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.

Knowledge of the law about withholding or withdrawing life-sustaining treatment by intensivists and other specialists.

OBJECTIVE: Decisions about withholding or withdrawing life-sustaining treatment (WWLST) from adults who lack capacity are an integral part of intensive care (IC) practice. We compare the knowledge, attitudes and practice of intensivists in relation to the law about WWLST with six other specialties most often involved in end-of-life care. DESIGN, SETTING AND PARTICIPANTS: We used a cross-sectional postal survey of medical specialists in the three most populous Australian states, and analysed responses from 867 medical specialists from the seven specialties most likely to be involved in WWLST decisions in the acute-care setting (emergency, geriatric, palliative, renal and respiratory medicine, medical oncology and IC). MAIN OUTCOME MEASURES: Attitudes to, and knowledge and practice of, the law relating to end-of-life care. RESULTS: Of 2702 surveys sent to eligible practitioners, 867 completed questionnaires were returned. There was an overall response rate of 32% and an IC response rate also of 32% (125/388). Intensivists performed better than average in legal knowledge but important knowledge gaps remain. Intensivists had a more negative attitude to the role of law in this area than other specialty groups but reported being seen as a leading source of information about legal issues by other medical specialists and nurses. Intensivists also reported being the specialists most frequently making decisions about end-of-life treatment. CONCLUSIONS: Improved legal knowledge and open engagement with the law can help manage the risk of harm to patients and protect intensivists from liability. IC guidelines and continuing professional development are important strategies to address these issues.

What does "futility" mean? An empirical study of doctors' perceptions.

OBJECTIVE: To investigate how doctors define and use the terms "futility" and "futile treatment" in end-of-life care. DESIGN, SETTING, PARTICIPANTS: A qualitative study using semi-structured interviews with 96 doctors from a range of specialties which treat adults at the end of life. Doctors were recruited from three large Brisbane teaching hospitals and were interviewed between May and July 2013. RESULTS: Doctors' conceptions of futility focused on the quality and prospect of patient benefit. Aspects of benefit included physiological effect, weighing benefits and burdens, and quantity and quality of life. Quality and length of life were linked, but many doctors discussed instances in which benefit was determined by quality of life alone. Most described assessing the prospects of achieving patient benefit as a subjective exercise. Despite a broad conceptual consensus about what futility means, doctors noted variability in how the concept was applied in clinical decision making. More than half the doctors also identified treatment that is futile but nevertheless justified, such as short term treatment that supports the family of a dying person. CONCLUSIONS: There is an overwhelming preference for a qualitative approach to assessing futility, which inevitably involves variability in clinical decision making. Patient benefit is at the heart of doctors' definitions of futility. Determining patient benefit requires discussing with patients and their families their values and goals as well as the burdens and benefits of further treatment.

Doctors' knowledge of the law on withholding and withdrawing life-sustaining medical treatment.

OBJECTIVES: To examine doctors' level of knowledge of the law on withholding and withdrawing life-sustaining treatment from adults who lack decision-making capacity, and factors associated with a higher level of knowledge. DESIGN, SETTING AND PARTICIPANTS: Postal survey of all specialists in emergency medicine, geriatric medicine, intensive care, medical oncology, palliative medicine, renal medicine and respiratory medicine on the AMPCo Direct database in New South Wales, Victoria and Queensland. Survey initially posted to participants on 18 July 2012 and closed on 31 January 2013. MAIN OUTCOME MEASURES: Medical specialists' levels of knowledge about the law, based on their responses to two survey questions. RESULTS: Overall response rate was 32%. For the seven statements contained in the two questions about the law, the mean knowledge score was 3.26 out of 7. State and specialty were the strongest predictors of legal knowledge. CONCLUSIONS: Among doctors who practise in the end-of-life field, there are some significant knowledge gaps about the law on withholding and withdrawing life-sustaining treatment from adults who lack decision-making capacity. Significant consequences for both patients and doctors can flow from a failure to comply with the law. Steps should be taken to improve doctors' legal knowledge in this area and to harmonise the law across Australia.

Medical merchants: conflict of interest, office product sales and notifiable conduct.

Professional ethical codes identify the issue of conflict of interest, which can distort doctors' objective judgements concerning the best interests of patients. Legal fiduciary duties may be owed by doctors to patients in situations of potential conflict of interest. Prescribing and dispensing functions have been largely legally separated to prevent conflicts of interest arising. The advent of integrative medicine has been accompanied by an apparent growth of in-house selling of therapeutic products. Medical merchandising constitutes a prima-facie conflict of interest and may amount to notifiable conduct under the Health Practitioner Regulation National Law provisions. We believe that doctors who sell therapeutic products should adhere to strict conditions to avoid significantly departing from accepted professional standards. Doctors who have a reasonable belief that a colleague is failing to comply with these conditions could consider notifying the Medical Board of Australia.

Normative lessons: codes of conduct, self-regulation and the law.

Good medical practice: a code of conduct for doctors in Australia provides uniform standards to be applied in relation to complaints about doctors to the new Medical Board of Australia. The draft Code was criticised for being prescriptive. The final Code employs apparently less authoritative wording than the draft Code, but the implicit obligations it contains are no less prescriptive. Although the draft Code was thought to potentially undermine trust in doctors, and stifle professional judgement in relation to individual patients, its general obligations always allowed for flexibility of application, depending on the circumstances of individual patients. Professional codes may contain some aspirational statements, but they always contain authoritative ones, and they share this feature with legal codes. In successfully diluting the apparent prescriptivity of the draft Code, the profession has lost an opportunity to demonstrate its commitment to the raison d'etre of self-regulation - the protection of patients. Professional codes are not opportunities for reflection, consideration and debate, but are outcomes of these activities.

Dealing with "rogue" medical students: we need a nationally consistent approach based on "case law".

There is strong agreement in the medical profession and among academic commentators about why professionalism has become an important focus of medical regulation and education, and about the need to respond to serious instances of unprofessional behaviour among doctors and medical students. Admission processes which include interviews do not prevent the entry of a small number of students who behave extremely poorly. Fair, reliable assessment of students' attitudes and behaviour is achievable, but the challenge of preventing the progress of students who behave poorly through academic assessment remains. A nationally consistent approach to the management of poorly behaved students within the academic program is vital in the interests of equity across programs and protection of the public.

Impact of specialty on attitudes of Australian medical practitioners to end-of-life decisions.

OBJECTIVE: To compare attitudes and practices of Australian medical practitioners, by specialty, to a range of medical decisions at the end of life. DESIGN, SETTING AND PARTICIPANTS: As part of an international study, in 2003, a structured questionnaire was mailed to 2964 medical practitioners drawn from membership registers of Australian and Australasian professional colleges. Data from 1478 questionnaires were statistically analysed using validated instruments. MAIN OUTCOME MEASURES: Practitioners' willingness to comply with requests from patients and/or their relatives for symptom relief which might also hasten death; provision of terminal sedation and euthanasia, or willingness to provide these on their own initiative. RESULTS: Respondents reported being much more willing to comply with a patient's request for increasing symptom relief, even at risk of hastening death, than for terminal sedation. Over a quarter of respondents would provide terminal sedation to competent patients on their own initiative. A small number of respondents would intentionally hasten death. There were significant differences by specialty for all three actions. Oncologists, palliative care physicians and geriatricians were least likely to actively hasten death, and more likely to act unilaterally to relieve symptoms as a medical necessity. CONCLUSIONS: Perceptions about the causation of death and aspects of medical culture appear to influence physicians' attitudes towards medical decisions at the end of life. Our findings have implications for medical education, interprofessional communication and discussion between the medical profession and the community.

Medical school selection criteria and the prediction of academic performance.

OBJECTIVE: To assess how well prior academic performance, admission tests, and interviews predict academic performance in a graduate medical school. DESIGN, SETTING AND PARTICIPANTS: Analysis of academic performance of 706 students in three consecutive cohorts of the 4-year graduate-entry medical program at the University of Queensland. MAIN OUTCOME MEASURES: Proportion of academic performance during the medical program explained by selection criteria, and correlation between selection criteria and performance. Selection criteria were grade point average (GPA), GAMSAT (Graduate Australian Medical School Admissions Test) score, and interview score. Academic performance was defined as overall total in all examinations combined, in first and fourth year examinations, and in individual written, ethics and clinical components. RESULTS: Selection criteria explained 21.9% of variation in overall total score, falling from 28.2% in Year 1 to 17.7% in Year 4. This was highest for the written examination in Year 1 (30.5%) and lowest for the clinical examination in Year 4 (10.9%). GPA was most strongly correlated with academic performance (eg, for overall score, partial Spearman's correlation coefficient [pSCC], 0.47; P < 0.001), followed by interviews (pSCC, 0.12; P = 0.004) and GAMSAT (pSCC, 0.07; P = 0.08). The association between GPA and performance waned from Year 1 to Year 4, while the association between interview score and performance increased from Year 1 to Year 4. CONCLUSION: The school's selection criteria only modestly predict academic performance. GPA is most strongly associated with performance, followed by interview score and GAMSAT score. The school has changed its selection process as a result.

Advance care planning and end of life decision making.

BACKGROUND: Aging populations with greater rates of cognitive decline demand increased attention to the issues of end of life decision making and advance care planning (ACP). Legislatures have passed statutes that recognise the necessity for both substitute decision making and the declaration in advance of wishes relating to health care. OBJECTIVE: This article discusses ACP and the role of the general practitioner. DISCUSSION: Advance care planning provides patients, relatives and doctors with greater confidence about the future. There is good evidence that patients desire to discuss end of life care, and GPs are in a good position to engage their patients in considering the issues. They have a responsibility to confirm the decision making capacity of patients who write advance health directive documents, to inform and educate their patients about future health care, and to keep the ACP conversation going.

The regulation of complementary health: sacrificing integrity?

In response to the increasing use of complementary and alternative medicine (CAM), governments are exploring ways to ensure patients' safety and respond to complaints. One solution is to establish registration boards and procedures based on the model of existing health practitioner Acts. Registration will require defined minimum standards for competence, which will have to be based on scientific evidence. As scientific evidence accumulates, these modalities are likely to lose their identities as "alternative" and become assimilated into Western medicine.

Eugenics or empowered choice? Community issues arising from prenatal testing.

The prevention of inherited disabilities is viewed in two contrasting ways--either as enhancing reproductive choice and improving population health, or as discriminating against disabled community members. We argue that modern clinical genetics, including preimplantation genetic diagnosis (PGD), reflects a persistent and defensible desire by the community to prevent disability, rather than as increasing discrimination or threatening to produce a 'new eugenic' society Screening should be presented as a distinct issue for decision-making about the prevention or acceptance of disability, rather than as a routinely accepted component of antenatal care. The community must improve its understanding of the experiences of those who manage disability, and continue to debate the issues of discrimination, selective genetic prevention and enhancement, reproductive freedom, and eugenics.