"How to navigate this new area": Intensive care clinicians' perceptions of voluntary assisted dying in the intensive care unit: A multisite exploratory study.

BACKGROUND: There is growing momentum worldwide for assisted dying. In Australia, voluntary assisted dying may occur in any setting, including an intensive care unit (ICU). As the subject of much debate worldwide, exploring ICU clinicians' perceptions of assisted dying is essential. AIM: The aim of this study was to explore clinicians' perceptions of and preparedness for voluntary assisted dying in the ICU. METHOD: An exploratory qualitative descriptive design using individual interviews was used. Medical, nursing, and allied health clinicians from three ICUs were recruited. Interviews were conducted between Nov 2022 and Jan 2023, with a hypothetical scenario about voluntary assisted dying used to prompt discussion. Interviews were recorded, professionally transcribed, and analysed using inductive content analysis. FINDINGS: ICU registered nurses (n = 20), physicians (n = 2), and allied health clinicians (n = 4) participated with interviews lasting 18-45 min (mean: 28 min). Analysis revealed four themes: (i) purpose of ICU reflected that ICU care was not all about saving lives, yet recognising dying and changing priorities was challenging; (ii) dying in the ICU is complex due to difficulties in talking about dying, accepting death as the outcome and evaluating care efficacy; (iii) voluntary assisted dying is a lot of grey because of perceived clinical and ethicolegal challenges; and finally, (iv) respecting choice was about respecting patients' values, beliefs, and autonomy, as well as clinicians' beliefs and right to exercise autonomy through conscientious objection. CONCLUSION: Dying and death are inevitable, and views and perspectives about assisted dying will continue to evolve. Respecting patient choice is at the core of assisted dying, but respecting clinicians' perspectives and choice is equally important. With voluntary assisted dying now legal in all Australian states, ensuring ICU team and individual clinician preparedness through access to education, resources, and specialist support services is key to raising awareness and easing uncertainty about deaths through voluntary assisted dying.

Implementing voluntary assisted dying laws in healthcare: Exploring beliefs to identify implementation hurdles.

The number of countries introducing voluntary assisted dying (VAD) laws is increasing. Actively taking steps to end a person's life is contentious so implementing these laws into healthcare services presents unique challenges. Theoretically underpinned by the Advocacy Coalition Framework, this study identified the beliefs of classes of stakeholders who engaged with the parliamentary process associated with the introduction of VAD laws in Queensland, Australia. Submissions about VAD made to a parliamentary inquiry were allocated to a class and qualitatively analysed to identify underlying beliefs. The data were then subjected to statistical analysis including nonmetric dimensional scaling and one-way analysis of similarity. Data visualisation techniques were used to generate a chord map and heatmap, to identify the belief types, as well as similarities and differences between beliefs and among classes. Fourteen different beliefs were identified in the 91 reviewed submissions. Six were deep core beliefs and eight were policy core beliefs. Beliefs could be associated with a positive or negative sentiment toward VAD. In this study, the class of Health Services expressed more negative sentiments to VAD than neutral or positive sentiments. The sentiments expressed by the class of Health Professionals were equally divided between positive, neutral and negative. These findings provide important insights for implementors as laws become operational. In particular, for organisations that provide health services, clear articulation of their stance in relevant policy and guidance documents is recommended.

Medication reconciliation at hospital discharge: A qualitative exploration of acute care nurses' perceptions of their roles and responsibilities.

BACKGROUND: Safe medication management is a cornerstone of nursing practice. Nurses prepare patients for discharge which includes the ongoing safe administration of medications. Medication reconciliation at hospital discharge is an interprofessional activity that helps to identify and rectify medication discrepancies or errors to ensure the accuracy and completeness of discharge medications and information. Nurses have a role in medication safety; however, their involvement in medication reconciliation at hospital discharge is poorly described. The study's aim was to describe acute care nurses' perceptions of their roles and responsibilities in medication reconciliation at hospital discharge, including barriers and enablers. DESIGN: Using focus groups, this exploratory descriptive study gathered qualitative data from nurses working in five acute care clinical units (medical, surgical and transit/discharge lounge) at a tertiary Australian hospital. The data were analysed using inductive content analysis and reported following the COREQ checklist. RESULTS: Thirty-two nurses were recruited. Three themes emerged from the data: nurses' medication reconciliation role involves chasing, checking and educating; burden of undertaking medication reconciliation at hospital discharge; team collaboration and communication in medication reconciliation. CONCLUSIONS: Nurses had a minor role in medication reconciliation at hospital discharge due to a lack of organisation clinical practice guidance and specialised training. Standardising interprofessional medication reconciliation processes and increasing nurses' involvement will help to streamline this task, reduce discharge delays, workload pressure and improve patient safety. RELEVANCE TO CLINICAL PRACTICE: Medication reconciliation at hospital discharge is an interprofessional patient safety activity, however little is known about nurse's role and responsibilities. This study reports nurses' important contribution to patient safety in terms of healthcare team coordination, medication checking and patient education. Supportive organisations and collaborative teams increased nurses' willingness to complete this activity.

Exploring healthcare professionals' perspective of the process of obtaining consent for adult patient's having planned surgery: A scoping review.

AIM: The aim of this scoping review was to provide an overview of the literature about the process of obtaining consent from adult patients undergoing planned surgery from the healthcare professionals' perspective and analyse knowledge gaps. BACKGROUND: The process of obtaining consent for planned elective surgery manifests an individual's fundamental right to decide what happens to their body. The process is often suboptimal and problematic, placing a significant resource burden on health systems globally. Deficiencies in the documentation on consent forms have also been shown to increase the risk of operating room error. DESIGN: Scoping review. METHODS: Arksey and O'Malley's (International Journal of Social Research Methodology, 8, 2005 and 19) five-step scoping review methodology was used. RESULTS: Fifty-three articles were included; 39 primary and 14 secondary research publications. Three key findings were identified; there is currently low-level evidence about surgical consent processes to inform clinical practice; junior doctors obtain surgical consent frequently, yet this process was likely undertaken sub-optimally; and current knowledge gaps include capacity assessment, decision-making and pre-procedural consent checks. CONCLUSION: Planned surgical consent processes are complex, and both surgeons and perioperative nurses are essential during the process. While surgeons have responsibility to obtain consent, perioperative nurses provide a safety net in the surgical consent process checking the surgical consent information is correct and has been understood by the patient. Such actions may influence consent validity and patient safety in the operating room. Knowledge gaps about capacity assessment, decision-making, pre-procedural checks and the impact of junior doctors obtaining consent on patient understanding, safety and legal claims are evident. RELEVANCE TO CLINICAL PRACTICE: This review highlights the importance of the surgical nurse's role in the planned surgical consent process. While the responsibility for obtaining surgical consent lies with the surgeon, the nurse's role verifying consent information is crucial as they act as a safety net and can reduce error in the operating room. NO PATIENT OR PUBLIC CONTRIBUTION: The authors declare that no patient or public contribution was made to this review in accordance with the aim to map existing literature from the healthcare professionals' perspective.

Identity disclosure between donor families and organ transplant recipients: an integrative review of the international literature.

Anonymity of deceased organ donation is a legal requirement in many international jurisdictions where legislation prohibits health professionals from disclosing identifiable information about donors, recipients or their families. Written correspondence between donor families and transplant recipients that is coordinated by healthcare professionals must remain anonymous. Internationally, an increasing number of donor families and transplant recipients have advocated for law reform and policy amendment to enable the exchange of identifiable written correspondence and/or face-to-face meetings. This paper aims to synthesise and critically evaluate published, peer-reviewed literature on the perceptions, benefits and challenges of identifiable communication or anonymity between donor families and organ transplant recipients in the international context. Analysis of the findings revealed two major themes: (1) views held by donor families, transplant recipients and healthcare professionals towards identity disclosure in the context of organ donation are diverse across and within groups (2) there are benefits and burdens associated with connecting donor families and transplant recipients through written correspondence. Less is known about the impact of face-to-face meetings between donor families and transplant recipients. However, what is known is that for some donor families, meeting with the transplant recipient(s) may provide a range of positive emotions.

Emergency department and intensive care unit health professionals' knowledge and application of the law that applies to end-of-life decision-making for adults: A scoping review of the literature.

BACKGROUND: Laws that regulate healthcare practice at the end of life reflect the values of the society where they apply. Traditionally, healthcare professionals rely on their clinical knowledge to inform treatment decisions, but the extent to which the law also informs health professionals' decision-making at the end of life is uncertain. OBJECTIVE: The objective of this study was to describe what healthcare professionals working in emergency departments and intensive care units know about the law that relates to end-of-life decision-making for hospitalised adults and what affects its application. REVIEW METHOD: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. DATA SOURCES: Data were sourced by searching the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL [via EBSCOhost]), Nursing and Allied Health and Health and Medical Collection (via ProQuest Central), Excerpta Medica dataBASE (Embase), PubMed, PsycINFO, and HeinOnline. RESULTS: Systematic screening of the search results and application of inclusion criteria resulted in the identification of 18 quantitative and three qualitative articles that were reviewed, summarised, and reported. Ten of the quantitative studies assessed knowledge and attitudes to law or end-of-life decision-making using hypothetical scenarios or vignettes. Qualitative studies focussed on how the law was applied when end-of-life decisions were made. End-of-life decision-making is mostly based on the clinical needs of the patient, with the law having a secondary role. CONCLUSION: Around the world, there are significant gaps in healthcare professionals' legal knowledge. Clinical factors are considered more important to end-of-life decision-making than legal factors. End-of-life decision-making is perceived to carry legal risk, and this results in the provision of nonbeneficial end-of-life care. Further qualitative research is needed to ascertain the clinician-related factors that affect the integration of law with end-of-life decision-making.

Voluntary assisted dying in Victoria: Why knowing the law matters to nurses.

In 2017, Victoria became the first state in Australia to pass legislation permitting voluntary assisted dying. Under this law, only those people who are near the end of their lives may access voluntary assisted dying, and because many of these people require nursing care to manage the progression of their illness or their symptoms, it will invariably have an impact on nursing practice. The Victorian law includes a series of procedural steps as safeguards to ensure that the law operates as intended. To support people who choose voluntary assisted dying and to practice safely within boundaries of the law, nurses must be aware of these requirements and how they operate. However, there are often gaps in nurses' legal knowledge. This was demonstrated in an article that aimed to inform nurses about the operation of Voluntary Assisted Dying Act 2017 (Vic) but contained several errors and misstatements of the law. Our article corrects these errors and discusses how the law is intended to be applied by revisiting the fictional case of Chloe - a woman with a terminal illness who is seeking voluntary assisted dying. As the Voluntary Assisted Dying Act 2017 (Vic) also protects nurses from liability if they act in accordance with its provisions, we conclude that sound knowledge and understanding of its operation support nurses to provide the safe, comprehensive and compassionate care their patients deserve at the end of life.

Just healthcare and human flourishing: Why resource allocation is not just enough.

Over many years, different theories have been developed to guide the social practices and policies of institutions so that they demonstrate equal concern and respect for all, and satisfy the requirements of justice. Although the normative principles described in a theory may support just institutions, whether this results in just outcomes will depend on how the decisions that implement the principles are made and actioned. As a societal institution charged with caring for people, ensuring just outcomes is a distinct concern in healthcare. Relationships within this institution are constitutive of human flourishing and are also important to justice. Yet, it is not possible to create, maintain or evaluate interpersonal relationships in the same manner as institutions because rather than being universal and impartial, they are particular and partial. Consequently, the link between theories of justice that guide decision-making in relation to structures or institutions, and the relationships that influence those with a proximate effect on individuals, is not explicit. To address this gap, this article argues that a focus on human flourishing provides a nexus between the decision-making for just institutions and just outcomes for individuals.

The Ethical, Legal and Regulatory Issues Associated with Pharmacogenomics: Systematically Quantifying the Literature.

Since the human genome was successfully mapped much academic attention has been given to ethical, legal and regulatory issues associated with the integration and application of genomics in health care. In line with the recent political commitment to promoting precision medicine that relies heavily on omic knowledge, it is timely to review the issues that this body of literature has addressed. Focusing on pharmacogenomics, this review quantifies the issues identified in this body of academic work. It reveals that, after nearly two decades, interest in the regulatory and legal issues associated with pharmacogenomics continues to generate significant attention. The ethical issues, while not as predominant, also persist. The analyses highlights that there is a dearth of empirical research exploring the impact that these issues have had.

National Competition Policy and Australia's Health Care System: A Look at the Policy Landscape with New Eyes.

Australia spends nearly 10% of its gross domestic product on health services. With such a substantial financial commitment, even relatively minor improvements in efficiency, effectiveness and productivity can increase community welfare. Competition is a well-recognised policy lever implemented to achieve these goals in market economies. However, it has for many years struggled to gain traction in the health care sector. This article traces recent attempts to promote competition principles in Australia's health care sector. Highlighting where these attempts have stalled, it compares Australia's recent health reforms with those instituted in the United Kingdom's National Health Service where a sector-specific competition regulator has been in place for several years. It concludes that there is room in Australia's regulatory landscape to improve public reporting and increased choice in health care. A sector-specific regulator is envisaged to support these important competition-based initiatives.

Translating Knowledge from Research to Outcomes: Pharmacogenomics in the Treatment of HIV/AIDS.

Although therapeutic medicines are frequently prescribed to improve health, individual responses are often inconsistent, unpredictable and potentially harmful. Recognising that individual genetic variation can influence response, pharmacogenomics aims to identify clinically relevant medicine/genome relationships, and use this knowledge to improve the safe and effective use of medicines. To facilitate the translation of new pharmacogenomic knowledge from the scientific laboratories where it is generated, into the clinical health services where it can be applied, Khoury et al developed a framework outlining a continuum of translation research. This framework must be embedded within a social and political environment conducive to supporting translational research if the desired outcomes are to be achieved. Drawing on the example of one pharmacogenomic test that is now well integrated into clinical practice, this article traces the contemporaneous social and political factors that facilitated translational pharmacogenomic research, and enabled the safe use of a vital medicine.

Postsurgery wound assessment and management practices: a chart audit.

AIMS AND OBJECTIVES: To examine wound assessment and management in patients following surgery and to compare these practices with current evidence-based guidelines for the prevention of surgical site infection across one healthcare services district in Queensland, Australia. BACKGROUND: Despite innovations in surgical techniques, technological advances and environmental improvements in the operating room, and the use of prophylactic antibiotics, surgical site infections remain a major source of morbidity and mortality in patients following surgery. DESIGN: A retrospective clinical chart audit METHODS: A random sample of 200 medical records of patients who had undergone surgery was undertaken over a two-year period (2010-2012). An audit tool was developed to collect the data on wound assessment and practice. The study was undertaken across one healthcare services district in Australia. RESULTS: Of the 200 records that were randomly identified, 152 (76%) met the inclusion criteria. The excluded records were either miscoded or did not involve a surgical incision. Of the 152 records included, 87 (57·2%) procedures were classified as 'clean' and 106 (69·7%) were elective. Wound assessments were fully documented in 63/152 (41·4%) of cases, and 59/152 (38·8%) charts had assessments documented on a change of patient condition. Of the 15/152 (9·9%) patients with charted postoperative wound complications, 4/15 (26·6%) developed clinical signs of wound infection, which were diagnosed on days 3 to 5. CONCLUSIONS: The timing, content and accuracy of wound assessment documentation are variable. Standardising documentation will increase consistency and clarity and contribute to multidisciplinary communication. RELEVANCE TO CLINICAL PRACTICE: These results suggest that postoperative wound care practices are not consistent with evidence-based guidelines. Consequently, it is important to involve clinicians in identifying possible challenges within the clinical environment that may curtail guideline use.

The role of law in end-of-life decision-making in emergency departments and intensive care units: a retrospective review of current practice in a Queensland health service.

Objective There is limited evidence about how legal frameworks that underpin end-of-life decisions are applied in practice. This study aimed to identify how end-of-life decisions are made and documented in emergency departments and intensive care units. The secondary aim was to explore the extent to which the legal processes featured in these decisions. Methods A retrospective chart audit of 85 adult patients who died in the emergency departments and intensive care units of a Queensland health service was undertaken. Quantitative data were analysed and reported using descriptive statistics. Qualitative textual data were analysed using inductive content analysis. Results Nearly all admissions were unplanned (97.6%), and most patients (74.1%) were admitted from home. Only one patient had an advance health directive, although all had an eligible substitute decision-maker. The qualitative analysis revealed two main concepts - 'healthcare professionals choreograph the end of life' and 'patients and families are carried on an unplanned journey'. Conclusions There was limited documentation related to the application of the legal framework in these decisions. Healthcare professionals relied on their clinical judgment about what was in the best interest of the patient. It was common for there to be a substantial effort to achieve consensus in decision-making which coincidently complied with the law.

End-of-life decision-making in the emergency department and intensive care unit: Health professionals' perspectives on and knowledge of the law in Queensland.

OBJECTIVE: To investigate ED and intensive care unit healthcare professionals' perspectives and knowledge of the law that underpins end-of-life decision-making in Queensland, Australia. METHODS: An online survey with questions about perspectives, perceived, and actual, knowledge of the law was distributed by the professional organisations of medical practitioners, nurses and social workers who work in Queensland EDs and intensive care units. RESULTS: The survey responses of 126 healthcare professionals were included in the final analysis. Most respondents agreed that the law was relevant to end-of-life decision-making, but that clinician and family consensus mattered more than following the law. Generally, doctors' legal knowledge was higher than nurses'; however, there were significant gaps in the knowledge of all respondents about the operation of advance health directives in Queensland. CONCLUSIONS: The legal framework that supports end-of-life decision-making for adults who lack decision-making capacity has been in place for more than two decades. Despite frequently being involved in making or enacting these decisions, gaps in the legal knowledge of healthcare professionals who work in EDs and intensive care units in Queensland are evident. Further research to better understand how to improve knowledge and application of the law is warranted.

Is whistleblowing now mandatory? The impact of mandatory reporting law on trust relationships in health care.

Trust is vital for promoting positive health care relationships aimed at achieving positive patient outcomes. Patients, as well as the broader society, trust that health care practitioners who have been granted authority by the state to provide safe and beneficial health care are competent to do so. Recent instances where patients have been harmed as the result of treatment that fell below the accepted standard of competence have negatively impacted on trust. As the state has a responsibility to protect the public from this type of harm, legislation that mandates reporting of certain instances where the behaviour of health care professionals has fallen below the acceptable standard has been introduced. While this may have been designed to restore public trust, this article argues that it has the potential to diminish trust on the basis that mandatory reporting may be equivalent to mandatory whistleblowing.

Identity Disclosure Between Donor Family Members and Organ Transplant Recipients: A Description and Synthesis of Australian Laws and Guidelines.

INTRODUCTION: The disclosure of information that identifies deceased organ donors and/or organ transplant recipients by organ donation agencies and transplant centres is regulated in Australia by state and territory legislation, yet a significant number of donor family members and transplant recipients independently establish contact with each other. AIM: To describe and synthesize Australian laws and guidelines on the disclosure of identifying information. METHOD: Legislation and guidelines relevant to organ donation and transplantation were obtained following a search of government and DonateLife network websites. Information about the regulation of identity disclosure was extracted and synthesised using a process guided by Walt and Gilson's (1994) policy analysis framework. FINDINGS: Nineteen documents were examined. Six guidelines refer to and were consistent with current legislation. Four documents did not address identity disclosure. All jurisdictions prohibit healthcare professionals from disclosing identifying information. In three states, the prohibition extends to all members of the public including donor family members and transplant recipients. CONCLUSION: Restrictions on identity disclosure have implications for public promotion of donation and transplantation where sharing of stories and images of organ donors and transplant recipients is common. Further research is required to understand the perspective of donor family members, transplant recipients, and healthcare professionals impacted by the current laws.

Development of Voluntary Assisted Dying Training in Victoria, Australia: A Model for Consideration.

BACKGROUND: Voluntary assisted dying was legalized in Victoria, Australia in June 2019, and was the first jurisdiction internationally to legislatively mandate training for doctors conducting eligibility assessments of patients. Mandatory training was designed as a safeguard to ensure compliance within the system, so that only eligible patients would gain access to voluntary assisted dying. OBJECTIVE: This article outlines the development of training mandated for doctors prior to undertaking eligibility assessments for voluntary assisted dying. The training addressed required legal knowledge, including doctors' roles, duties and legal protections, and also provided instruction on relevant clinical skills. DESIGN: Training design was based on 2 main principles: to comprehensively impart the legal duties imposed by the legislation; and to be readily accessible for busy doctors. The law was first mapped into a curriculum, and circulated to medical colleges, societies and professional organizations as well as international experts for feedback. The training was converted into an online e-learning format and tested at a focus group of doctors. RESULTS: The training comprises 9 modules including an assessment module. While the predominant focus of the modules is on law, they also contain some clinical components and links to further resources. Modules also contain videos, case studies and interactive exercises. The assessment consists of 30 questions, selected randomly from a question bank, with a pass mark of 90%. CONCLUSION: The Victorian legislatively-mandated voluntary assisted dying training provides standardized baseline knowledge to enhance the quality and consistency of decision-making by doctors. While further evaluation of this training is needed, it may provide a model for other jurisdictions considering making voluntary assisted dying lawful.

The accuracy, completeness and timeliness of discharge medication information and implementing medication reconciliation: A cross-sectional survey of general practitioners.

BACKGROUND AND OBJECTIVES: General practitioners (GPs) require accurate medication information to care for recently discharged hospital patients. Pre-discharge medication reconciliation improves the accuracy of patient medication lists that GPs receive. This study aimed to explore GPs' perceptions of the accuracy, completeness and timeliness of hospital discharge medication information, and how they undertake medication reconciliation. METHOD: Using a cross-sectional online survey, quantitative and qualitative data were collected from a convenience sample of GPs practising across the Gold Coast, Australia. Data were analysed using descriptive statistics and content analysis. RESULTS: Twelve GPs were recruited. Patient hospital discharge medication information was mostly accurate and complete, but delays in receiving this information affected the ability of GPs to undertake medication reconciliation. DISCUSSION: Receiving accurate and timely patient discharge medication information can reduce errors. Optimising the communication of medication information to GPs may improve patient safety.