Professionals' views and experiences in supporting decision-making involvement for people living with dementia.

BACKGROUND: The provision of supported decision-making for people living with disabilities is an emerging area of practice and rights-based law reform, and is required under international law. OBJECTIVES: This qualitative study aimed to understand how Australian health and legal professionals conceptualised their professional roles in the practice of providing decision-making support for people living with dementia. METHODS: The methods were informed by grounded theory principles. In-depth, semi-structured interviews were conducted with 28 health and legal professionals involved in providing care or services for people with dementia. Interviews explored how professionals described their practice of providing support for decision-making and how they conceptualised their roles. The analysis was underpinned by the theoretical perspective of symbolic interactionism. RESULTS: Participants described providing support across a range of decision domains, some of which were specific to their professional role. Four key themes were identified: 'establishing a basis for decision-making', 'the supportive toolbox', 'managing professional boundaries' and 'individualist advocacy versus relational practice'. Participants identified a range of generic and specialised techniques they used to provide support for people with dementia. These techniques were applied subject to resource limitations and perceived professional obligations and boundaries. A continuum of professional practice, ranging from 'individualist advocacy' to 'relational practice' describes the approaches adopted by different professionals. DISCUSSION: Professionals conceptualised their role in providing support for decision-making through the lens of their own profession. Differences in positioning on the continuum of 'individualist advocacy' through to 'relational practice' had practical implications for capacity assessment, engaging with persons with impaired decision-making capacity, and the inclusion of supporters and family members in decision-making processes. Further progress in implementing supported decision-making (including through law and policy reform) will require an understanding of these inter-professional differences in perceived roles relating to the practice of providing decision-making support.

"A Real Bucket of Worms": Views of People Living with Dementia and Family Members on Supported Decision-Making.

Supported decision-making has been promoted at a policy level and within international human rights treaties as a way of ensuring that people with disabilities enjoy the right to legal capacity on an equal basis with others. However, little is known about the practical issues associated with implementing supported decision-making, particularly in the context of dementia. This study aimed to understand the experiences of people with dementia and their family members with respect to decision-making and their views on supported decision-making. Thirty-six interviews (twenty-one dyadic and fifteen individual) were undertaken with fifty-seven participants (twenty-five people living with dementia and thirty-two family members) across three states in Australia. Interpretative Phenomenological Analysis (IPA) was used as the methodological approach, with relational autonomy as a theoretical perspective. We identified two overarching themes relating to participants' experiences with decision-making: "the person in relationship over time" and "maintaining involvement." Participant views on the practical issues associated with supported decision-making are addressed under the themes of "facilitating decision-making," "supported decision-making arrangements," "constraints on decision-making," and "safeguarding decision-making." While participants endorsed the principles of supported decision-making as part of their overarching strategy of "maintaining involvement" in decision-making, they recognized that progressive cognitive impairment meant that there was an inevitable transition toward greater involvement of, and reliance upon, others in decision-making. Social and contextual "constraints on decision-making" also impacted on the ability of people with dementia to maintain involvement. These themes inform our proposal for a "spectrum approach" to decision-making involvement among people living with dementia, along with recommendations for policy and practice to assist in the implementation of supported decision-making within this population.

An examination of organisational policies for healthcare and lifestyle decision-making among Australian aged care providers.

OBJECTIVE: Examine policies of aged care organisations relating to healthcare and lifestyle decision-making. METHODS: Seven aged care organisations submitted policy documents. Policies were analysed using the Australian Law Reform Commission (ALRC) "Decision-Making Principles" as a framework. Senior staff (N = 9) with policy development roles participated in follow-up interviews. RESULTS: The structure and content of policy documents varied significantly between organisations. Most acknowledged the need to support the rights of care recipients in decision-making; however, the nature of this support was often unclear. Interview themes included factors relating to "organisational contexts" "policy development and implementation" and "ethical challenges." An overarching theme among high-performing organisations was "proactive response aimed at pre-empting decision-making dilemmas". We provide recommendations for policy development, including a self-assessment audit tool. CONCLUSION: Aged care provider organisations may need to review policies in the areas of healthcare and lifestyle decision-making to meet current best practice principles.

Treatment of premenstrual syndrome with the desogestrel-only pill (Cerazette) in an adolescent girl.

BACKGROUND: Premenstrual syndrome has been recognized as an important problem in adolescent gynecology. CASE: We here report the treatment of a 13-year-old girl with premenstrual syndrome who had a strong family history of thrombophilia. In this case the combined pill was contraindicated and the use of other pharmacological treatments, such as selective serotonin uptake inhibitors, was considered inappropriate for adolescents. We suggested the use of the desogestrel-only pill, because it is known to suppress ovulation. The outcome was good, with the patient being symptom-free in the follow-up visit, three months later. SUMMARY AND CONCLUSION: We hope that this report will add another therapeutic option for premenstrual syndrome in teenagers and will be useful in further studies on the treatment of this condition in adolescence.

Fibrinogen adsorption and platelet adhesion to metal and carbon coatings.

In order to study the haemocompatibility of metal and carbon coatings, fibrinogen adsorption and platelet adhesion to various coatings have been investigated. Two metallic coatings--titanium and zirconium, and two carbon coatings - isotropic diamond-like and isotropic graphite-like coatings, were prepared by plasma vapour deposition onto stainless steel substrate. It has been shown that the adsorption of fibrinogen to metal and carbon coatings and its post-adsorptive transition are dependent on both the material properties and the fibrinogen environment. The adsorption of fibrinogen from human plasma on titanium and zirconium coatings is similar to that on uncoated stainless steel surface. Both carbon coatings adsorb much greater amount of fibrinogen from plasma, and fibrinogen retention by carbon surfaces is also greater than by metal surfaces. Increased numbers of adhered platelets have been found on both carbon coatings in comparison to the metal materials, although this does not correlate with the amount of adsorbed fibrinogen.