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Basics of Informed Consent (Part 1)

Basics of Informed Consent (Part 1). Paula Bistak, DMH, RN, MS, CIP, CHRC Executive Director, HSPP Donna Hoagland, LPN, BS, CIP, CCRC, CHRC IRB Director, New Brunswick/Piscataway and Stratford/Camden Carlotta Rodriguez, BS, CIP, CHRC IRB Director, Newark Campus IRB

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Basics of Informed Consent (Part 1)

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  1. Basics of Informed Consent (Part 1) Paula Bistak, DMH, RN, MS, CIP, CHRC Executive Director, HSPP Donna Hoagland, LPN, BS, CIP, CCRC, CHRC IRB Director, New Brunswick/Piscataway and Stratford/Camden Carlotta Rodriguez, BS, CIP, CHRC IRB Director, Newark Campus IRB Cheryl Forst, RN, BSN, CCRP HSPP Analyst Director Christine Asmann-Finch, DMH, MS Program Development Specialist/Medical Humanist

  2. Session Overview • Introduction • Ethical Principles • Regulations • Consent as a Process • Specifics • Required Elements • Documentation • Waivers • Common Findings • Subject Perspectives

  3. Informed Consent • Basic Ethical Principles for the Protection of Human Subjects in Research • Belmont Report • Established in 1979 by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research • Ethical Principles and Guidelines for the Protection of Human Subjects in Research • Respect for Persons • Beneficence • Justice

  4. Informed Consent • Respect for Persons • “Informed consent for persons requires that subjects, to the degree that they are capable, be given the opportunity to choose what shall or shall not happen to them. This opportunity is provided when adequate standards for informed consent are satisfied”. * Ethical and Regulatory Aspects of Clinical Research

  5. Respect for Persons • Application through Informed Consent • Information • Comprehension • Voluntariness

  6. Informed Consent • Informed consent results • when a full disclosure of the role, benefits, risks, choices, and outcomes are explained in understandable ways. • Voluntary informed consent cannot be realized until • differentials of power, class, economics, desperation, and other possible sources of coercion are considered and addressed.

  7. Legally Effective Informed Consent • Consent by • Research Subject or • Research Subject’s Legally Authorized Representative for Research (LAR) under State Law • State of New Jersey • Access to Medical Research Act

  8. Legally Effective Informed Consent • No coercion or undue influence (recruitment) • Obtained by Investigator/Staff trained and authorized by IRB • Language understandable to the subject • Use lowest level vocabulary and syntax • Avoid jargon • No exculpatory language • Contains required elements • If applicable - Six additional elements

  9. General Requirements for informed consent 45 CFR 46.116 Common Rule 21 CFR 50. 25 FDA ICH E-6 Section 4.8.10 (GCP)

  10. Informed Consent Informed consent is a process, not just a signed document.

  11. Informed Consent Process • The process should: • Provide adequate information • generally, what a reasonable person would want to know before making a decision • Confirm the participants comprehend the information • Assure consent is given voluntarily

  12. Elements • Statement that the activity is research • Purpose of the study • Description of the study procedures (identifying those that are experimental) • Duration of subject involvement

  13. Elements (continued) • Potential risks and discomforts of participation • Potential benefits of participation (to the subject and others) • Alternatives (if any) • Confidentiality of records description • Number of subjects (if it may have an impact on the decision)

  14. Elements (continued) • Compensation for injury statement (for greater than minimal risk studies) • Statement of voluntary participation • Contact person for questions • About research • About rights • About injury

  15. Required Elements If the study is a clinical trial, the following must be included: "A description of this clinical trial will be available on ClinicalTrials.gov, as required by U.S. Law. This Web site will not include information that can identify you. At most, the Web site will include a summary of the results. You can search this website at any time."

  16. Additional Elements • Statement that there may be risks which are unforeseeable • Under what circumstances investigator could terminate subject’s participation (include plan to exit subjects) • Additional costs to subject

  17. Additional Elements (cont.) • Consequences of subjects withdrawal from research (include plan to exit subjects) • Statement that will be told of new findings • Approx. number of subjects in study

  18. Documentation of informed consent (46.117) • …informed consent shall be documented by the use of a written consent form approved by the IRB and signed by the subject or the subject’s legally authorized representative. A copy shall be given to the person signing the form

  19. Waivers • Waiver of Informed Consent • Waiver of the Requirement to Obtain Documentation of Consent • no signature

  20. Waiver or Alteration of Informed Consent • The research involves no more than minimal risk to the subjects; • The waiver or alteration will not adversely affect the rights and welfare of the subjects; • The research could not practicably be carried out without the waiver or alteration; and

  21. Waiver or Alteration (continued) • Whenever appropriate, the subjects will be provided with additional pertinent information after participation

  22. Waiver of Documentation • The only record linking the subject and the research would be the consent document and the principal risk would be potential harm resulting from a breach of confidentiality. • The research presents no more than minimal risk of harm to subjects and involves no procedure for which written consent is normally required outside of the research context.

  23. Waiver of Documentation (continued) In cases in which the documentation requirement is waived, the IRB may require the investigator to provide subjects with a written statement regarding the research.

  24. Passive Consent • Federal regulations do not support the concept of passive consent. There is no such thing as passive consent from the regulatory standpoint.

  25. Informed Consent Process • Process can vary but should generally include: • Research team member provides the informed consent document for the participant to read • A member of the study team explains the study to the participant • The participant is given an opportunity to ask questions • The participant is given the opportunity to review the consent document with family and consider participating • Participant is given a copy of the signed consent document

  26. Informed Consent Process • Process: • Ongoing • Researcher should determine the subjects willingness to continue throughout the trial • Participation is voluntary • Subject can refuse to continue • Subject can withdraw at any time

  27. Informed Consent Audit Privacy & Confidentiality : • Location matches IRB approved protocol • Confidentiality maintained • Limited Access – Electronic enrollment • Original consent form locked in separate location from other study data

  28. Validate Source Documents : • Consent forms equal number of subjects • Confirmed as signed prior to the start of activities • Appropriately Executed (Signatures & dates) • Study personnel who are obtaining consent are named on the IRB approved protocol. • Content of executed consents corresponds to IRB approved versions(current IRB stamp).

  29. Consent Process Documentation: • Mirrors the description in IRB approved protocol • Truly represents the consent process • Subject questions answered • Given time to voluntarily decide to participate • Copy of the consent form given to subject • Auditors may visit to observe the process 45CFR 46.117 45 CFR 46.116

  30. Informed Consent Form ICF: • Contain all required elements • In language understandable to the study subject. • Study activity represents what the subject has been informed( recruitment, study visits , procedures, risks, benefits, payment for participation ect…)

  31. Top 10 Consent Audit Findings 10. Subject signature and person obtaining consent on different dates 9. Subject consented with wrong version of consent/expired consent 8. Subject consented by individual not named on the IRB protocol 7. Check boxes within consent incomplete (future use of samples) 6. Crossed out or white out anywhere on the consent document 5. Unable to locate consent(s) for subject(s) on study 4. Subjects not re-consented with revised consent 3. Ineligible subjects enrolled 2. Wrong contact telephone number listed in consent 1. Copy of the consent document NOT provided to the subject

  32. Strive for the BEST Informed Consent • It starts with you ! • It is the first instructional piece of information provided to the subject • Should be clearly written and presented to promote decision making • Understand that each interaction is different(circumstances, questions, communication style) • Take it serious and fully inform & document !

  33. CONSENT TO PARTICIPATION IN CLINICAL TRIALS FROM A SUBJECT’S POINT OF VIEW CONTENT What terms and ways of writing are difficult to comprehend? CONTEXT What does participation mean in the context of a person’s life?

  34. The Obvious Problems Language Key Concepts, Procedures & Rights Literacy Reading level Health & Research Literacy Randomization Placebo Probabilities HIPAA Authorization

  35. Confusing Terms/Phrases “Experiment”, “research”, “new treatment”, “study”, “investigation” “We are experimenting with this drug to determine if it will lengthen time to disease progression.” “Some ‘side effects’ of the experimental drug are…” “We would like to keep track of your medical condition for x years.” “You can withdraw from the clinical trial at any time.” Active v Passive verbs: “Improving the Treatment of Disease X with Drug Y” v “Drug Y in the Treatment of Disease X”

  36. Listener Harm Fortune Telling • “Ninety-five percent of the people diagnosed with this cancer will not be alive 5 years later.” Point of View Phrases • “Some ‘side effects’ of the experimental drug are…” • We would like permission to store your ‘left-over’ tissue.” • “You will be randomized to an arm of the trial, like a ‘flip of a coin’.” • “We are researching ways to improve our procedures because patients like you are usually not compliant with our instructions (or you are difficult to work with).”

  37. Listener Harm • Metaphors • War – “The experimental drug will fight the invasive cells and try to kill/destroy them.” • Kitchen – “Think of your intestines as a bowl of spaghetti. Through our surgery we will strain and cut…” • Container – “You will be randomized to an arm of the trial…” • Other • Curb your enthusiasm – “Plastic is ubiquitous in our homes. Exposure to the chemicals in plastic may be harmful to you and your children. We would like to measure your newborn’s exposure to plastic while in the hospital and see if there are any correlations with markers in the blood.”

  38. What Subjects Would Like or Would Like to Know • Permission • Knowledge (about self, others, disease) • Research results • Out-of-Pocket Costs for treatments, tests, transportation & incidentals • Accurate estimation of time commitment to participate (including office wait-time) • Who will pay if I am injured as a result of participation (please make me/my family whole)

  39. Motives and Meaning of Participation in Clinical Research Motives: • Coercion by Disease • Personal Benefit • Restore Health • Income & Access • Knowledge • Relationships • Health Care Provider • Family & “Community” • Altruism

  40. Motives and Meaning Meaning: • Mistrust • research as a metaphor for past transgressions • Stigma • diseaseas a metaphor for social disgrace/discrimination/taboo • Meaningin suffering

  41. Contact Information • http://www.umdnj.edu/hsp • HSPP – (973) 972-1149 • New Brunswick IRB (732) 235-9806 • Newark IRB – (973) 972-3608 • Stratford IRB – (856) 566-7196

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