Junior Doctor Experiences and Challenges in Obtaining Surgical Informed Consent: A Qualitative Systematic Review and Meta-Ethnography.

INTRODUCTION: Surgical informed consent (SIC) to procedures is necessary to ensure patient autonomy is adequately respected. It is also necessary to protect doctors, and their institutions, from claims of negligence. While SIC is often acquired by senior consultants, it also commonly falls to the junior doctors on a team to ensure SIC is adequately acquired and documented. A growing body of literature suggests that junior doctors are not sufficiently educated about the legal and practical issues concerned with obtaining medical consent. This may open up this cohort, and their hospitals, to medico-legal liability. AIMS: to provide a systematic review of the qualitative literature on junior doctors' experiences and challenges in consenting surgical patients and to synthesize evidence on this issue in order to guide policy-makers in the medicolegal and medical education spheres. METHODS: a systematic review of qualitative literature was performed. Analysis of the literature was guided by Noblit and Hare's seven-step approach to meta-ethnography, with the final synthesis presented as a thematic analysis of the literature. CONCLUSION: This research concludes that a significant proportion of SIC is likely to be acquired by junior doctors, many of whom are Post-Graduate Year (PGY) 1-2 and who lack adequate training and education. This cohort face challenges in assessing capacity, in ensuring adequate disclosure related to surgical procedures, and in adequately documenting consent. This may impact the validity of any SIC they acquire. Medical educators and policy-makers should be aware of these issues when creating policies impacting SIC, and when designing surgical education programs for medical students and junior doctors alike.

Abortion law across Australia--A review of nine jurisdictions.

This article reviews the current legal status of abortion in Australia and its implications. Australian abortion law has been a matter for the states since before Federation. In the years since Federation there have been significant reforms and changes in the abortion laws of some jurisdictions, although not all. Across Australia there are now nine sets of laws, state and Commonwealth, concerned with abortion. The test of a lawful abortion varies greatly across jurisdictions. In a number of states and territories, it is necessary to establish a serious risk to the physical or mental health of the woman if the pregnancy was to continue. In some cases, the certification of two doctors is required, particularly for abortions at later gestations. There are also physical restrictions on access, such as in South Australia and the Northern Territory where abortion must take place in a hospital. Only in the ACT has abortion been removed from the criminal law altogether. Variations in the law and restrictions arising from these are not consistent with the aims and provision of the universal, accessible health care system aspired to in Australia. There is an urgent need for overall reform and the introduction of uniformity to Australia's abortion laws, including removal of abortion from the criminal law.

A right to refuse: legal aspects of dealing with intoxicated patients who refuse treatment.

Doctors in hospital emergency departments are frequently confronted with intoxicated patients who may be uncooperative, aggressive and refuse to undergo diagnosis and treatment. In the chaotic environment of the emergency department, the doctor must decide whether to override the patient's refusal and detain the patient for treatment or respect the refusal and allow the patient to leave and potentially suffer further injury. A preliminary pilot survey of emergency doctors in a regional Queensland hospital indicated that those surveyed had limited understanding of the circumstances in which they could, or could not, legally detain and continue to treat an intoxicated patient who refuses treatment, and the concomitant legal consequences. This article considers the complex common law and statutory framework existing in Queensland to determine the legal position of doctors treating intoxicated patients who refuse treatment.

Multidisciplinary Clinicians and the Relational Autonomy of Persons with Neurodegenerative Disorders and an Advance Care Plan: A Thematic Analysis.

INTRODUCTION: People diagnosed with neurodegenerative disorders often grapple with threats to their agency, prompting some to engage in advance care planning. Advance care plans are intended to protect autonomy by helping patients receive goal-consistent healthcare. Accordingly, there is a need to better understand factors associated with hospital doctors' application of advance care plans to treatment decisions of this patient cohort. PURPOSE: The purpose of this study was to explain the recommendations of multidisciplinary hospital-based clinicians about the benefits of advance care plans for people diagnosed with neurodegenerative disorders, and the elements that influence how doctors apply such plans. MATERIALS AND METHODS: Using a constructivist grounded theory informed thematic analysis, semi-structured interviews were conducted with purposively and theoretical sampled hospital-based clinicians: 16 doctors, six registered nurses and 10 allied health clinicians who self-reported having experience delivering healthcare to people with neurodegenerative disorders and an advance care plan. Allied health and nurse data helped to inform questions posed to doctors. Data were inductively analysed using open and focused coding. RESULTS: Analysis revealed two main themes: recommending agency through advance care plans; and limiting agency through advance care plans. These themes formed the basis of the core category: patient agency. All clinicians held positive attitudes towards advance care plans as a means to preserve patient voices and alleviate family of responsibility. However, the extent to which doctors shared decisions with family revealed a tension between individualistic agency associated with advance care plans and relational autonomy perceived by doctors as appropriate. CONCLUSION: Although doctors expressed positive attitudes towards advance care plans, they typically practiced relational autonomy wherein they partner with family in contemporaneous healthcare decision on patients' behalf. Accordingly, the healthcare preferences of hospitalised, incompetent people with neurodegenerative disorders are balanced against judgements of both doctors and family.

Advance Care Plans and the Potentially Conflicting Interests of Bedside Patient Agents: A Thematic Analysis.

AIM: People diagnosed with a neurodegenerative disorder often contend with a threat to independence and control, leading some to complete an advance care plan. Advance care plans are commonly associated with treatment limitations; however, key patient agents (such as doctors, allied health, nurses and family) may instead make temporal, best interests or good medical practice decisions on behalf of the patient. Accordingly, there is a need to better understand ancillary decision-maker's perspectives, particularly of doctors. PURPOSE: To explain how the potentially conflicting interests of bedside patient agents operates as a factor which influences doctors' application of advance care plans of people with a neurodegenerative disorder. PARTICIPANTS AND METHODS: Using a constructivist grounded theory informed thematic analysis, 38 semi-structured interviews were conducted with hospital-based doctors, allied health, nurses and family of people with a neurodegenerative disorder who had an advance care plan. Data were inductively analysed using open and focused coding. RESULTS: Analysis revealed two main themes: dynamics of discerning best interests; and avoiding conflict. Rather than applying advance care plans, doctors largely involved families to attempt best interests decision-making partnerships on patients' behalf. Bedside agents demonstrated significant intra and interpersonal challenges associated with their roles as patient agents. Doctors appeared protective of families and patients with neurodegenerative disorder. CONCLUSION: Although bedside agents value advance care plans, doctors often favour temporal healthcare decisions in consultation with family. We suggest there are limitations to the effectiveness of advance care plans in practice, with application typically only occurring close to death. Despite the intentions of advance care planning, bedside agents may still experience considerable dissonance.

Factors Which Influence Hospital Doctors' Advance Care Plan Adherence.

CONTEXT: Advances in medicine have seen changes in mortality in Western countries. Simultaneously, countries such as Australia, Canada, U.S., New Zealand, U.K., and Germany have encouraged consumer-directed care and advance care plan (ACP) completion, giving patients a voice despite incapacity. Adhering to ACPs relies on the decision-making of treating doctors, making hospital doctors key partners, and their perspectives on ACP adherence critical. OBJECTIVES: The aim of this review was to explore and map existing research on factors associated with hospital doctors adhering to adult patients' ACPs. METHODS: A scoping review of English language publications within CINAHL, Emcare, Medline, PsycInfo, and Scopus was conducted, following PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. ACPs were defined as adult patient-generated, written health care directions or values statements. Studies of any design, which reported original research associated with hospital doctors adhering to ACPs, were included. RESULTS: Twenty-seven publications were included in the final analysis. Results suggested ACPs were thought potentially useful; however, adherence has been associated with doctors' attributes (e.g., specialty, seniority), attitudes toward ACP (e.g., applicability), and legal knowledge. CONCLUSION: Current literature suggests doctors hold largely positive attitudes toward ACPs that provide useful patient information that enables doctors to make appropriate treatment decisions. Doctors often perceive limitations to ACP applicability due to legal requirements or ambiguity of patient outcome goals.