Informed consent for PSA screening: does it happen?
(33/1957)
CONTEXT: Screening for prostate cancer with serum prostate-specific antigen (PSA) is controversial. Ideally, patients should be aware of the potential benefits and risks related to testing. PURPOSE: To assess whether patients remembered having PSA screening and to determine whether they recalled having a discussion with their primary care provider about the pros and cons of such testing. METHODS: A questionnaire was sent to patients who had PSA screening ordered by a primary care practitioner during a 2-month period at a university-affiliated Veterans Affairs medical center. Approximately 3 months after the PSA test was done, patients were asked about their baseline health as well as their knowledge of and attitudes toward screening with PSA and treatment for prostate cancer. RESULTS: The overall response rate was 197 out of 421 (46%) patients. Among 173 eligible respondents without prostate cancer, 53 (31%) were unaware that their physician had ordered a PSA test. Among the 120 patients who were aware of receiving the test, only 56 (47%) recalled having a discussion with their primary care provider about the risks and benefits of screening. Support for the test was more common among patients who recalled having PSA screening than those who did not recall having the test (91% vs. 70%, respectively; P = 0.003). CONCLUSIONS: Patients who have PSA screening often are unable to recall relevant facts about the test and may have no knowledge of its associated risks and benefits. The role and effectiveness of obtaining verbal informed consent for PSA screening should be re-evaluated. (+info)
How can we help people make sense of medical data?
(34/1957)
CONTEXT: Information is a basic prerequisite to informed medical decision making. GENERAL QUESTION: How can we help people interpret the quantitative data they need to make informed decisions? SPECIFIC RESEARCH CHALLENGE: To develop and evaluate interventions that will help people make sense of the quantitative data relevant to their health care decisions. STANDARD APPROACH: Traditional patient education interventions focus on providing disease-specific information (e.g., educational brochures about a single disease). POTENTIAL DIFFICULTIES: Interventions that focus on content--the provision of facts--may not be sufficient help for people facing medical decisions. Training that prepares people to make sense of the facts that they are given may be necessary. ALTERNATE APPROACH: We propose developing a generic (i.e., not disease-specific) tutorial to prepare people to better understand and more critically evaluate data on disease risk and the benefits and harms of treatment. This tutorial aims to improve critical reading skills by teaching people about risk (e.g., probability and rates) and showing them what to look for in statements about risk (e.g., time frame), how to put disease risk and treatment benefit in context (e.g., evaluating competing risks), how to interpret changes in risk, and whether to believe the statements about changes in risk. (+info)
Mastectomy or lumpectomy? Helping women make informed choices.
(35/1957)
PURPOSE: To develop an instrument to help clinicians inform their patients about surgical treatment options for the treatment of breast cancer and to evaluate the impact of the instrument on the clinical encounter. METHODS: We developed an instrument, called the Decision Board, to present information regarding the benefits and risks of breast-conserving therapy (lumpectomy plus radiation therapy) and mastectomy to women with early-stage breast cancer to enable them to express a preference for the type of surgery. Seven surgeons from different communities in Ontario administered the instrument to women with newly diagnosed clinical stage I or II breast cancer over an 18-month period. Patients and surgeons were interviewed regarding acceptability of the instrument. The rates of breast-conserving surgery performed by surgeons before and after the introduction of the instrument were compared. RESULTS: The Decision Board was administered to 175 patients; 98% reported that the Decision Board was easy to understand, and 81% indicated that it helped them make a decision. The average score on a true/false test of comprehension was 11.8 of 14 (84%) (range, 6 to 14). Surgeons found the Decision Board to be helpful in presenting information to patients in 91% of consultations. The rate of breast-conserving surgery decreased when the Decision Board was introduced (88% v 73%, P =.001) CONCLUSION: The Decision Board is a simple method to improve communication and facilitate shared decision making. It was well accepted by patients and surgeons and easily applied in the community. (+info)
Re-engineering the process of surgical informed consent.
(36/1957)
We have created a clinical performance support system that transforms surgical informed consent into an interactive process capable of evolving in response to institution-specified, provider-specified and patient-specified needs. The system functions in several capacities, including: (1) a source of standardized and comprehensive content and format the transmission of procedure-related risk and complications; (2) as expert critique, providing cues in an effort to reduce the effects of biased risk appraisal; (3) captures and archives clinician behavior relating to use, modification and disclosure of standardized knowledge sources; (4) provides just-in-time access to procedural descriptions information relating to risks and complications; (5) captures, archives and makes available to the clinician patient use of procedure-related knowledge resources. By design, the system will be used to assess the relationship between clinician perception and heuristics surrounding risk appraisal and disclosure and patient perceptions based on response to the disclosure process. The system prototype is currently being deployed in a breast surgery unit at the Beth Israel Deaconess Medical Center. (+info)
A medico-legal review of some current UK guidelines in orthodontics: a personal view.
(37/1957)
This article is a critical analysis from a medico-legal perspective of some current authoritative UK clinical guidelines in orthodontics. Two clinical guidelines have been produced by the Royal College of Surgeons of England and four by the British Orthodontic Society. Each guideline is published with the analysis immediately following it. Following recent UK case law (Bolitho v City & Hackney Health Authority, 1997) which allows the courts to choose between two bodies of responsible expert medical opinion where they feel one opinion is not 'logical', it is likely that the UK courts will increasingly turn to authoritative clinical guidelines to assist them in judging whether or not an appropriate standard of care has been achieved in medical negligence cases. It is thus important for clinicians to be aware of the recommendations of such guidelines, and if these are not followed the reasons should be discussed with the patient and recorded in the clinical case notes. This article attempts to highlight aspects of the guidelines that have medico-legal implications. (+info)
Postal consent for upper gastrointestinal endoscopy.
(38/1957)
BACKGROUND: Standards for good practice in clinical risk management issued by the Clinical Negligence Scheme for Trusts indicate that "appropriate information is provided to patients on the risks and benefits of proposed treatment, and of the alternatives available before a signature on a consent form is sought". AIMS: To investigate the practicability and patient acceptability of a postal information and consent booklet for patients undergoing outpatient gastroscopy. METHODS: Information about gastroscopy procedure, personalised appointment details, and a carbonised consent form were compiled into a single booklet. This was mailed to patients well in advance of their endoscopic procedure. Patient satisfaction for this new process was assessed by questionnaire. RESULTS: 275 patients received a patient information booklet. Of these, 150 (54.5%) returned the consent form by post when they confirmed their attendance; 141 (94%) had signed the form, and the other nine requested further information. Of the remaining 125 booklets sent out, 115 (92%) forms were brought back on the day of the investigation having been previously signed. The remaining 10 (8%) required further information before signing the form. An audit of 168 patients was used to test reaction to the booklet and the idea of filling in the form before coming to hospital; 155 patients (92. 2%) reported the information given in the booklet to be "very useful", and all reported it to be "clear and understandable". CONCLUSION: A specifically designed patient information booklet with integral consent form is accepted by patients, and improves the level of understanding prior to the investigation being carried out. (+info)
Does informed consent alter elderly patients' preferences for colorectal cancer screening? Results of a randomized trial.
(39/1957)
OBJECTIVE: To assess the impact of informed consent on elderly patients' colorectal cancer (CRC) screening preferences. DESIGN: Randomized, controlled trial. SETTING: Four general internal medicine practices. PATIENTS: We studied 399 elderly patients visiting their primary care provider for routine office visits. INTERVENTIONS: Patients were randomized to receive either a scripted control message briefly describing CRC screening methods or one of two informational interventions simulating an informed consent presentation about CRC screening. One intervention described CRC mortality risk reduction in relative terms; the other, in absolute terms. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was intent to begin or continue fecal occult blood testing (FOBT), flexible sigmoidoscopy, or both. There was no difference in screening interest between the control group and the two information groups (p =.8). The majority (63%) of patients intended to begin or continue CRC screening. Informed patients were able to gauge more accurately the positive predictive value of screening (p =.0009). Control patients rated the efficacy of screening higher than did patients receiving relative risk reduction information, who rated it higher than did patients receiving absolute risk reduction information (p =.0002). CONCLUSIONS: Elderly patients appeared to understand CRC screening information and use it to gauge the efficacy of screening, but provision of information had no impact on their preferences for screening. In view of the large proportion who preferred not to be screened, we conclude that elderly patients should be involved in the screening decision. However, factors other than provision of information must determine their CRC screening preferences. (+info)
Withholding/withdrawing treatment from neonates: legislation and official guidelines across Europe.
(40/1957)
Representatives from eight European countries compared the legal, ethical and professional settings within which decision making for neonates takes place. When it comes to limiting treatment there is general agreement across all countries that overly aggressive treatment is to be discouraged. Nevertheless, strong emphasis has been placed on the need for compassionate care even where cure is not possible. Where a child will die irrespective of medical intervention, there is widespread acceptance of the practice of limiting aggressive treatment or alleviating suffering even if death may be hastened as a result. Where the infant could be saved but the future outlook is bleak there is more debate, but only two countries have tested the courts with such cases. When it comes to the active intentional ending of life, the legal position is standard across Europe; it is prohibited. However, recognising those intractable situations where death may be lingering and unpleasant, Dutch paediatricians have reported that they do sometimes assist babies to die with parental consent. Two cases have been tried through the courts and recent official recommendations have set out standards by which such actions may be assessed. (+info)