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Research with Vulnerable Populations. Marisue Cody, PhD, RN IRB Chair Training Washington DC, April 9, 2004. Objectives. Criteria for permissible research Levels of risk justified Capacity assessment Surrogate decision-making and consent. Subject vulnerability.

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research with vulnerable populations

Research with Vulnerable Populations

Marisue Cody, PhD, RN

IRB Chair Training

Washington DC, April 9, 2004

objectives
Objectives
  • Criteria for permissible research
  • Levels of risk justified
  • Capacity assessment
  • Surrogate decision-making and consent
subject vulnerability
Subject vulnerability

“when some or all of the subjects are likely to be vulnerable to coercion or undue influence,…additional safeguards must be included in the study to protect the rights and welfare of these subjects.”

45 CFR 46.111(b)

diminished autonomy
Diminished autonomy
  • Mental capacity—ability to understand and process information
  • Voluntariness—freedom from the control or influence of others
examples of vulnerable subjects
Examples of vulnerable subjects
  • Children, prisoners, pregnant women
  • Handicapped, or mentally disabled persons, or economically or educationally disadvantaged persons
  • Students, employees, members of the armed forces
  • Patients with incurable diseases, persons in nursing homes, patients in emergency situations
what are they vulnerable to
What are they vulnerable to?
  • Physical control
  • Coercion
  • Undue influence
  • Manipulation
impaired decision making capacity

Impaired decision-making capacity

VHA Handbook 1200.5

Appendix D

slide8

If subjects with psychiatric disorders, dementia, and other mental impairments were excluded from studies, persons with these conditions would be deprived of the improved health care research can produce.

Dresser R. Mentally disabled researchsubjects: The enduring policy issues. JAMA 1996; 276: 67-72.

when can research be done
When can research be done?
  • They comprise the only appropriate study population
  • The research question focuses on an issue unique to subjects in this population
degree of risk
Degree of risk
  • Minimal risk
  • “Minor over minimal”
  • Acceptable risk-knowledge ratio
  • “Maximal potential risk”
acceptable risk
Acceptable risk?
  • Initial trials of a new drug for AD:
    • 63% stops the progress of the disease
    • ~50% it even produces some restoration of cognitive capacity
    • 20% -- no effect.
    • 15% serious and, in two cases, a fatal reaction.
  • Is this level of risk acceptable?
  • Post SG, Full-spectrum proxy consent for research participation when persons with Alzheimer Disease lose decisional capacities: Research ethics and common good. Alzheimer Disease and Associated Disorders 2003; 17: S3-S11.
limiting risks
Limiting risks
  • Inclusion/exclusion criteria
  • “Aggressive monitoring”
    • Routine and constant
    • Respect for subjects’ physical resistance or other expressed dissent
    • When to halt…..
capacity to consent
Capacity to consent
  • Presumed competent to consent unless there is evidence of serious mental disability
  • Provide a plan for determining the incapacity
competence vs capacity
Competence vs. capacity
  • “Competence” -- legal and moral status of individuals that entitles them to make their own decisions
  • “Capacity” – cognitive, affective, and volitional abilities that underlie competence
formal procedures for capacity assessment
Formal procedures for capacity assessment
  • Goes against the presumption of assumed competence in adults
  • Reserve for populations with high probability of decisional-impairment
  • Who decides?
    • Structured questionnaire
    • Clinical care model: leave the decision to a disinterested 3rd party
surrogate consent
Surrogate consent
  • When prospective patient is incompetent or has impaired decision-making capacity
    • Practitioner, in consultation with the chief of service, or COS, after an appropriate medical exam
    • Consultation with psychiatrist or licensed psychologist if based on a diagnosis of mental illness
    • Consent disclosures to the surrogate
    • Explanation to subject
legally authorized representative
Legally authorized representative
  • Court appointed guardian, only with the court’s consent
  • Health care agent appointed in a durable power of attorney
  • Next of kin (1200.5 pg. 20): Spouse, Adult child, Parent, Adult sibling, Grandparent, or Adult grandchild (depending on state law)
what to tell representative
What to tell representative…
  • Description of the proposed research and the risks and benefits of participation
  • Their obligation as the patient’s representative, i.e., try to determine what the patient would do if competent or, what they think is the subjects’ best interests