by presenting consent-relevant information through a narrator explaining key points, with simultaneous visual presentation using graphics, pictures, animations, and summary text (bullet-pointed). Subjects were encouraged to ask the RA to stop the DVD and repeat any segments that were unclear. Participants were encouraged to discuss and clarify issues with the RAs. Such discussion is important for multimedia consent aids to aid person-to-person interaction not to substitute. Adults with impaired capacity | 128 middle-aged and older persons with schizophrenia and 60 healthy comparison subjects | Key findings: outpatients with schizophrenia provided with a multimedia-aided consent procedure demonstrated better comprehension of a research protocol and were more likely to be categorised as being capable of consent under three different standards examined, compared with those presented with an enhanced routine consent procedure. MacCAT-CR understanding subscale for outpatients with schizophrenia trial 1 (d = 0.6384, p = 0.0055, 95% CI 0.54, 0.74), trial 2 (d = 0.6108, p = 0.0237, 95% CI 0.52, 0.71), trial 3 (d = 0.6117, p = 0.0169, 95% CI 0.52, 0.70), UBACC total (d = 0.6795, p = 0.0003, 95% CI 0.59, 0.77). There were few differences between the two (routine and multimedia) consent conditions among the healthy controls. Challenge: comprehension can be improved with simple procedures such as corrective feedback/iterative learning. Hence, considering the additional resources, whether a full-multimedia presentation is needed is questionable. Solutions: multimedia consent procedures may be a valuable consent aid that should be considered for use when enrolling participants at risk for impaired decisional capacity, particularly for complex and/or high-risk research protocols. |
Harmell et al. [91], USA, A3 | 2012 | RCT to evaluate the preliminary feasibility and potential effectiveness of a web-media approach to consent, i.e. to determine whether development of such web-media based tools warrants further pursuit. | Unclear | Mental health: patients with schizophrenia | Enhanced informed consent: participants allocated to web-media consent reviewed the study information on a web-media prototype, which involved video clips, static images/graphics, and bullet-pointed text to explain the consent form. The printed consent form was presented on the screen in sections covering: e.g. study introduction, a timeline with study visits, description of procedures, risks/discomforts, possible benefits, action if injured, and voluntary participation. The tool included questions with corrective feedback after each section to check understanding. Participants could ask questions at any point and replay the presentation. Adults with impaired capacity | 19 patients with schizophrenia and 16 normal comparison | Key findings: relative to those receiving the routine consent procedure, those receiving the web-media consent evidenced better UCSD Brief Assessment of Capacity to Consent (UBACC) scores, U = 19, z = − 2.15, p = 0.03 (d = 0.94; ‘large’ effect size). Participants rated the quality of the enhanced consent procedure as ‘better’, and no participant reported worse experience. Challenge: increased length of administration and that computer-based approaches may intimidate people with less computer literacy. Solutions: incorporating audio-visual materials on a computer/web platform to enable a more interactive and flexible presentation is feasible and more acceptable than presentation on a DVD. Such presentation may enable researchers to capitalise on the benefits of audio-visual learning, while circumventing the limitations of a DVD presentation. |
Sudore et al. [82], USA, B3 | 2006 | Observational nested in a trial of two advance directives to describe a modified research consent process, and determine whether literacy and demographic characteristics are associated with understanding consent information. | Hospital | Geriatric care/older patients: ethnically diverse subjects, aged ≥ 50, consenting for a trial to improve the forms used for advance directives | Enhanced informed consent: a modified consent process—consent form (written at a sixth grade level) read to participants, combined with 7 comprehension questions and targeted education, repeated until comprehension achieved (teach-to-goal). | 329 potential participants. Twenty participants refused to participate, 39 excluded due to scheduling issues, 61 did not meet the eligibility criteria, and data were missing for 1 participant, leaving 208 participants. 208/329 (63.2%) | Key findings: despite significant consent modifications (improving readability of the consent form, having bilingual research assistants read the consent form to participants, and allowing time for discussion), few participants (28%) had complete comprehension and required only 1 pass through the consent process. However, further use of a teach-to-goal strategy was successful in achieving complete comprehension in 98% of all participants who engaged in the consent process, including those with literacy or language barriers. Challenge: the comprehension statements could have addressed all of the required elements of informed consent, making our results more generalisable. Solutions: for the majority of these participants, little additional education was required. |
Rikkert et al. [81], Netherlands, C1 | 1997 | Pre- and post-test study of a step-wise consent process to determine the effects of research experience on the capacity to consent. | Hospital | Geriatric care: geriatric patients | Step-wise consent: (1) Eligibility screening. (2) Research experience was given by a try-out period of a week. Verbal and written information about the try-out was given to all eligible subjects (n = 78). For 40% of potential subjects, the family members were willing to accompany them when they received information. 70 subjects (90%) provided verbal consent to participate in the try-out. (3) After the try-out, written informed consent was requested. The verbal information was repeated. Assessment of the capacity to consent was conducted before and after experiencing research by testing comprehension and ability to weigh risks and inconveniences. Adults with impaired capacity | 53/78 (68%) | Key findings: the try-out effect on the comprehension scores could be tested in 53 subjects who provided written informed consent. Initially, the subjects answered only 5.0 of the ten questions correctly, this number increased to 7.0 after the try-out. This step-wise consent procedure resulted in a participation rate of 68% (53/78) of all eligible subjects. During the try-out, seven subjects withdrew consent. Ten subjects refused informed consent to continue research following the try-out. Solutions: research experience seems to improve the capacity to consent in demented and depressed subjects as well as in subjects without psychogeriatric illnesses. |
Processes to enable adults lacking capacity to participate in research | |||||||
Advance and process consent | |||||||
Olazaran et al. [64], Spain, C1 | 2012 | Research protocol to provide an overview of the clinical research protocol of the ACRSF (Alzheimer Center Reina Sofia Foundation), to analyse the adequacy of the assessment instruments, and to report on changes to the protocol. | ACRSF research centre | Dementia: patients with Alzheimer’s or other dementia and their relatives who agreed to receive treatment from the ACRSF (MMSE 6.7 (6.1)—nursing home to 9.1 (7.6)—day-care centre) | Advance consent upon arrival to the facility; legal representative to provide informed consent: upon admission, one or two ACRSF research physicians introduced the patient and family caregivers to the ACRSF research programme and invited the legal representative to sign consent to participate. The consent form included separate boxes for agreement to specifically participate in the clinical, biochemical, genetic, MRI, and neuropathological programmes. Adults with impaired or diminished capacity | 180 (80% of the total) | Informed consent was obtained from 180 patients. Those patients represented approximately 80% of all patients admitted at the ACRSF during that period. Demographics: the two groups of patients studied were old (outpatients) or very old (inpatients), had very low educational achievement, and were predominantly women. Solutions: multidisciplinary action. |
Gysels et al. [45], UK, C1 | 2013 | Consultation workshop and TEC to present the processes and outcomes of a workshop and consensus exercise on agreed best practice to accommodate ethical issues in research on palliative care. | N/A | Palliative care | Advance consent, process consent Adults with impaired or diminished capacity | 28 | Key findings: 16 recommendations generated. The recommendations on obtaining and maintaining consent from patients and families were the most contentious. Challenge: fluctuating capacity, time, risks involved in participating. Solutions: informing all the patients/relatives on admission that the facility conducts research, minimises gatekeeping, and identifies people interested in research participation. The level of detail on the information sheets should be proportional to burden and risks. Advance consent (early informed consent when the patient still has capacity) for all research, not just CTIMPs. Contemporaneous assent should also be obtained for all trials. Consent should be a continuous process. Consent process < 24 h after approach with clear justification to avoid coercion. |
Cowdell et al. [70], UK, B3 | 2008 | Ethnographic study exploring strategies that were used to enable older people with dementia to become actively engaged in research with them. | Hospital | Dementia: inpatients ≥ 65, with a dementia diagnosis at an advanced stage of the illness | Process consent: verbal or behavioural consent was taken from participants at the beginning of every period of observation to ensure they were willing to continue. This consent was negotiated between the person with dementia, the researcher, the staff on duty, and on occasion the next of kin. Participants were observed for any signs that they might wish to withdraw. For the interview part of the study, participants were asked to sign a consent form. | 125 h of observations and interviews (n unclear) in an inpatient setting | Key findings: actively engaging older people with dementia even at advanced stages (e.g. instead of having a pre-defined MMSE cut-off) in research is possible. Researchers need to apply ethical principles and rules sensitively and flexibly. Challenge: ensuring the informed nature of the consent, without having a formal capacity assessment. |
Dunning et al. [46], Australia, B3 | 2012 | Individual semi-structured interviews, field notes, philosophical framework to discuss the ethical and methodological issues encountered when undertaking research to develop guidelines for managing diabetes at the EoL. | Participants’ homes | Palliative care: semi-structured interviews with 14 men and women with diabetes and 10 spouses of the 14 participants | Process consent: involved asking participants whether they wanted to continue the conversation during the interview. Process consent was used when a participant became physically or emotionally distressed (in addition to informed consent). Adults with impaired capacity | Not known | Key findings: qualitative research deemed to be the most effective data collection method. Solutions: attention to protecting participants’ privacy, ensuring they can give informed consent, being aware of their physical and mental state, and periodically checking their willingness to continue participating during interviews and focus groups, is essential. |
Hughes et al. [65], UK, C1 | 2015 | Qualitative consultation aiming to develop an approach within the guidance of the Mental Capacity Act (2005) to meaningfully include people diagnosed with dementia in research endeavours. | Integrated dementia day care services | Dementia: people with a dementia diagnosis residing at residential care homes | Process consent Adults with impaired capacity | 8/9 (one declined to participate due to unexpected housing issues) | Consent process: first consent of participating service leads to allow identification of eligible patients. Then, the tested consent process was implemented, and patients’ consent was assessed and recorded. Consent reliability—not having a one-off consent and renewing consent at every encounter. Challenge: participants lost track of the purpose of the research. Important to attend to non-verbal cues. Gatekeeping from relatives and switch of decision-maker from patient to relative based on the context of the decision. Solutions: researchers should be trained in reflexive assessment of consent using verbal and behavioural cues. Initial approach to participate could be by a trained service user consultant to balance the power dynamics. Researchers should involve all parties not limit to, for example, family caregiver. |
Carey et al. [95], Ireland, B3 | 2017 | Qualitative study to explore theoretical underpinnings of intellectual disability research, and to discuss the ethical and methodological considerations in recruiting and obtaining informed consent from adults with intellectual disabilities. | Intellectual disability service/participants’ preferred place and time | Mental health: adults with intellectual disability | Process consent Adults with impaired capacity | 12/14 | Consent process: ongoing informed consent—detail information session, option to have a support person present. Written consent. Six participants also wanted their consent to be recorded. Non-verbal cues were considered while assessing ongoing consent. Solution: the structure of these meetings facilitated discussions about the nature of the study. Key findings: making reasonable accommodations to support decision-making, making space for the development of empathic relationships with both the potential participants and with the structures and service supports. |
Deferred consent | |||||||
Adamis et al. [100], UK, B3 | 2010 | Prospective cohort to assess serum IGF-I in patients with delirium and the way in which results altered when including patients with delirium who lacked capacity. | Elderly care unit | Delirium: patients 70 years or more with the presence of delirium using Confusion Assessment Method–Fluctuating capacity | Deferred consent: those who lacked capacity were entered (deferred) to study and their capacity were re-assessed to see if they gained capacity or proxy assent was obtained. Adults with diminished capacity | 164/233 (70%). 13/23 recruited lacked capacity and 151/210 recruited with capacity. | Key findings: the inclusion of the more incapacitated subjects allowed a significant finding (lower serum IGF-I in prevalent delirium cases). Strengthened the evidence that IGF-I has a role to play in the pathophysiology of delirium. Solution: informal approach to capacity may allow for more representative results of the study population. |
Honarmand et al. [104], Canada, B3 | 2018 | Prospective, pilot study to describe the feasibility of the deferred consent model in a low-risk, observational study of critically ill patients (Prognostic Value of Elevated Troponins in Critical Illness Study [PRO-TROPICS]) and to determine the factors associated with consent procurement. | Intensive care units at three study sites across Canada | Intensive care: critically ill patients | Deferred consent: patients are enrolled to the study and then themselves or their surrogate decision-maker is approached for consent. Consent can be provided to ongoing study participation, use of data collected so far, or no consent for data to be used. Adults with diminished capacity | 214/267 (80%) | Key findings: deferred consent model was feasible with 80% consent rate. Of 53 persons declining consent, 37 (70%) agreed to the use of the data collected to that point. One patient withdrew consent after it was provided by a proxy decision-maker. But, patients unlikely to recover were excluded. Consent rate did not differ based on who (patient/surrogate) was consenting. Challenge: exclusion of patients who might not recover/die and exclusion of patients who die early or cannot provide consent within the study timeframe lead to selection bias, reduced statistical power, and decreased external validity. |
Consultee advice | |||||||
Black et al. [60], USA, C1 | 2007 | Methodological paper focusing on three aspects of the consent process for dementia research: (1) providing information, (2) assessing understanding and capacity to consent, and (3) obtaining assent and informed consent. For each aspect, the differences between drug and non-drug studies in CDRS examined. | Six parent dementia studies | Dementia | Informed consent and/or personal consultee advice (dual consent) | Researchers (n = 11), patients, and their personal consultees from six dementia studies—46 consent process observations | Key findings: study revealed wide variability in how informed consent was obtained. (1) Consents forms were provided to the patients and personal consultees prior to enrolment visits and often served as a guide for consent discussions; (2) consent discussions were more consistent and comprehensive for drug studies than non-drug studies; (3) study procedure explanations dominated the discussions, whereas the rights of research subjects were mentioned less frequently; (4) assessments of affected individuals’ understanding and capacity to consent occurred in a minority of cases but were more likely to occur on drug studies; (5) personal consultee advice was sought more often using an implicit rather than an explicit approach; (6) dual consent by both the affected individual and surrogate decision-maker was most common on both drug and non-drug studies; (7) personal consultees often played a major role in facilitating the consent process. Solutions: describing the purpose of the study; discuss the individual’s rights in detail; involving the personal consultees; explicitly ask the potential participants for their involvement; use a standardised way of assessing capacity; explain why a personal consultee advice is needed. |
Agarwal et al. [69], UK, C1 | 1996 | Observational study examining the relevance of the Law Commission recommendations in accessing informed consent from early dementia patients and their carers subjected to a double-blind, placebo-controlled trial of a potentially therapeutic agent. | Unclear | Dementia: patients and carers | Personal consultee advice: two questionnaires (for patients and their carers) were designed to examine whether subjects fulfilled the criteria for a ‘cognitive’ or ‘function’ test of capacity to consent to participate in a research study. This was an attempt to establish whether consent was a ‘true choice’. Adults with impaired capacity | 15 patients and carers | Key findings: a single legal ‘test’, with stringent criteria, applied across the board for all treatment and research conditions, may impede future research activity as none of the subjects fulfilled the criteria for determining whether participation was a true choice. Challenge: implied consent (opt-out) could lead to exploitation of vulnerable patients. Solutions: the role and involvement of carers in the decision-making process need to be considered. Provided that they are acting in the patient’s best interests, that the patient has not actively expressed a desire not to participate, and that the research is potentially therapeutic, with the research drug having negligible side effects, this is unlikely to violate his fundamental rights. |
2010 | Methodological paper hypothesising that the requirement that informed consent for an incapacitated subject’s participation to research be given by a legal representative appointed by the courts slows down the recruitment process in research thus complicating the conduction of dementia research in Italy. | Outpatient clinic | Dementia: outpatients seeking medical advice for cognitive complaints | Legally appointed consultee advice: the procedure to obtain informed consent in the study was quite elaborated. First, subject’s competence was evaluated by means of the MMSE. If the subject’s score was ≥ 20, then he/she underwent four additional neuropsychological tests. If the subject’s score to the four tests was higher than the established cut-offs, the subject was deemed able to give informed consent. If the subject’s MMSE score was < 20, adjusted for age and education, or if the subject’s score to the other four tests was lower than the established cut-offs, the subject was deemed unable to give informed consent and consent had to be given by a legally authorised representative. Adults with impaired capacity | 78/172 (46.2%) required legal consultee appointment, 55/78 (70.5%) received appointment | Key findings: the requirement that the legal representative be appointed by the courts may impede a subject’s participation in research. It may cause embarrassment and conflicts among family members, it may have been received as a bureaucratic and burdensome task, and relatives may be reluctant to go to court due to stigma. This results in only a privileged selection of patients being involved in the studies. Solutions: Removal of legal procedure for the involvement of consultees or fastening the legal processes and reducing burden. | |
Adamis et al. [99], UK, A3 | 2005 | RCT to investigate whether different methods of obtaining informed consent affected recruitment to a study of delirium in older, medically ill hospital inpatients. | Acute medical service for older people at a hospital | Delirium: patients 70 years or older admitted to the unit within 3 days of hospital admission | Informed consent or proxy assent: both groups of patients were given routine same information (verbally and written). After a formal capacity assessment, assent was sought from a proxy (if available) if patient lacked capacity in group A, whereas in group B, an informal capacity assessment took place and those individuals who deemed to lack capacity were excluded. | 57 assessed in group A (43.8%), 25/57 (43.9%) entered the study. 73 assessed in group B (56.2%), 54/73 (74%) entered the study. 20 patients in each group were recorded as ‘case note delirium’. | Key findings: implementing best ethical practice by a formal assessment of capacity to consent to a research project in an acute medical ward will lead to a considerable reduction in the proportion entering the study. A stringent assessment of capacity may lead to reduced generalisability of the study findings. In turn, this undermines the ethical justification of the study. Of the 20 patients in each of the initial randomised groups (A and B) with case note delirium, 7 (35%) in group A and 16 (80%) in group B (p = 0.004) entered the study (χ2 = 8.29, df = 1; p = 0.004). Challenge: researcher assessing the capacity was not blinded to group allocation. Many potential participants with delirium do not have formal capacity to consent. In this study, including almost all prospective patients admitted to an elderly care unit, 40% lacked capacity to give consent to this research when judged formally. The process of formal testing of capacity might have resulted in bias by inducing higher rates of declining to give consent. Solutions: the consent rate may be greater if a step-wise approach to consent during participation is used. In this approach, called ‘experienced consent’, verbal consent is accepted initially, and after the subject has experienced the project, written consent is sought. |
Morán-Sánchez et al. [90], Spain, C1 | 2016 | Cross-sectional survey to evaluate the association between capacity to consent to research and the more prevalent psychiatric disorders, and to characterise factors associated with impairments in capacity across diagnostic groups. | Mental health care | Mental health: psychiatric patients | Informed consent and legal guardian consent: capacity was assessed using MMSE and MacCAT-CR. Adults with impaired capacity | 139/235 (59%) | Consent process: informed consent patients with capacity or from legal guardian if lacked capacity. Capacity: the level of understanding needed to provide meaningful consent to participate in this minimal-risk protocol was much lower than that required for a complex or higher-risk clinical trial, such as that described in the hypothetical protocol used to evaluate capacity in the study. MacCAT-CR used to assess capacity. Key findings: no subject was excluded because of a lack of capacity. 31% of the participants lacked decisional capacity to provide informed consent. Those lacking capacity were more likely to be older, with severe illness over a longer time. The number of psychiatric admissions was higher in the incapacitated group. They were more likely to have a psychotic or mood disorder and to score lower on the MMSE. Solutions: cognition must be considered in capacity assessment. Understanding can be improved through enhanced consent procedures. |
Thomalla et al. [87], Germany, A3 | 2017 | RCT (baseline data only). Aim to determine if the manner of consent, i.e. informed consent by the participant or by proxy decision-maker, affected clinical characteristics of samples of acute stroke patients enrolled in clinical trials. | Hospital | Stroke: stroke patients | Informed consent (written or oral) by patient, personal or legal proxy, consensus between the investigator and an independent clinician: six options give including written or oral consent by the patient, legal guardian consent, NoK consent, investigator’s decision (followed with consent from NoK as soon as possible). Adults with diminished capacity | 1005/1039 (ongoing trial) | Key findings: in 646 (64%) patients, informed consent was given by the patients; in 359 (36%), consent was by a proxy. The relative frequency of the informed consent type used varied among countries (p < 0.001). In this analysis of baseline data of the first 1005 patients enrolled in the WAKE-UP trial, about 1 in 3 patients were enrolled by proxy consent. In these cases, consent was provided by the legal guardian, by next of kin, by an independent consultant, or by the investigator based on an emergency clause. Challenge: limited guidance around regulation of clinical research in patients lacking capacity to give informed consent, and the consequence of different approaches for informed consent used in different stroke trials, among countries or trial sites. |
Kim et al. [66], USA, C1 | 2011a | To assess the extent to which persons with Alzheimer’s disease (AD) retain their capacity to appoint a research proxy. | Interview study | Dementia: people with Alzheimer’s disease (MMSE 18–23) | Proxy consent Adults with diminished or impaired capacity | 700 | Key findings: successful recruitment had the highest proportion (46.3%) of participants with MMSE score range of 18–23. Reliability of the judges’ determination of capacity was high. 61.7% of participants had the capacity to appoint a research proxy, 41.4% had capacity to consent to the drug RCT, and 15.6% had the capacity to consent to the neurosurgical RCT. A substantial proportion of AD subjects thought incapable of consenting to lower or to higher risk studies had capacity to appoint a research proxy. Solutions: providing for an appointed proxy even after the onset of AD may help address key ethical challenges to AD research. Appointing a proxy is advocated early in the disease trajectory. |
Warren et al. [47], USA, C1 | 1986 | Qualitative interviews to examine the bases on which the proxies made their decision, to identify characteristics that distinguished proxies who refused consent from those who gave consent, and to determine reasons for refusal. | Nursing home | Palliative care: nursing home residents’ (those who were > 65 years old) proxies | Proxy/surrogate consent Adults with diminished capacity | 90/168 (54%) | Key findings: 54% (n = 90) of proxies approached consented to patients’ participation. 60% of proxies consulted other people about their decision; 27% consulted a clinician about advising participation (or not). No significant difference in the frequency of consent among those who decided alone, those who consulted others, and those who consulted a clinician. Most proxies were not opposed to research in general, but as beliefs and perceptions about research became more relevant to their own family members, their support for research, even in the abstract, declined. 96% thought research in general was important for medical care; 87% agreed for research to be undertaken in hospital; 83% thought that elderly people should participate in research; only 66% thought that research should be conducted in nursing homes. Solutions: broad educational effort to increase awareness of the relevance of research to the health of older people across care settings. To discuss participation in research with patients while they are competent and to include potential proxies in these early discussions. |
Karlawish et al. [67], USA, C1 | 2008 | Companion study to an RCT placebo controlled of a potential Alzheimer’s disease treatment (drug) study to examine the views of Alzheimer’s disease patients and their study partners on the ethics of proxy consent for clinical research. | Universities | Dementia: patients with mild-to-moderate AD (MMSE 12 to 16), and their study partners (spouse or adult child) | Proxy consent Adults with diminished capacity | 59/73 (81%) patients, 60/75 (80%) study partners | Key findings: study partners of patients judged incapable of giving informed consent reported the same degree of patient involvement in the decision to enrol as the study partners of patients capable of giving informed consent. Most study partners and patients supported proxy consent for the clinical trial, and nearly all patients chose their study partner and their proxy. Study partners generally made research enrolment aligned with maximising the patient’s well-being. Solution: pursue a process of shared decision-making between patient and study partner to recruit patients with impaired capacity. |
Smith et al. [107], Canada, C1 | 2013 | Qualitative study with interactive focus groups to present strategies that may optimise the process of obtaining informed consent from substitute decision-makers for participation of critically ill patients in trials. | Intensive care unit | Intensive care: research coordinators working with critically ill patients | Surrogate consent: informed consent from substitute decision-makers of critically ill patients Adults with diminished capacity | 71 | Key findings/solutions: (1) brand the trial with key messages, (2) train the local personnel, (3) promote a culture of research, (4) be familiar with patient family dynamics, (5) involve bedside staff—make them aware that you are interested in recruiting their patient, (6) introduce the idea of research in a professional manner—explain why you are approaching the surrogate decision-maker, (7) present the facts about the research problem and outcomes, (8) convey risks and benefits transparently, (9) describe alternatives to participation and support the consent decision, (10) explain all research-related activities, (11) Document the consent process, (12) provide thanks and ongoing study updates to all stakeholders, and (13) follow-up with the patient to ensure ongoing consent. Strategies reinforce requirements outlined in existing legislations and additional process to enhance the integrity of the consent process. |
Bolcic-Jankovic et al. [105], USA, C1 | 2014 | Cross-sectional quantitative survey on (a) the determinants of confidence in a surrogate’s ability to make a decision for the patient, (b) the difference between surrogates’ and patients’ confidence, (c) if greater confidence increases agreement between the surrogate’s and patient’s response. | Intensive care unit | Intensive care: patients who required ICU and who had potential to regain capacity after recovery, and surrogate decision-makers. | Surrogate consent Adults with diminished capacity | 445 surrogates, 214 patients | Consent process: surrogate consent obtained during the patient’s ICU admission. Key findings: the research funder, knowledge about the study, and discussing with a trusted person were associated with surrogates’ confidence in advocating participation and attitudes towards research. Patients’ confidence in their surrogates’ decision was associated with a previous discussion about research participation (p < .001). Confident surrogates responded in agreement with patients’ wishes (80%). Most surrogates wanted to represent the person’s wishes. Solution: Early discussions between the proxy and patient about research participation. |
Fowell et al. [48], UK, A3 | 2006 | Randomised crossover trial to explore the feasibility of two designs of consent for dying patients: randomised consent (aka Zelen’s design) and cluster consent to see which design is more effective for trials in palliative care. | One oncology and one palliative care unit | Palliative care/cancer: patients with a terminal cancer diagnosis who were on an integrated care pathway for the dying | Cluster consent: consent at unit level for a group from a ‘cluster guardian’, and ‘cluster gatekeeper’ responsible for individual patient approach. Both guardian and gatekeeper must give written agreement for their cluster to participate in the trial. Randomised consent (Zelen’s design): seeks informed consent after randomisation but only if the patient is to receive the experimental treatment. Adults with declining, impaired, or diminished capacity | 20/50 (60%) | Key findings: the initial request to abstract data was identical in both designs and significantly fewer Zelen patients in the larger unit consented to this. Zelen’s design reduces the burden of seeking consent for treatment allocation but did not improve recruitment. Solutions: cluster randomisation runs in the background, reducing burden on the patient, carer, and clinician. Consent to treatment allocation is at the unit level with individual patient consent for access to confidential medical data. This study illustrates how cluster randomisation exploits these natural advantages, particularly with dying patients. |
Levine et al. [106], USA, C1 | 2017 | Expert consultation—electronic survey followed with Delphi rounds aiming to establish a broader consensus on the barriers to emergency care research globally and proposes a comprehensive array of new recommendations to overcome these barriers. | Global emergency medicine covering | Intensive care/emergency medicine: experts in global emergency medicine | Community consent Adults with diminished capacity | 80 | Solutions/suggestions: streamline data collection, identifying alternatives to local IRB approval and the use of community consent when appropriate where the individuals can choose to opt-out of the study later on. Key findings were divided into four categories. (1) Limited availability of research training. (2) Logistical issues and lack of data collection standardisation. (3) Ethical barriers regarding conducting research in low-income countries. (4) Dearth of funding for global emergency research. Key findings: need for ethical curriculums including important topics related to the ethics of acute care research internationally such as consent, loss to follow-up, coercion, and undue influence for enrolment was highlighted. |
Boxall et al. [88], UK, B3 | 2016 | Qualitative focus groups and interviews exploring the barriers to recruiting stroke patients to clinical trials from the viewpoint of experienced nurse researchers. Secondary aims included exploring the factors affecting the recruitment of stroke patients, explore the main themes that influence recruitment, and determine if stroke research faces unique recruitment issues. | Hospitals | Stroke: stroke research nurses | Surrogate consent, paramedic/early-on-scene consent, exception/delayed consent Adults with diminished capacity | 12 | Challenges: restrictive inclusion/exclusion criteria, physician endorsement, and lack of clinical equipoise. Impairments affecting capacity to consent—lack of validated tools to help assess capacity. Acute time frame to recruit, paternalism of (especially less-experienced) nurse researchers. Solutions: engaging caregivers and, if possible, using surrogate consent. Finding a balance between giving patients the opportunity yet not coercing them. Consent process (suggestions): ■ Traditional, in-hospital consent with a clinician and written information. ■ Paramedics/early on-scene consent. ■ Exception or delayed consent. ■ Surrogate (relative, legal representative, or independent physician) consent. ■ Short or abbreviated written information. ■ Use of pictorial information sheets or videos to explain a study ■ Telephone or video consent. |
Quality appraisal
Innovating research methods to recruit adults across the capacity spectrum
Maximise individuals’ autonomy and decisional capacity in the consent process
Processes of consent to enable recruitment of adults across the capacity spectrum
Applying consent processes across the capacity spectrum in studies on serious illness
Authors, country, EPOC | Year | Study design and aim | Setting | Sample description | Consent process for adults with declining, impaired, or lacking capacity | No. patients/eligible (%recruited) | Key findings, challenges, and solutions |
---|---|---|---|---|---|---|---|
Palliative care | |||||||
Abernethy et al. [51], Australia, A3 | 2006 | Cluster RCT 2 × 2 × 2 to test GP educational outreach visiting and case conferencing to improve patient outcomes, e.g. pain management. | Community settings | Palliative care | Assent personal consultee, or nominated consultee, e.g. GP capacity assessment MMSE ≤ 24 indicate require assent. | n = 461/607 (76%) Sample not differentiated by capacity/lack capacity | Key findings: strategies used enabled recruitment of largest community study in palliative care. Solutions: (1) study design pragmatic 2 × 2 × 2 cluster RCT and methods, broad inclusion criteria, defined recruitment plan, detailed intervention; (2) minimise patient burden, and clinician burden, e.g. research nurses collect data. Challenges: (1) time and resource complex trial design. (2) 7 patients ineligible no caregiver available/no pain. |
Gardiner et al. [49], UK, B3 | 2013 | Cross-sectional survey to explore palliative care need in hospital and agreement between informants. | All hospital inpatient adult ward | Palliative care | Assent personal consultee ALC (n= 38). Capacity assessment MCA criteria: HCP, family if available. | n = 654/1359 (48%) (mean age 78 years) | Key findings: 36% patients’ palliative care needs. Low identification medical (16%) and nursing (17%) staff. In 23 cases, consultees completed questionnaires on behalf of patients who lacked capacity to consent, and responses given via consultee may not be accurate. Challenges: non-consenting patients (n = 582)—(1) patient/consultee declined (e.g. too ill) (n = 407); (2) consultee not contactable (n = 109). |
Rees et al. [54], UK, A3 | 2003 | Feasibility RCT on anti-muscarinic medication (hyoscine versus glycopyrronium) for ‘death rattle’ to develop a process of advance consent enabling research to be undertaken in the terminal phase. | Palliative care ward | Palliative care | Advance and process consent: patients identified on admission, asked if prepared to enter study if develop secretions, informed consent documented medical notes, consent reconfirmed at readmissions. | n = 58/107 (54%) (n = 15 developed death rattle randomised) | Key finding: Advance consent is a viable and acceptable method to consent for trials in dying phase. Patient accrual rates to date are lower than needed to recruit adequate numbers in the time allotted to answer the research question. Challenges: (1) complexities of recruiting patients, e.g. too unwell (n = 15), died elsewhere (n = 16), died pre-randomisation (n = 15); (2) resource intense—estimate takes 3 years to meet sample size; (3) consent process time-consuming and emotionally draining. Solutions: (1) study across care settings, e.g. hospices; (2) involve all HCP disciplines; (3) patient acceptability trials dying phase (16 patients declined). |
Whelan et al. [52], UK, A3 | 2013 | RCT exploring the impact of the requirement for ‘proxy assent’ on recruitment in a trial of antibody response to influenza vaccination and use of a booster dose when indicated versus usual care in care homes (FEVER Trial). | All care homes in three London boroughs | Older people in care homes | Personal consultee advice (n = 82, 14%) if unavailable professional consultee care home staff (n = 40, 13%). Capacity assessment informal (study pre-dates MCA 2005). | Lack capacity n = 122/557 (22%) Capacity n = 155/411 (38%) Overall = 277/968 (29%) | Key findings: difficulties attaining consultee advise cause of recruitment bias with lower recruitment, e.g. older participants. Care home staff as consultee rarely used, e.g. reluctance of responsibility. Further research required independent risk/benefit expert panels, e.g. Independent Mental Capacity Advocates (MCA 2005). Challenges: (1) high lack of capacity to consent (62%, n = 602); (2) no contactable consultee (n = 304, 55%); (3) relative declined permission enrolment (n = 27, 5%); (4) researcher considered patient likely to resist procedures (n = 146, 26%). |
Henwood et al. [56], Australia, B3 | 2014 | Cross-sectional study with random sampling. Aim to establish the prevalence and risk factors to sarcopenia among older adults with compromised well-being residing in residential aged care (RAC). | Residential aged care | Very old (mean age 84.5 years) residents of the care facility | All participants were required to give informed consent directly or by the substitute decision-maker, or by the service manager or director of nursing following discussion with the substitute decision-maker. | 102/273 (37%)—91 provided consent and 11 were consented by proxy | Key findings/challenges: highest reason of non-recruitment was not wanting to participate (79%), followed by ‘My GP does not want me to’ (7%), changes in health status, and death. Solutions: To facilitate recruitment, requires involvement of key staff members in planning and execution of the research study to support the study and understanding of the study protocol. |
Myers et al. [50], USA, B3 | 2018 | Prospective cohort study to determine whether unplanned hospital transfer can be avoided. | One large county with a single system of emergency medical services | Assisted living residents who fall | Each patient’s primary care physician informed the patient or his or her healthcare Power of Attorney of the study during usual care. Patients choosing to participate or their powers of attorney signed a written informed consent document. | 953/1473 (65%) | Key findings: of the 953 residents in the study, 359 had 840 falls during 43 months. The protocol recommended non-transfer after 553 falls. Eleven of these patients had a time-sensitive condition. 549 of the 553 patients (99% [CI, 98 to 100%]) with a protocol recommendation for non-transfer received appropriate care. Challenge: participant accrual was slower than anticipated and time-sensitive conditions were less prevalent. |
Irwin et al. [55], USA, C1 | 2008 | Pilot study using a convenience sample to assess cognition and evaluate the presence of cognitive impairment in alert and awake hospice patients who did not have a current or past diagnosis of a cognitive disorder or cognitive impairments. | Hospice | Hospice inpatients/palliative care patients approaching the end of life (prognosis of < 6 months) | Written (n = 14) or oral informed consent (n = 16) | 30 | Key findings: cognitive impairments are common among inpatient hospice patients (12/30 patients were diagnosed with dementia—DSM V). Findings highlight the under-recognition of cognitive impairment in this population. Solutions: (1) psychoeducation for family members and caregivers, (2) psychopharmacological treatment for the patient, and (3) more timely final preparations to maximise function, adequate understanding and coping mechanisms, complete personal affairs, e.g. wills, advanced directives, legacy work and saying ‘good-byes’. |
Davies et al. [53], UK, A3 | 2018 | A feasibility cluster RCT. Aim ‘can a definitive (adequately powered) study be done?’ Hypothesis was that adequate clinically assisted hydration during the last few days of life would maintain renal perfusion and prevent hyperactive delirium (‘terminal agitation’). | Cancer centres and hospices | Cancer patients at the end of life with delirium | Informed consent from the patient where possible, if not personal consultee assent from a relative or a friend or nominated consultee assent from the site Study Guardian (an independent senior clinician). Process consent—if patient lost capacity during the study, personal/nominated consultee was required to confirm continued involvement in the study. | 200/219 (91%) | Key findings: the study recruited 91.3% of eligible patients by using multiple consent processes. Only 13/219 (6%) declined to take part and no withdrawals. Data collection burden from the patient and family members was minimised. Informed consent was received from patients (16, 8%), advice from personal consultees (161, 81%), and nominated consultees (23, 12%). Challenge: Unbalanced trial arms due to differences in eligible participants and ‘competitive’ recruitment strategy. Solutions: Multiple consent processes and minimise data collection burden. |
Dementia and geriatric care | |||||||
Baskin et al. [76], USA, A3 | 1998 | RCT to identify challenges to informed consent in research involving subjects with advanced dementia to check purpose of bid. | Inpatient hospital | Advanced dementia | Personal consultee advice | n = 75/146 (51%) | Key findings: this study is the first to examine barriers to research in patients with advanced dementia. 49% (n = 71) eligible participants could not be enrolled in a study on palliative approaches to care. 68 because of an inability to engage the proxy in the consent process (22 because of the absence of a suitable proxy), and 4 because proxy declined consent. The findings indicate barriers in clinical research in end-stage dementia, and implications for medical decision-making in this vulnerable population. Challenges: (1) relative declined permission enrolment (n = 4); (2) proxy uncontactable (n = 41/63); no suitable proxy identified (n = 22). |
Sampson et al. [40]*, UK, B3 | 2018 | A 9-month prospective cohort study aiming to describe (1) physical and psychological symptoms, (2) health and social care service utilisation, and (3) care at end of life in people with advanced dementia. | 14 nursing homes in the UK or participant’s own homes | People with advanced dementia (Functional Assessment Staging Scale 6e and above), aged 65 or over | Personal consultee advice, consultee uncontactable approach professional consultee | 85/159 (54%) | Key findings: recruitment target not reached with 30% of patients/carers declining. Of 157 eligible care home residents, 80 people recruited by carer consultee (62, 1 patient died), or professional consultee (18). 32 declined, 28 uncontactable consultee, and 17 died. 42 people residing at home, 6 recruited by carer consultee. 16 consultees declined, 19 uncontactable, and one died. |
Jones et al. [39]*, UK, B3 | 2012 | Protocol for the above cohort study. | Care homes and own home | Dementia (early stage) | Personal consultee advice, consultee not contactable approach professional consultee | Study protocol (recruitment target n = 100) | Personal consultee, consultee not contactable approach professional consultee, e.g. staff not involved in study. |
Black et al. [73], USA, B3 | 2006 | Cohort study to describe health problems and comorbidities in nursing home residents, and correlations with staff identified pain. | Nursing homes | Advanced dementia | Personal or legally appointed representative Capacity assessment informal HCP | n = 126/289 (44%) | Key findings: physician high recognition symptoms at EoL, but detection decreases with increasing cognitive impairment indicate sample bias. Challenges: (1) consultee denied enrolment permission (18%); (2) no response consultee (5%); (3) patient died (23%); (4) physician denied recruitment permission (5%). |
Goodman et al. [74], UK, B3 | 2011 | Cohort mixed method design to understand EoLC needs and support for people with dementia in care homes. | Care homes (residential, 6 homes) | Advanced dementia | Continuous consent adults able consent in moment (n = 65); personal consultee advice adults lacking capacity (n = 68). Capacity assessment MCA criteria researcher and care staff. | n = 133/215 (62%) | Key findings: 65 (74%) people with dementia who had capacity to understand the study agreed to participate, and those lacking capacity personal consultees advised participation (68/126, 54%). Solutions: greatest impact on recruitment care home culture, e.g. working practices. Challenges: (1) consultees declined permission participant enrolment (n = 9); (2) consultee uncontactable (n = 49); (3) resource—5 months full-time researcher recruit 133. Solutions: (1) engagement families and care staff; (2) accessibility study information, e.g. A4 summary sheet. |
Hanson et al. [75], USA, A3 | 2010 | Cluster RCT of a decision aid to inform and support the choice between tube feeding and assisted oral feeding in dementia. To describe recruitment strategies in nursing homes and ethical approaches to minimise harm and maximise benefits. | Nursing homes (n = 24) | Advanced dementia | Personal consultee, e.g. son/daughter (68%). Capacity assessment: Cognitive Performance Scale and Global Deterioration Scale. | n = 256/425 (60%) (paired resident and personal consultee) | Key findings: clinical trials involving adults lacking capacity require multiple strategies to engage consultees and recruit in nursing homes. Recruitment approaches ensured adequate time to address concerns of family surrogates, and compensation for their time commitment to the study interviews. Challenges: (1) care home culture recruitment rate varied by nursing homes (3 to 36, 30–94%). Solutions: (1) study design clear potential benefits for residents; (2) engage consultees, e.g. monetary reimbursement for time; researcher frequent calling to book interview and flexibility—interviews convenient time and location/by telephone, repeated provision accessible study information; (3) engage care home staff, e.g. prior contacts, time and resource, minimal burden for care staff. |
Sampson et al. [42]*, UK, B3 | 2015 | Cohort study to define the prevalence of pain using self-rated and observational pain scales in people with dementia in the general hospital, and to examine demographic and clinical factors associated with pain and to explore a hypothesised association between pain and behavioural and psychiatric symptoms of dementia (BPSD). | Two large acute general hospitals in London | Patients with dementia who were admitted to general medical wards of two large acute hospitals | Consent process: patient to give written informed consent or with an informal carer or ‘professional consultee’. The consent procedure followed the England and Wales MCA 2005. No formal capacity assessment. A personal consultee was identified to give agreement either verbally over the telephone, and posted an agreement form to sign and return. If forms were not returned, participants’ data were destroyed. If a personal consultee could not be reached in 48 h of screening, a professional consultee advice (e.g. geriatrician not involved in the study or patient care). | 230/292 (79%) | Challenge: 62 excluded because they did not fulfil the inclusion criteria or because carers who gave telephone agreement did not return signed forms. Solutions: consent process practical and feasible in the acute setting. |
Scott et al. [41]*, UK, B3 | 2011 | Protocol for the above cohort study. | Hospital inpatient | Dementia and unplanned hospital admission | Assent personal consultee, if no consultee identified in 48 h, nominated ‘professional’ consultee—senior member clinical team not involved study. Capacity assessed MCA criteria identify consent/assent. | Study protocol (recruitment target 250) | Key finding: protocol developed MCA guidance, i.e. assess the person using structured assessment for capacity, seek assent from a carer for person lost capacity, and use professional consultees when carer not contactable. |
Warner et al. [72], UK, A3 | 2007 | RCT of dementia treatment, Ginkgo biloba, to assess the proportion of people with capacity to consent, describe use of the MCA 2005 to assess capacity in a research setting, and identify variables associated with the presence of capacity. | Community settings | Dementia | Informed consent or personal consultee advice for adults lacking capacity. Capacity assessed MCA criteria and MMSE. | n = 42/176 (24%) | Key findings: cognitive testing alone is insufficient to assess the presence of capacity. Recommend researchers record outcome capacity assessment and basis for the finding; cognitive measures considered poor proxy for judging capacity. Research may be undertaken with incapacitous participants who nevertheless appear to agree to participation, but is only permissible if there is some potential direct or indirect benefit to the patient and the research cannot be carried out on patients who have capacity. Challenges: (1) high cognitive impairment, 76% participants assessed lacked capacity for informed consent; (2) MMSE did not predict the presence of capacity. |
Ellis-Smith et al. [78], UK, B2 | 2018 | Prospective, mixed methods feasibility study to explore the mechanisms of action, feasibility, acceptability, and implementation requirements of a measure, the Integrated Palliative care Outcome Scale (IPOS-Dem), used in routine care to support comprehensive assessment of symptoms and concerns of care home residents with dementia and their family members. | Three residential care homes registered to provide care for people aged 65 and over in a London borough, UK | Palliative/residential care home residents with dementia | The research team met with residents to ascertain willingness to participate and assess mental capacity to consent for themselves. Those residents that had capacity gave written informed consent. Advice of consultees was sought if ALC. The care home therefore sent a letter on behalf of the research team to a close friend or family member to invite them to advise on whether the resident should participate in research (personal consultee). Two letters were sent. If no response was received after 1 week of the second letter being sent, a nominated consultee was asked to advise on resident participation. The nominated consultee was independent from the research study and used all available information (including meeting with the resident, reviewing case notes, and speaking to care home staff) in order to give advice on resident participation. | 10 family members approached. 22 professionals approached. 47 residents approached. 32 baseline and 30 final time point patient data. 20 professionals involved in focus groups and serial interviews. Six family members involved in a focus group and interviews | Key findings: of 47 participants approached, one patient provided informed consent, 45 were assessed as not having capacity to consent. Consultee approached for n = 39. Personal consultees provided advised for n = 15, and professional consultees for n = 24. One resident declined, four NoKs uncontactable. Not recruited on consultee advice (n = 3), advised against participation (n = 2), professional consultee (external to the care home and study) advised NoK involvement, but NoK did not respond (n = 1). Findings showed that possible to introduce a measure into routine care of residents and change care processes to improve resident and family outcomes. Solutions: mutliple procedures of approaching the NoK, and if uncontactable, a professional consultee is feasible in care homes. The staff members know the residents and could inform the researchers about preferences for research participation (or not). |
Mitchell et al. [77], USA, B3 | 2006 | Cohort study to examine EoLC in advanced dementia and to describe how research challenges were met (CASCADE study). | Nursing homes (n = 15) | Residents with advanced dementia and their healthcare proxies—Cognitive Performance Scale score 5/6 | Professional consultee (healthcare staff) involving consent for themselves and providing proxy consent for residents (data collection chart review, brief clinical examination, nursing interview). Capacity assessment: Cognitive Performance Score 5 or 6. | n = 189/343 (55%) (patient/HCP dyad) | Key findings: involving ALC in research on palliative care, including the dying phase, acceptable to staff surrogate decision-makers in nursing homes. Findings suggest that the emotional distress of families does not decline when patients with dementia are institutionalised. Challenges: clinicians’ refusal (n = 154), e.g. too burdensome (n = 30), lack of interest (n = 53). Solutions: (1) nursing home culture, e.g. track record conducting research; (2) engage care home staff, e.g. researcher trained geriatric nurse, participation low burden; (3) research team credibility. |
Davies et al. [84], UK, B3 | 2010 | Cohort study to examine health trajectories and outcomes of people aged 85+ cohort and associations with biological, medical, and social factors. | Usual place of residence, e.g. at home, care home | Older people aged > 85 years | Advance consent—consent document participant nominate a personal consultee should they lose capacity. Used continuous consent process, fluctuating capacity awaited re-gain capacity. Capacity assessment. MCA criteria researcher. | n = 1042/1453 (72%) | Key findings: 72% recruitment rate using consultees, separate consent protocols for participants in care homes and flexibility regarding those with fluctuating capacity. Cognitive impairment is common requiring consideration of the relevant ethical and legal issues. Challenges: (1) consultee declined recruitment (n = 5); (2) consultee uncontactable (n = 9). Solutions: (1) comprehensive protocols for consent and capacity assessment that anticipated high cognitive impairment guided by legislation; (2) training researchers on consent and capacity processes, sensitively handling complex situations; (3) time and resource to engage family and care home staff; (4) follow-up telephone call/visit 1 week after receipt study information; (5) design study information for older person, e.g. font size, language. |
Mason et al. [83], UK, A3 | 2006 | RCT to determine effectiveness and cost-effectiveness of pressure relieving mattresses on pressure ulcers. | 10 research centres involving inpatient units | Patients with pressure ulcers aged > 55 years with or without cognitive impairment | Personal consultee advice for ALC. | Lack capacity n = 87/2445 (4%) Capacity n = 1972/2395 (82%) | Key findings: a higher proportion of relatives declined enrolment, than patients themselves. Proxy consent allowed only a small increase in trial recruitment. Recruitment challenges: (1) no relative available (n = 2286); (2) relatives declined permission to enrol (n = 72/159, 45%). |
Botker et al. [85], Denmark, A3 | 2018 | RCT. Aim to examine if the addition of brain natriuretic peptide measurement to the routine diagnostic work-up by prehospital critical care team physicians improved triage in patients with severe dyspnoea. | Prehospital critical care units at Central Denmark Region hospitals | Patients with severe dyspnoea | Deferred consent: included patients prior to informed consent. Subsequent oral and written informed consent was obtained from all participants or next of kin by one of 10 study investigators. | 711/747 (95%) | Key findings: 28 (4%) participants withdrawn consent based on patient or proxy request. 7 (0.9%) patients were excluded as consent could not be obtained. The routine addition of prehospital NT-proBNP measurement did not improve the triage of patients with dyspnoea of cardiac cause directly to the department of cardiology and did not significantly improve treatment or patient outcomes. |
Galeotti et al. [79], Italy, A3 | 2012 | RCT. The ADCare study aimed to evaluate the long-term safety and efficacy profiles of three atypical antipsychotic drugs and one conventional antipsychotic drug in treating psychosis, aggression, and agitation in outpatients with AD. The aim of this paper is to report the ADCare study experience and to analyse in depth the possible reasons for the low accrual. | N/A | Alzheimer’s disease patients | Informed consent | 83/~ 800 eligible patients from 19 clinical centres | Key findings: ~ 800 eligible patients in 1 year were identified in the clinical centres. Although initially willing to participate, most of these patients/family members declined because a legal court nomination was required to participate in the trial. Court nomination was perceived by patients and family members as intrusive and potentially creating conflicts in families. Challenges: only 9 clinical centres participating in the study enrolled patients with the involvement of a legal proxy, even with initiatives to disseminate information on legal agency for research participants. The main obstacles were caregivers’ reluctance to designate a legal proxy and court delays. |
Intensive care | |||||||
Day et al. [109], UK, B3 | 2015 | Pilot RCT single centre. Aim to report challenges to undertake the RCT and feasibility of delivering and evaluating a complex intervention in a critical care unit. | Two mixed critical care units of a large inner London hospital | Mixed medical, surgical, and trauma patient population requiring either level 3 (intensive) or level 2 (high dependency) care | Researchers not involved in data collection were responsible for the consent process. In this study, patients were willing to consent verbally but deferred to their relative to provide written consent. If ALC, their relative provided advice, the researchers then ensured that when patients regained capacity and they requested an informed consent. | 158/221 (72%) | Key findings: rushing the decision-making process was a concern. Some patients approached felt unable to say no, but kept saying come back later. This may indicate concern that their care may be affected if decline. Viewing informed consent as a process and revisiting it throughout the trial period to ensure participants can recall providing consent. Challenges: Most of those approached felt too tired or lacked the concentration to read the study information. Patients with no appropriate consultee were excluded. Solutions: (1) avoid consent bias, risk of coercion and allow more time for decision-making. (2) Participant information sheet clear and concise. (3) To review capacity in patients with memory loss. |
Bench et al. [110], UK, A3 | 2015 | Pilot RCT. Aim (1) providing an initial evaluation of a user-centred critical care discharge information pack (UCCDIP), (2) inform decisions about its further development and evaluation, and (3) estimate the sample size for a full trial. | Two ICUs within a single teaching hospital in central London | Mixed medical, surgical, and trauma patient population requiring either level 3 (intensive) or level 2 (high dependency) care | Informed consent from the patient was then obtained prior to data collection on the ward. For ALC, informed written consent at the point of ICU discharge (deferred), personal consultee declarations, usually from the patient’s next of kin, were sought. The relatives of all recruited patients were given study information when they visited the ICU or telephoned and invited to participate. Written consent was obtained from relatives during their next hospital visit. | 158/221 (36 declined to participate) (72%) | Key findings/challenges: The a priori enrolment goal was not reached, and attrition was high leading to insufficient statistical power to determine outcome benefit. 101 (64%) patient participants provided primary outcome data at time point 1. A total of 48 (60%) patients’ relatives provided at least one set of outcome data. Twenty-seven (17%) patients and 32 (40%) relatives were lost to any follow-up. |
Higginson et al. [111], UK, B3 | 2016 | Prospective ethnographic study. Aim to explore the nature and patterns of decision-making processes during ICU admission, including sources of conflict and resolution. | Two ICUs in an inner city hospital serving an ethnically and socially diverse population | ICU patients where clinicians had potential end of life concerns, discussions or a high risk of dying during the current admission | Where possible, informed consent from patients. For patients who lacked capacity, following the Mental Capacity Act 2005, firstly capacity was assumed to be present, unless proven to be absent. Clinicians assessed capacity. If lacked capacity, approach for advice a personal consultee (e.g. family member), if not identified a nominated consultee (e.g. clinician) | 16 patients and 19 relatives | Solutions: the researchers looked for instances where capacity was present and discussed with the clinicians. The research team ensured that the nominated consultee was not part of the research team. Relatives also provided informed consent/assent for interviews and observations. |
Rouzé et al. [112], France, A3 | 2017 | RCT to test the hypothesis that the use of an algorithm based on fungal biomarkers would increase the percentage of early discontinuation of empirical antifungal treatment among critically ill patients. | Mixed 50-bed ICU department of the University Hospital of Lille, France | ICU patients with Candida infection | An informed written consent was obtained before randomisation from the patients or their proxies. | 110/387 (28%) | Key findings: 8/510 patients who were assessed for eligibility refused. One patient withdrew consent after receiving the biomarker strategy. The use of a biomarker-based strategy increased the percentage of early discontinuation of empirical antifungal treatment among critically ill patients with suspected invasive Candida infection. |
Mental health | |||||||
Ho et al. [97], Australia, B3 | 2018 | Methodological paper aiming to describe an informed consent process used when recruiting persons with intellectual disability for a study which is currently investigating falls among people with intellectual disability, and to reflect on the methods of informed consent used. | Community—participant’s home, small group homes with up to two to four co-inhabitants with paid support | People with intellectual disability | Informed consent and proxy advice from the participants themselves where possible. The process was designed to provide a collective perspective of the capacity of the person with intellectual disability to consent. The researcher uses repeated observations to establish if the person has capacity to provide consent, and consult with the caregiver. Use of a decisional questionnaire involving score of > 3 out of six suggest capacity to provide informed consent. The next of kin, family member, or caregiver is asked to be present during this process to provide a supportive, comfortable environment and to provide oversight to the discussion. | [84] 40/68 (59%) | Key findings: only 3 out of 40 participants were able to provide informed consent. 22 participants were able to have a discussion about their involvement in the study with the support of their caregiver. 15 participants were unable to engage in the process. The decisional questionnaire gave an accurate representation of participants’ decision-making capacity. Challenges: more than 40% caregivers declined taking part in the study on behalf of the person. This consent process was time-consuming. Solutions: Training and building relationships with patients and their caregivers. |
Ramerman et al. [96], Holland, B3 | 2018 | Experimental study to examine challenging behaviour, physical symptoms, and quality of life associated with antipsychotic drug. | Hospital intellectual disability mental healthcare clinics | Adults with intellectual disabilities | Written informed consent was obtained from participants and/or their legal representatives. | 159 (no data on number of people approached) | Key findings: mean age was 46.2 (SD 17.7). Health quality of life (HQoL) was negatively associated with both symptoms of challenging behaviour and physical symptoms associated with antipsychotic drugs. No data on differentiation proxies and patients in informed consent process. |
Delirium | |||||||
Marcantonio et al. [101], USA, A3 | 2010 | RCT to determine whether a delirium abatement programme (DAP) can shorten duration of delirium in new admissions to postacute care (PAC). | Hospital | Patients with delirium older than 65 (mean age = 84); MMSE and CAM used to assess capacity | In those who had delirium, family caregivers, acting as proxies, provided informed consent for trial participation. | 457/667 (69%) | Key findings: this study was the largest cohort of patients with delirium ever enrolled in a research study. Facilities received a small incentive based on their performance. Clustering effect widened the confidence intervals. Possible to ascertain adherence and outcomes only in trial participants whose proxies provided informed consent to allow medical records to be reviewed. Challenges: Of 667 patients who were eligible, 138 relatives refused (21%), 56 relatives uncontactable (8%). |
Cole et al. [102], Canada, A3 | 2002 | RCT to determine if systematic detection and multidisciplinary care of delirium in older patients could reduce time to improvement in cognitive status. | Hospital | Older patients 65 years old or more admitted to a general hospital medical service | Informed consent was obtained from the patient or substitute decision-maker. Confusion assessment method was used to assess capacity. | 227 /299 (76%) | Key findings: 72 were excluded as they could not provide consent. Study was not powered to detect any statistically significant differences. |
Emergency medicine | |||||||
Offerman et al. [108], USA, B3 | 2013 | Observational prospective multicentre study to describe the rate of successful consent using an altered (deferred telephone) consent process in emergency department (ED) patients. | Emergency department | Adults who had attended ED with blunt head trauma | Informed consent was obtained from the patient or substitute decision-maker. | 506 | Key findings: follow-up telephone contact was successfully accomplished in 501 of the 506 subjects (99.0%; 95% CI = 97.7 to 99.7%). Consent for study inclusion and conduct of the telephone survey was obtained in 500 of 501 subjects at time of the follow-up call (99.8%; 95% CI = 98.9 to 100.0%). Surrogate consent was obtained in 199 of the 501 subjects (39.7%; 95% CI = 35.4 to 44.2%) |
Public attitudes on enrolling adults lacking capacity in research
Transparent expert consultation
-
Area 1. ‘Information about a research study is comprehensible, short and written in accessible language’ (R2, median 9, IQR 9–9) and ‘Although the legal significance of advance consent will vary depending on the relevant legal framework, it is good practice for researchers to seek an advance consent while individuals have capacity to consent for themselves, for example, shortly after a diagnosis of a progressive illness’ (R10, median 8, IQR 7–9)
-
Area 2. ‘The consent process is tailored to the individual’s needs, capabilities and values with researchers observing for non-verbal and verbal cues that may indicate an individual may wish to withdraw’ (R9, median 9, IQR9–9) and ‘Advance care planning to include discussing and recording in a Statement of Wishes document an individual’s nominated or personal consultee whose opinion on participating in a research study is sought if the patient loses capacity’ (R21, median 8, IQR 7–8)
-
Area 3. ‘Researchers to demonstrate to Research Ethics Committees a clear process of consent for potential participants with compromised capacity that details how the researchers will proceed to tailor the consent process to maximise individuals’ ability to consent for themselves and when and how they will seek an opinion from a consultee’ (R29, median 9, IQR9–9) and ‘Health and social care practitioners to recognise research as a core clinical activity in a similar way as teaching and training’ (R23, median 9, IQR 9–9)
-
Area 1. Involving and supporting consultees in the decision-making process with uncertainty on how best to support consultees to engage in the research process, with four recommendations indicating equivocal broad agreements (recommendations 6, 8, 15, 22, 27)
-
Area 2. Practitioner training and education with agreement on the requirement to increase training and support to researchers and clinicians, but areas of uncertainty concerned for example how to provide and disseminate training and guidance, and how to fund (R5)
-
Area 3. Legislative frameworks and the incorporation into research practice
Discussion
Solutions | |
---|---|
Ethics | 1. Researchers should design all aspects of the study in the context of potential risk, burden, and benefit of study participation. |
2. Institutional review boards and research ethical committees should have transparent decision-making processes to ensure consistency on ethical approvals for studies from various health specialties involving adults across the mental capacity trajectory. | |
3. The individuals (e.g. relative, friend, formal carer, nursing home staff, healthcare staff) who can act as a consultee to advise on whether the individual would have wanted to participate in the research study had they had capacity should depend on the nature of the study, rather than legal restrictions. | |
4. Researchers should be able to demonstrate a clear process of consent for potential participants with compromised capacity that details how the researchers will tailor the consent process to maximise an individual’s ability to consent for themselves and when and how they will seek an opinion from a consultee. | |
Maximising individual autonomy | 5. Clinicians should engage in research participation conversations with patients at the early stages of illness, discussing varying levels of risk, burden, and benefit, and document the person’s preferences and wishes in for example an advance directive. |
6. Individuals who are likely to lose capacity should be asked to designate a consultee whose opinion on their participation in a research study will be sought if the individual loses capacity. | |
7. For individuals who have capacity to consent in the moment, but overtime may not remember the discussion, process consent should be adopted whereby researchers re-confirm the individual’s wish to participate at each data collection time point. | |
8. Researchers should check for non-verbal (e.g. agitation) and verbal cues (e.g. ‘I’m unsure why you are asking me’) that may indicate a wish to withdraw during the study. | |
Involving consultees | 9. Personal consultees should be present in research participation conversations with patients at the early stages of illness. |
10. Where possible, to improve social support, personal consultees/family members should be engaged in the (enhanced) informed consent process for adults with impaired capacity. | |
11. The nature and extent of the responsibility of a consultee acting on behalf of a patient should be clarified. | |
12. Establish a national body to provide support and information to family members/informal carers acting as personal consultees. | |
Tailoring recruitment process to need | 13. Researchers should incorporate in the study design research participation information and (where applicable) data collection tools in multiple formats (e.g. verbal, written, electronic). |
14. Studies where potential participants are expected to be adults across the mental capacity trajectory should incorporate multiple consent processes (e.g. personal and professional consultees, informed and process consent). | |
Time | 15. When possible, potential participants should be allowed time for further discussions regarding their research participation decision. |
16. The study design should allow time proportionate to the risk, burden, and benefit of participation for consent or consultee decision (before or after research participation if consent is deferred). | |
17. Researchers should build in the time required to engage with and train clinical staff who will be involved, and those who might act as professional consultees in the study. | |
Enhancing the research culture and infrastructure | 18. Health and social care practitioners should recognise research as a core clinical activity in a similar way as teaching and training. |
19. Clinicians should be supported and provided with training to ensure they are confident in their skills to discuss research studies with patients (and/or family members) during routine clinical contact. | |
20. Health and social care practitioners should support adults across the mental capacity trajectory at all stages of the research study by considering the person’s best interests and individual wishes and preferences to uphold individual autonomy and minimise the risk of harm, and enable family members to act as a personal consultee by ensuring sufficient information and understanding about the role. |