Caring for pregnant women for whom transfusion is not an option. A national review to assist in patient care.

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality and morbidity globally. Obstetric bleeding can be catastrophic and management is challenging, involving a coordinated multidisciplinary approach, which may include blood products. In settings where blood transfusion is not an option, either because of patient refusal (most commonly in Jehovah Witnesses) or because of unavailability of blood, management becomes even more challenging. Observational studies have demonstrated an association between refusal of blood products in major obstetric haemorrhage and increased morbidity and mortality. This review draws upon evidence in the literature, physiological principles and expert opinion for strategies and guidance to optimise the outcomes of pregnant women in whom blood transfusion is either refused or impossible. The importance of a multidisciplinary antenatal and perinatal management plan, including optimisation of haemoglobin and iron stores pre-delivery, blood loss minimisation, early haemorrhage control and postpartum anaemia treatment, is discussed.

Part of the fabric and mostly right: an ethnography of ethics in clinical practice.

OBJECTIVES: To describe how ethics is practised in a health care setting, and to ascertain whether there was interest in establishing clinical ethics support services. DESIGN AND SETTING: Observations and interviews undertaken between April and November 2012 in a large NSW urban hospital with newborn care, maternity and oncology departments and analysed by coding and categorising the data. MAIN OUTCOME MEASURES: Key themes in the participants' attitudes to professional ethics were identified. RESULTS: Ethics is not typically an explicit feature of clinical deliberations, and clinicians tend to apply basic ethical principles when ethical problems are identified. They also discuss difficult decisions with colleagues, and try to resolve ethical differences by discussion. Participants judged the ethics of clinical practice to be "mostly right", primarily because ethics is "part of the fabric" of everyday clinical work that aspires to "optimising care". Nevertheless, most clinicians would welcome ethics support because ethics is integral to health care practice, is not always "done well", and may be the source of conflict. CONCLUSIONS: Ethics is very much a part of the fabric of clinical practice, and the ethical challenges that arise in patient care in this particular setting are generally managed adequately. However, many clinicians have concerns about the ethical aspects of some practices and decisions, and believe that access to expert ethics support would be useful. Helping clinicians to provide ethically sound patient care should be a priority for health care providers across Australia.

Managing ethical issues in patient care and the need for clinical ethics support.

OBJECTIVE: To investigate the range, frequency and management of ethical issues encountered by clinicians working in hospitals in New South Wales (NSW), Australia. METHODS: A cross-sectional survey was conducted of a convenience sample of 104 medical, nursing and allied health professionals in two NSW hospitals. RESULTS: Some respondents did not provide data for some questions, therefore the denominator is less than 105 for some items. Sixty-two (62/104; 60%) respondents reported occasionally to often having ethical concerns. Forty-six (46/105; 44%) reported often to occasionally having legal concerns. The three most common responses to concerns were: talking to colleagues (96/105; 91%); raising the issue in a group forum (68/105; 65%); and consulting a relevant guideline (64/105; 61%). Most respondents were highly (65/99; 66%) or moderately (33/99; 33%) satisfied with the ethical environment of the hospital. Twenty-two (22/98; 22%) were highly satisfied with the ethical environment of their department and 74 (74/98; 76%) were moderately satisfied. Most (72/105; 69%) respondents indicated that additional support in dealing with ethical issues would be helpful. CONCLUSION: Clinicians reported frequently experiencing ethical and legal uncertainty and concern. They usually managed this by talking with colleagues. Although this approach was considered adequate, and the ethics of their hospital was reported to be satisfactory, most respondents indicated that additional assistance with ethical and legal concerns would be helpful. Clinical ethics support should be a priority of public hospitals in NSW and elsewhere in Australia.

Knowledge, beliefs, and decisions of pregnant Australian women concerning donation and storage of umbilical cord blood: a population-based survey.

BACKGROUND: Many women giving birth in Australian hospitals can choose to donate their child's umbilical cord blood to a public cord blood bank or pay to store it privately. We conducted a survey to determine the proportion and characteristics of pregnant women who are aware of umbilical cord blood (UCB) banking and who have considered and decided about this option. The survey also sought to ascertain information sources, knowledge, and beliefs about UCB banking, and the effect of basic information about UCB on decisions. METHODS: Researchers and hospital maternity staff distributed a survey with basic information about UCB banking to 1,873 women of at least 24 weeks' gestation who were attending antenatal classes and hospital clinics in 14 public and private maternity hospitals in New South Wales. RESULTS: Most respondents (70.7%) were aware of UCB banking. Their main information sources were leaflets from hospital clinics, print media, antenatal classes, TV, radio, friends, and relatives. Knowledge about UCB banking was patchy, and respondents overestimated the likelihood their child would need or benefit from UCB. Women who were undecided about UCB banking were younger, less educated, or from ethnic or rural backgrounds. After providing basic information about UCB banking, the proportion of respondents who indicated they had decided whether or not to donate or store UCB more than doubled from 30.0 to 67.7 percent. CONCLUSIONS: Basic information for parents about UCB banking can affect planned decisions about UCB banking. Information should be accurate and balanced, should counter misconceptions, and should target specific groups.

Ethical and legal issues raised by cord blood banking - the challenges of the new bioeconomy.

• Cord blood banking raises ethical and legal issues which highlight the need for careful regulatory approaches to the emerging bioeconomy. • Consent processes for both private and public banking should be inclusive and representative of the different familial interests in the cord blood. • Property law is a potentially useful way of understanding the mechanisms for donation to both public and private banks. • Increasing tensions between public and private models of banking may require the adoption of hybrid forms of banking.

Open disclosure: ethical, professional and legal obligations, and the way forward for regulation.

Open disclosure (OD) after adverse health care events is the subject of a national standard that has been implemented in state health policy documents, and is included in the Medical Board of Australia's code of conduct for doctors. Nevertheless, doctors have been slow to embrace the practice of OD. There is a strong ethical case for implementing OD in the primary interests of patients, and additionally from a medicolegal risk management point of view. There are no statutory requirements in relation to OD, but common law judgments have imposed a duty of OD in tort and contract. There are a number of barriers to the better uptake and implementation of OD, including perceptions of legal risk, lack of education and training, reluctance to admit error, uncertainty concerning what and how much to disclose, and the variations in state and territory "apology laws". The implementation of OD could be improved by making apology laws consistent across jurisdictions, including providing "blanket" cover for admissions of fault; by preventing insurers voiding contracts when apologies are made, either through self-regulation or legislation; and by inserting OD obligations into different structures within the health system.

A defence of the requirement to seek consent to withhold and withdraw futile treatments.

Futility assessments, which are unavoidable in end-of-life settings, need to be procedurally fair. This necessitates communication between health professionals and substitute decisionmakers regarding the decision to define treatments as futile. The common law test for whether treatment should be withheld or withdrawn is the best interests test. A futile treatment is not in any patient's best interests. While it is rare for the law to disagree with a futility determination made by health professionals, if a determination has been made without consultation and fails to reflect the patient's best interests, the courts will overturn it. The best regulatory regimes provide for a balance between the powers of health professionals and substitute decisionmakers to make decisions for incompetent patients, and for clear and efficient dispute resolution. The Queensland law and its requirement for consent to withhold or withdraw futile treatment represents a good model of futility determination, with clear powers given to substitute decisionmakers and health professionals. Disputes concerning the treatment of incompetent patients automatically trigger the appointment of the adult guardian as the decisionmaker, and there are avenues for appeal.

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.