Discussion:
Obtaining informed consent to perform LP could be considered more challenging compared to other common procedures, and it has been reported to be refused by many patients.1 With retrospective charts review, it was found that many important points were not adequately documented on the consent forms.3 This may imply that parents were not making real, informed decisions. They have also recommended using alternative methods, like video, when informing parents about procedures. This is especially important in emergency settings when the same, sufficient information is urgently needed for proper consenting of patients and relatives. Using such digital media may be more relevant during the infectious disease outbreaks, such as with the current COVID-19 pandemic. Nicol et al. reported the need to minimize face-to-face contact during the pandemic by utilizing digital tools, such as adopting electronic informed consent.10 Many hospitals have recently changed their standard operating procedures during the COVID-19 outbreak,11 with the process for obtaining appropriate procedural informed consent from patients has been revised to decrease the risk of transmitting infection. Moreover, a video with details on the LP procedure gives the parents the possibility to watch it again, at their own pace.
Refusal of LP has been reported in some studies, and the refusal rate was ranging from 24 to 44%.1 The main reasons for refusal were fear of paralysis, painful nature of the procedure, and fear of death. Other possible reasons that were fewer common causes for refusal included scoliosis, developmental delay, and epilepsy. Moreover, it was reported that 21% of parents who refused LP felt that the procedure was unnecessary, and two families in the same study doubted motives behind the request of consent.1Patients or their families’ misconceptions about the procedure and inadequate communication tools and skills utilized when the consent is sought might have impacted their reluctance to give consent for LP. Informed consent about any medical procedure implies proper communication in the same person’s terminology and language, so the participant is aware of the procedure’s risks and benefits.
In the current study, we reported a significant increase in the number of parents who agree to consent after both ways of interventions (verbal explanation and video-guided counseling) in the parents’ native language. Similar to our findings, videos have been reported to be useful for education in various medical disciplines.5, 12-13 A prospective randomized study on the use of videos for preoperative education of patients undergoing regional anesthesia found that those who watched a video before the procedure had significantly less anxiety than those who received verbal education only.5 Patients with closed ankle fracture viewing video-recorded information before giving consent for ankle fracture surgery demonstrated an overall increased understanding of the risks, benefits, alternatives, and postoperative treatment compared to patients who received information verbally.14 However, some reported that using video-guided counseling leads to more comprehension and understanding of the procedure, while others reported no significant differences compared to conventional counseling methods.5-7 This variation in results could be caused by differences in the quality and content of videos in relation to the targeted procedure, the counselors’ communication skills, and the cultural and socio-demographic characteristics of the targeted population.
Noteworthy, that while Arabic is the native language is Saudi Arabia, the health care system uses English as the official communication among various healthcare providers and in the medical health records. Moreover, some of the health care providers within Saudi Arabia, who might be responsible for counseling parents, are not of native Arabic origin with relative Arabic language difficulties that might create a communication barrier between the health care provider and the parents. Providing such educational videos in Arabic, with English subtitles, can bridge the gaps of some communication difficulties among parents and healthcare workers, as well as providing appropriate knowledge about such medical procedures. Moreover, video consent has the potential to minimize the time required for prolonged counseling by physicians, especially in busy services like the emergency department. Instead, brief counseling after the videos may be sufficient, without sacrificing knowledge. Epstein et al. had also reported more change in attitude in the video group as compared to the audio group about the Cardiopulmonary resuscitation (CPR) procedure, as patients saw in the video of the aggressive nature of CPR, but not in the narrative arm.15
Differences in the results between studies could be attributed to many factors such as the procedure itself, the educational material content and context, the situation for the watcher, and cultural believes among different levels of education and socioeconomic status.
Conventional verbal explanation in our study showed a more consistent effect when it was done with constant information with a more consistent gain of knowledge, in comparison to video-guided education that is presenting the same information, in which the gain could be more widely dispersed. This difference could be attributed to the various factors related to educational video’s content and audio-visual effects. It also suggests that while the video method can be useful, the need for the individualized approach is still warranted for these parents.Joseph et al. demonstrated that while the informed consent using an educational video ensured good comprehension in most of their participants; however, additional educational sessions were advisable for some participants.16 The healthcare provider-patient interaction before LP is an integral part of counseling because adequate patient’s informed consent necessitates the ability of the patients or their families to directly discuss their concerns regarding the indications, alternatives, and complications of any medical procedure they undergo.
Video education in parents’ native language was demonstrated to be an equally effective method for education regarding lumbar puncture as verbal explanation counseling. However, the video guided counseling and education has the additional advantage of reproducibility, which is training-dependent and might be subjected to human errors in verbal explanation counseling.6
In terms of overall comprehension, the current study showed a statistically significant increase in knowledge score following the two methods (verbal and video-guided education), and both were equally effective in educating parents, regardless of their educational level. However, the observed difference in the change in knowledge scores between those two groups was not statistically significant. Dunbar et al. recently described that using the educational video about LP resulted in a significantly higher parental understanding of the procedure.17 In our study, the equal effect on knowledge score in both arms might be attributed to having different study team operators in the verbal explanation method with different potential, aptitudes, and vocal skills.
Our finding that people with less knowledge perceived higher risk for LP after watching the video-guided education could be due to the demonstrated animation of the anatomical positioning and procedure explanation with needle insertion in the back of the patients. Other research demonstrated that while videos standardized the educational message, and maybe particularly useful with low literacy populations, however, additional educational sessions may be necessary for some participants with lower educational level.16Dunbar et al., on the other hand, demonstrated contradictory findings to our study, with more parental comfort with the LP procedure after watching the adjunctive educational video.17 This paradoxical negative effect could be minimized by supplementing the video with a one-to-one counseling session for the parents to clarify any worrying scenes, contents, and questions that may arise after viewing the demonstration. Alternatively, providing a disclaimer at the beginning of such educational videos, highlighting the potential graphical contents of the video, and emphasizing the availability of individualized counseling after the video. Furthermore, educational videos should be piloted among the targeted audience so that the content can be modified based on their feedback. Arnold reported that parents had increased understanding of retinopathy of prematurity (ROP) after watching a short educational video, and this instrument decreased face-to-face education time for the treating physician and appeared to improve the consent process for treatment.18
The combination of both video and phone verbal explanation could prove to be successful and tailor the counseling to the specific needs and understandings of the parents. Such an approach is needed during the COVID-19 pandemic and other infectious outbreaks, where the remote informed consenting process is intended to reduce the possibility of transmissible disease.10-11 Healthcare providers may adopt such educational videos, incorporated as an online link provided both as a character string and a quick response (QR) code, into the procedural electronic consent. These may be obtained in a manner like the telephonic consent process. Future studies to evaluate these video-integrated, remote informed consenting processes during the pandemic are warranted.