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Doctors are ethically bound to inform parents about risks
- Will Carroll (6 June 1999)
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Sensitive counselling still may be worth while
- John Kemm (8 June 1999)
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Re: Doctors are ethically bound to inform parents about risks
- Carl Henshall, Deborah Henshall (10 June 1999)
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Concerns from Newcastle
- E Browne, H Melsom, S Powell, G Roberts, J Wing (24 June 1999)
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Authors' response
- Linda Irvine, Iain Crombie, Roland Clark, Peter Slane (18 July 1999)
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Will Carroll, Specialist Registrar in Paediatrics City General Hospital, Stoke-on-Trent
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Doctors are ethically bound to inform parents about risks EDITOR – I was saddened if not wholly surprised to find that advice to parents about the detrimental effects of passive smoking on their asthmatic children did not seem to influence their behaviour (1). The authors of the paper correctly identified that further intervention may be required in order to protect children’s health but went on to conclude that the ‘parent’s smoking needs to be addressed as a separate issue from the child’s health’. Not only is this not always possible, I firmly believe that doctors are duty bound to inform parents fully about their children’s medical condition. The GMC guidance on good medical practice states that ‘..you must give patients the information they ask or need about their condition, its treatment and prognosis. You should provide this information to those with parental responsibility where the patients are under 16 years old and lack the maturity to understand what their condition or its treatment may involve, provided you judge it to be in the child’s best interests to do so’ (2). I acknowledge that many parents will choose to ignore the advice of doctors, even when it is clear they are damaging their children’s health, however, they cannot be allowed to do so from a position of ignorance. Will Carroll Specialist Registrar in Paediatrics Department of Paediatrics, City General Hospital, Stoke-on-Trent. 1. Irvine L, Crombie IK, Clark RA, Slane PW, Feyerabend C, Goodman KE, Cater JI. Advising parents of asthmatic children on passive smoking: randomised controlled trial. BMJ 1999;318:1456-1459. 2. General Medical Council July 1998. ‘Good Medical Practice.’ All correspondence should be sent to: Dr Will Carroll, 23 Ash Tree Hill, Cheadle, Stoke-on-Trent, ST10 1UQ. Competing interest: none Conflict of interest: none. |
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John Kemm
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The subject of the paper by Irvine et al [1] is important but without more information the paper provides no foundation for evidence based practice. The reader can safely conclude that something made no difference but is given no useful description of what that something was. The paper supplies only two of the five elements that Windsor, Boyd and Orleans [2] suggest as an adequate description of an intervention namely counselling content, theoretical framework from which methods are derived, duration of each patient contact, frequency of intervention components and training of intervention counsellors. It is sad that journals which take commendable steps to ensure that the outcomes are adequately reported still do not apply similar standards to the reporting of the intervention [3]. A further cause for concern is the context of the study. What was the nature of the families' consent? If they were given adequate information it is likely that the control group was appreciably contaminated and if they were not the ethics of the study are debatable. What previous advice and support had been given to these families? I hope we can assume that all practices in the study routinely advised all such parents of the possible connection between their smoking and their child's asthma in which case the additional intervention sounds marginal. One has to ask whether the intervention was in accord with best practice. The use of a research nurse unknown to the family and apparently unconnected with the patients practice does not utilise the practice patient relationship. The use of the phrase "telling patients what to do" in the discussion raises concern as to counselling style. Certainly we need more effective methods of helping smokers cut back or quit and the intervention used in this study was apparently ineffective. However this paper should not be interpreted as indicating that sensitive counselling by primary care teams of parents who smoke and have asthmatic children is not worth while. John Kemm Consultant in Public Health Medicine Llanishen Cardiff CF14 5EZ References 1 Irvine L,Crombie IK, Clark RA, Slane PW, Feyerabend C, Goodman KE, Cater JI Advising parents of asthmatic children on passive smoking: Randomised controlled trial. BMJ (1999) 318 1456-1459 2 Windsor RA, Boyd NR and Orleans CT A meta evaluation of smoking cessation intervention research among pregnant women: improving the science and art. Health Education Research (1998) 13 419-438. 3 Speller V, Learmonth A and Harrison D The search for evidence of effective health promotion. BMJ (1997) 315, 361-363. |
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Carl Henshall, Carers North Staffordshire, Deborah Henshall
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I read with interest this admirable concept of informing parents about their child`s medical condition and indeed the risks of any treatment or not to their health and wellbeing. Perhaps Mr Carroll would like to pin this advice on his hospital`s notice board so that other colleagues can share in his wisdom. Ironic when you consider the ongoing government inquiry into whether parents were misled and uninformed about the research projects their children were used in without their knowledge at his hospital! We will be cautiously hopeful that a change in culture is on the horizon for those parents unfortunate enough to need the services of the paediatric department when thier child is sick. Information from those clinicians treating ones child is vital to encourage trust and understanding between the doctor and parent who should be working together to help the child recover from whatever misfortune they find themselves in. |
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E Browne, Stage 3 Medical Students Dept. of Epidemiology & Public Health, The Medical School, University of Newcastle Upon Tyne., H Melsom, S Powell, G Roberts, J Wing
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Editor, Irvine et al report a randomised controlled study on the effects of advising parents of asthmatic children on passive smoking (1). They identified that it is as yet unproved whether the risks from passive smoking are appreciated. They then went on to conclude from their study that a brief intervention has no significant effect on parental smoking habits. We are concerned that firstly there appeared to be an information overload presented to the parents, during a single session, with no measure of comprehension and recall. Secondly, leaflets were sent to the parents involved with no apparent consideration of the issue of literacy. Without these measures in place it is difficult to assess appreciation of passive smoking risks and the effectiveness of the intervention they describe. The results are not unexpected. There have been several studies in the past that have shown brief interventions to be ineffective. In this study, however, Irvine et al did identify some individuals who displayed a change in their habit. It may therefore have been more useful to have analysed subset data in an attempt to elicit the factors that were important in influencing these changes. This could then have been used to direct further in depth studies. Competing Interests : none 1 Irvine L. et al, Advising Parents of Asthmatic Children on Passive Smoking: randomised controlled trial. |
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Linda Irvine , Iain Crombie, Roland Clark, Peter Slane
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We have read the responses to this paper with interest and will try to address all the points made and clarify by giving more details. Dr Carroll feels doctors are ethically bound to tell parents about the risks of passive smoking and quotes the GMC guidance on good medical practice which states that "you must give patients the information they ask or need about their condition, its treatment and prognosis". We do not dispute that parents should be given relevant information but what patients do not need is an intervention which is at best ineffective and may even be counterproductive. We have only suggested that trying to persuade parents to stop smoking at a consultation about their child’s asthma may not be appropriate. It is up to doctors to decide, given the clinical circumstance, what actions are warranted. Dr Kemm raised several important issues. He was concerned that the intervention was not described in enough detail. The extent of reporting was restricted by the word limit but we take this opportunity to give more details. The intervention was designed so that it could be easily used in the clinical situation, if found to be effective. It was brief, based on the method first described by Russell.[1] Parents were visited once and the nature of the intervention is described in the paper. Information given at the time of the consultation was reinforced in leaflets. The duration of the contact with the parents was approximately one hour although the actual intervention took around ten minutes. The intervention was delivered by research nurses, who were not trained counsellors. This was intentional, the purpose of the study being to test an intervention which could be delivered by any nurse. Dr Kemm was also concerned about the ethics of our study. Providing enough information about a study to obtain informed consent without contaminating the control group is a problem for all studies designed to change behaviour. Parents were told that the study was being carried out to look at ways of reducing passive smoking in children with asthma and gave written consent of participation. However the full details of the study design were not disclosed. The issue of informed consent was discussed in detail with the Tayside Committee on Medical Ethics prior to the start of the study. We were satisfied that parents were given sufficient information. Dr Kemm assumes that clinicians routinely advise all parents of the possible connection between their smoking and their child’s asthma. Several studies have shown that many clinicians do not give such advice routinely,[2,3] and some are uncertain about the impact of counselling smokers at every opportunity.[4] Finally, Dr Kemm queried the use of research nurses unknown to the study participants. The alternative, using practice staff to deliver the intervention was not a realistic option. Due to the size and complexity of the study and the large number of GP practices involved, it would have been impractical for the intervention to be delivered by practice staff. Further, we believe that the quality of large trials is dependent upon rigorous data collection by staff dedicated to the project. We remain confident that our study showed that brief intervention on parents is of no benefit to children with asthma. The main concern of the medical students from Newcastle was the nature of the leaflets given to the parents. Describing the design and content of the leaflets was beyond the scope of the paper, again due to the word restriction. The leaflets were based on the intervention with much of the information which was given orally repeated in the three leaflets. The leaflets were illustrated and the limited text was in large print, consisting of short sentences and commonly used words. The only medical term was the word asthma. We were satisfied that the parents would understand the content of the leaflets as they had already read the information leaflets and completed the consent forms. Information overload is a problem in consultations between patients and doctors. We were aware that the consultations were long (approximately one hour) and involved several components (obtaining informed consent from the parents and children, administering the questionnaire, collecting saliva samples and then further discussion on passive smoking with the intervention group). To reinforce the intervention, the information was repeated in the leaflets, the first of which was left with the parents on the day of the initial home visit. We did not try to measure comprehension or recall of the information given, but used an objective measure, salivary cotinine, to determine whether the intervention had any impact on passive smoking by the children one year later. Twelve parents reported stopping smoking and this was confirmed by salivary cotinine levels in only ten. We explored the histories of these parents but the numbers were insufficient to be analysed as a subset. 1. Russell MAH, Wilson C, Taylor C, Baker CD. Effects of general practitioners' advice against smoking. BMJ 1979;2: 231-235. 2. Goldstein MG, Niaura R, Willey-Lessne C, DePue J, Eaton C, Rakowski W, et al. Physicians counseling smokers. Arch Intern Med 1997;157 1313-1319. 3. Frankowski BL, Weaver SO, Secker-Walker RH. Advising Parents to Stop Smoking: Pediatricians’ and Parents' Attitudes. Pediatrics 1993;91 (2): 296-300. 4. Coleman T, Wilson A. Anti-smoking advice in general practice consultations: general practitioners' attitudes, reported practice and perceived problems. British Journal of General Practice 1996;46 (403): 87- 91. |
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