Medical practitioners' knowledge and self-reported practices of substitute decision making and implementation of advance care plans.

BACKGROUND: Advance care planning (ACP) provides patients with the ability to make their decisions known about how they would like to be treated if they lose capacity. Medical practitioners have a key role to play in providing information on ACP to their patients. This research explores their knowledge and attitudes to advance care planning and how this affects their practice. AIM: The objective of this study is to assess the NSW medical practitioners' knowledge and self-reported practice of ACP. METHODS: A postal survey of a random sample of 650 general practitioners plus 350 medical specialists from specialties most often involved in end-of-life decisions was conducted. Respondents' work location post codes were subsequently used to assign respondents to one of the eight NSW Area Health Services. The main outcome measures were medical practitioners' knowledge of and practice pertaining to ACP. RESULTS: Thirty-four per cent of specialists (n = 110) and 24% of general practitioners (n = 150) responded; the majority of respondents had heard of all ACP options. However, respondents' understanding of the uses and legal requirements of the relevant ACP options vary widely. CONCLUSIONS: Respect for patient wishes expressed in advance directives is reassuringly high. The findings suggest significant misunderstanding by medical practitioners of terminologies and systems around substitute decision-making for incompetent persons. Further education and standardisation of terminologies and systems across different jurisdictions would assist in addressing these issues. Low response rate, relating to only one legal jurisdiction, means results may not be generalisable.

Smoking mull: a grounded theory model on the dynamics of combined tobacco and cannabis use among adult men.

ISSUE ADDRESSED: Australians' use of cannabis has been increasing. Over a third of Australians (35.4%) have used cannabis at some time in their lives and 10.3% are recent users. Almost two-thirds of cannabis users combine cannabis with tobacco. The aim of this study was to understand the process of mulling - smoking tobacco and cannabis together - using a grounded theory approach. METHODS: Twenty-one in-depth semistructured interviews were conducted with men aged 25-34 and living on the North Coast of New South Wales. Interviews explored participants' smoking practices, histories and cessation attempts. RESULTS: A model describing mulling behaviour and the dynamics of smoking cannabis and tobacco was developed. It provides an explanatory framework that demonstrates the flexibility in smoking practices, including substance substitution - participants changed the type of cannabis they smoked, the amount of tobacco they mixed with it and the devices they used to smoke according to the situations they were in and the effects sought. CONCLUSION: Understanding these dynamic smoking practices and the importance of situations and effects, as well as the specific role of tobacco in mulling, may allow health workers to design more relevant and appropriate interventions. SO WHAT? Combining tobacco with cannabis is the most common way of smoking cannabis in Australia. However, tobacco cessation programmes rarely address cannabis use. Further research to develop evidence-based approaches for mull use would improve cessation outcomes.

Em-plaque subdural sarcoidosis: a rare neurological entity

En-plaque subbdural sarcoidosis is reported in a 74-year-old black woman. The diagnosis was mad at autopsy. The patient also had adenocarcinoma of the sigmoid colon with liver metastases. Subdural sarcoidosis is very rare in that only four cases have been previously reported, all of which were diagnosed clinically and treated