[Advance Directives - Not a Lot of Margin for Error - The Surgeon's View of a Complex Medical-Legal Topic]. / Patientenverfügungen - welchen Spielraum erlauben sie? - Chirurgische Sicht auf ein komplexes medizinjuristisches Thema.

Since September 1st, 2009, the most recent version of the German "Betreuungsrechtsänderungsgesetz" has been validated by the legislators. It precisely sets out how physicians and nursing staff have to deal with a written declaration of a patient's will. This new law focuses in a special way on advance directives, describes the precise rules for the authors of an advance directive and shows both its sphere of action and its limitations. This article aims to give an overview on the legal scope of advance directives, and to illustrate potential limitations and conflicts. Furthermore, it shows the commitments and rights of the medical team against the background of an existing advance directive.

Deliberative democracy and cancer screening consent: a randomised control trial of the effect of a community jury on men's knowledge about and intentions to participate in PSA screening.

OBJECTIVE: Prostate-specific antigen (PSA) screening is controversial. A community jury allows presentation of complex information and may clarify how participants view screening after being well-informed. We examined whether participating in a community jury had an effect on men's knowledge about and their intention to participate in PSA screening. DESIGN: Random allocation to either a 2-day community jury or a control group, with preassessment, postassessment and 3-month follow-up assessment. SETTING: Participants from the Gold Coast (Australia) recruited via radio, newspaper and community meetings. PARTICIPANTS: Twenty-six men aged 50-70 years with no previous diagnosis of prostate cancer. INTERVENTION: The control group (n=14) received factsheets on PSA screening. Community jury participants (n=12) received the same factsheets and further information about screening for prostate cancer. In addition, three experts presented information on PSA screening: a neutral scientific advisor provided background information, one expert emphasised the potential benefits of screening and another expert emphasised the potential harms. Participants discussed information, asked questions to the experts and deliberated on personal and policy decisions. MAIN OUTCOME AND MEASURES: Our primary outcome was change in individual intention to have a PSA screening test. We also assessed knowledge about screening for prostate cancer. RESULTS: Analyses were conducted using intention-to-treat. Immediately after the jury, the community jury group had less intention-to-screen for prostate cancer than men in the control group (effect size=-0.6 SD, p=0.05). This was sustained at 3-month follow-up. Community jury men also correctly identified PSA test accuracy and considered themselves more informed (effect size=1.2 SD, p<0.001). CONCLUSIONS: Evidence-informed deliberation of the harms and benefits of PSA screening effects men's individual choice to be screened for prostate cancer. Community juries may be a valid method for eliciting target group input to policy decisions. TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Registry (ACTRN12612001079831).

Defining, aligning, or declining do not resuscitate during surgery.

A Professor A. Droit, 93 years of age, formerly your college ethics teacher, developed a painful ischemic foot from distal aortic blockage. A daughter, who is a nurse, brought him to the hospital. He has multiple comorbidities, including leukemia for which he is getting chemotherapy. He agrees to surgery but hands you a completed do not resuscitate (DNR) form and insists it be honored throughout his care. As the operative wound is being closed, he has a slow ventricular tachycardia, which does not respond to intravenous therapy. You should:

The standard of care and conflicts at the end of life in critical care: lessons from medical-legal crossroads and the role of a quasi-judicial tribunal in decision-making.

PURPOSE: The goals of this qualitative study were to review the last 7 years of end of life legal decisions within the critical care field to explore how medical benefit is defined and by whom and the role of the standard of care (SoC) in conflict resolution. METHODS: A public online, non-profit database of the Federation of Law Societies of Canada was searched for relevant Consent and Capacity Board decisions from 2003 to 2012. In total, 1486 cases were collected, and purposive sampling identified a total of 29 decisions regarding use of life-sustaining treatments at end of life. Using modified grounded theory, decisions were read and analyzed from a central SoC concept to understand definitions of benefit, rationales for case adjudication, and repercussions of legal recourse in conflict resolution. RESULTS: Medical benefit was clearly defined, and its role in determining SoC, transparent. Perceptions of variability in SoC were enhanced by physicians in intractable conflicts seeking legal validation by framing SoC issues as "best interest" determinations. The results reveal some key problems in recourse to the Consent and Capacity Board for clinicians, patients and substitute decision makers in such conflict situations. CONCLUSIONS: This study can help improve decision-making by debunking myth of variability in determinations of medical benefit and the standards of care at end of life and reveal the pitfalls of legal recourse in resolving intractable conflicts.

Best interests at end of life: an updated review of decisions made by the Consent and Capacity Board of Ontario.

PURPOSE: To increase our understanding of the notion of "best interests" in end of life disagreements through an updated review of decisions made by the Consent and Capacity Board of Ontario. There was a significant increase (235%) in decisions from this tribunal between 2009 and 2011. "Best interests" test is used when no prior expressed wishes are known to the surrogate decision-makers. METHODS: Purposively sampled written decisions of the Consent and Capacity Board of Ontario between 2003 and 2011 that focused on the "best interests" of patients at the end of life. Interpretive content analysis was performed independently by 3 reviewers, and themes were identified by consensus. RESULTS: We found substitute decision makers (SDMs) rely on an appeal to their own values or religion in their interpretation of best interests; physicians rely on clinical conditions; board emphasizes alignment with Health Care Consent Act. In the more recent cases, we found that SDMs report that patients value suffering; that SDMs have unrealistic hope for recovery and can communicate and get direction from the incapable patient; that SDMs need education on their role and responsibility as SDM; and that SDMs need time to provide consent, and that most proposed treatment plans that were sources of conflict included "palliative care." INTERPRETATION: Several lessons are drawn for the benefit of health care teams engaged in disagreements at end of life with SDMs over the best interests of patients.

[End of life in France]. / La fin de vie en France.

Two major changes in end-of-life management have occured in recent decades: first, because of the increase in life expectancy and the resulting aging of the population, most deaths now involve old or very old people; second, more than two-thirds of deaths occur in a hospital or an institution. Our fellow citizens are afraid of suffering and death. They wish for a peaceful death, as rapid as possible and, in recent surveys, say they favour euthanasia. Yet euthanasia is illegal in France and in most other Western countries (with the exception of the Benelux nations). Palliative care ensures dignity in death, without anxiety of suffering, and is expanding rapidly in France. Léonetti's law of 22 April 2005 ensures the protection of the weakest, who should never be considered unworthy of life, yet is poorly known to the public and even to physicians. It now needs to be applied in practice.

Legal briefing: futile or non-beneficial treatment.

This issue's "Legal Briefing" column covers recent legal developments involving futile or non-beneficial medical treatment. This topic has been the subject of recent articles in JCE. Indeed, it was the subject of a "Legal Briefing" in fall 2009. Accordingly, this column focuses on legal developments from the past two years. These developments are usefully grouped into the following 11 categories: 1. Texas Advance Directives Act, 2. Ontario Consent and Capacity Board, 3. Surrogate selection, 4. Ex post cases for damages, 5. Ex ante cases for injunctions, 6. Coercion and duress, 7. Assent and transparency, 8. Brain-death cases, 9. Criminal and administrative sanctions, 10. Conscientious objection, 11. Penalties for providing futile treatment.

Cosmetic surgery on children - professional and legal obligations in Australia.

BACKGROUND: Public awareness and concern about cosmetic surgery on children is increasing. Nationally and internationally questions have been raised by the media and government bodies about the appropriateness of children undergoing cosmetic surgery. Considering the rates of cosmetic surgery in comparable Western societies, it seems likely that the number of physicians in Australia who will deal with a request for cosmetic surgery for a child will continue to increase. This is a sensitive issue and it is essential that physicians understand the professional and legal obligations that arise when cosmetic surgery is proposed for a child. OBJECTIVE: This article reviews the current professional and legal obligations that physicians have to competent and incompetent children for whom cosmetic surgery has been requested. DISCUSSION: A case study is used to highlight the factors that Australian primary care physicians must consider before referring and conducting cosmetic surgery on children.

Key role of social work in effective communication and conflict resolution process: Medical Orders for Life-Sustaining Treatment (MOLST) Program in New York and shared medical decision making at the end of life.

In this article, the authors review the development of the Medical Orders for Life-Sustaining Treatment (MOLST) Program and recent landmark legislation in New York State in the context of advance care planning and shared medical decision making at the end of life. Social workers are central health care professionals in working with patients, families, practitioners, health care agents, and surrogates in the health systems and in the communication and conflict resolution process that is integral to health care decision making. The critical importance of ethics and end-of-life training and education for social workers is also addressed. Data from a pilot study evaluating interdisciplinary ethics training on legal and ethical content in communication and conflict resolution skills in health care decision making are reported. Recommendations are made for research on education and training of social workers, and investigation of the role and influence of systems in shaping social work involvement in end-of-life and palliative care.

Perspectives of potential donors on cord blood and cord blood cryopreservation: a survey of highly educated, pregnant Korean women receiving active prenatal care.

BACKGROUND: The aim of the study was to investigate the knowledge of cord blood (CB) and attitudes toward CB banking among high-potential donors (i.e., well-educated pregnant Koreans) because their voluntary donation is indispensable to the success of unrelated CB transplantation. STUDY DESIGN AND METHODS: Questionnaires examining perspectives on CB were distributed to and completed by 1001 women attending a maternity education program from April to October 2008; 863 women answered that they had heard of CB. We analyzed the 863 questionnaires to identify the sources of information, the plan for CB, the reasons for decisions, beliefs about the potential uses of CB, and knowledge about current therapeutic uses. RESULTS: Most subjects received information from promotional materials distributed by CB banks and the media; however, minimal information was obtained from obstetricians. More than 90% of women who planned to donate cited "altruism," and 75.0% of the "private preservation" group indicated that a desire to "safeguard for the future" was the reason for their decision. The probability of autologous CB transplantation (p = 0.001) and current usefulness were significantly overestimated in the private preservation group (p = 0.02). In addition, 56% of subjects underestimated the probability of identifying a matched CB in the public bank, and the overall rate of correct answers about current usefulness was 57.4%. CONCLUSIONS: A considerable portion of educated pregnant Korean women has more than minimal knowledge of CB, but the levels of knowledge regarding the potency of the public bank and the current usefulness and limitations of CB are generally low; in addition, obstetricians play insignificant roles in disseminating knowledge. Providing accurate and detailed information to pregnant women not only via brochures and the media and/or Internet but also by obstetricians would encourage CB donation.

Legislative intervention in Queensland to restrict access to solariums and cosmetic procedures by children and young persons.

Breaking new ground, Queensland has enacted laws restricting access to cosmetic surgery by those under 18 years of age. Legislation in other Australian jurisdictions is narrower in scope, focusing on niche areas such as solarium use, tattoos and body piercing. Even in those niche areas there are inconsistencies of approach and now the unique Queensland cosmetic surgery restrictions further raise the prospects of "medical tourism" and highlight the difficulties of differing legislation throughout Australia. All implementations, however, face the same challenge: to balance protection of vulnerable children, respect for a young person's autonomy and due regard to parental consent.