Aged Services Learning and Research Centre

Influence of physicians' life-stance on attitudes towards end-of-life decisions and actual end-of-life decision-making in six countries

Joachim Cohen et al. — Sun, 22 Mar 2009 19:22:40 PDT

Aim: To examine how physicians’ life stances affect their attitudes to end-of-life decisions and their actual end-of-life decision-making. Methods: Practising physicians from various specialties involved in the care of dying patients in Belgium, Denmark, The Netherlands, Sweden, Switzerland and Australia received structured questionnaires on end-of-life care, which included questions about their life stance. Response rates ranged from 53% in Australia to 68% in Denmark. General attitudes, intended behaviour with respect to two hypothetical patients, and actual behaviour were compared between all large life-stance groups in each country. Results: Only small differences in life stance were found in all countries in general attitudes and intended and actual behaviour with regard to various end-of-life decisions. However, with regard to the administration of drugs explicitly intended to hasten the patient’s death (PAD), physicians with specific religious affiliations had significantly less accepting attitudes, and less willingness to perform it, than non-religious physicians. They had also actually performed PAD less often. However, in most countries, both Catholics (up to 15.7% in The Netherlands) and Protestants (up to 20.4% in The Netherlands) reported ever having made such a decision. Discussion: The results suggest that religious teachings influence to some extent end-of-life decision-making, but are certainly not blankly accepted by physicians, especially when dealing with real patients and circumstances. Physicians seem to embrace religious belief in a non-imperative way, allowing adaptation to particular situations. Physicians’ attitudes to life and death appear to orient their end-of-life decision-making.1 It is important therefore to both assess their attitudes2 and understand exactly how these are related to end-of-life decision-making. Research has generally corroborated that (stronger) theistic religious beliefs are associated with lower acceptance of various end-of-life decisions (ELDs), particularly euthanasia.3–9 Often this is explained by the traditional viewpoints of Judaism, Catholicism, Protestantism and Islam (or their religious authorities) regarding end-of-life issues, extensively described in the bioethical literature.10–18 However, as these traditional religious doctrines are commonly balanced by considerations of due care and general sentiments of humanity and compassion, which come into play in actually dealing with patients, there is some dispute over the decisiveness of statements of doctrine for physicians’ actual decision-making.19 A specific research question of this study is therefore: are viewpoints from different life stances on different kinds of ELDs, as illustrated in the recent Lancet series,11 16 18 also translated into attitudes and actual practices of the physicians who adhere to these life stances? We will examine the effect of life stance on physicians’: * general attitudes to different ELDs: non-treatment decisions (NTDs); alleviation of pain and symptoms with a possible life-shortening effect; terminal sedation; and administration of lethal drugs (ie, physician-assisted dying (PAD)); * willingness to make these ELDs, given certain circumstances; * actual decision-making. We will also examine whether the country of residence has an effect, making it possible to evaluate also the influence of the surrounding (secular) culture.

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

Malcolm H. Parker et al. — Sun, 22 Mar 2009 19:22:39 PDT

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.

Affordable rental housing for older people in Australia: What do older people want?

Colleen M. Cartwright — Sun, 22 Mar 2009 19:22:39 PDT

This study aims to determine the perspectives of older community members and service providers in relation to design and location of affordable rental housing in a coastal retirement area of NSW, Australia. This was achieved by holding focus groups and interviews with older community members (n = 21) and service providers (n = 43). All participants reported a shortage of affordable rental housing suitable for older people in the area. The preferred option was for cluster units, possibly with an on-site carer, located in or close to town. Participants agreed that if choice was limited to "one-bedroom with large living area" or "two-bedrooms with small living area," the majority of single older people would choose the former option, provided there was adequate storage. The importance of asking the "right" question was demonstrated by responses to options for one- or two-bedroom units. Further research is needed to identify what baby boomers think will meet their need for future affordable housing.

Advance care planning in Australia: challenges of a federal legislative system

Colleen M. Cartwright — Sun, 22 Mar 2009 19:22:38 PDT

There is increasing attention in Australia and internationally on advance care planning (ACP), a process which assists competent people to make decisions about their healthcare for a possible future time when they may no longer be competent. ACP can include the use of a written document and/or use of a substitute decision-maker to make healthcare decisions at a time of future incompetence. ACP is much more prevalent in the US than in Australia or other English-speaking countries. Australia is a federation of states and territories, which all make their own health law, resulting in different legislative provision, documentation and terminology. Despite research demonstrating strong support for ACP, it is not well understood, nor is it well utilised. Even in public hospitals, incorrect terminology and documentation put health professionals at risk. A recent position statement by the Australian Medical Association (AMA) recommends uniform national legislation for legally enforceable advance directives. Unfortunately, the AMA statement also proposes allowing doctors to ignore an advance healthcare directive if the doctor believes that it is 'inconsistent with good medical practice or advances in medical science, thereby preserving doctors' clinical judgement and discretion'. It is a fundamental pillar of the doctor/patient relationship that it is the patient who ultimately holds the power to consent to, or refuse, treatment. Competent patients must always have the last say over what happens to their bodies. For those who fear loss of capacity, ACP can provide reassurance and take away some of the fear around the end stage of life.

Evaluation of a project to raise community awareness of suicide risk among older men

Helen Bartlett et al. — Sun, 22 Mar 2009 19:22:37 PDT

Objective: To evaluate the effectiveness of a population-based strategy designed to raise awareness in the community, in all regions of Queensland, Australia, about the nature and extent of suicide by older men and to provide preventive strategies. Method: Trained presenters conducted information and skills training sessions in all Queensland regions in 2001 – 2002. The evaluation included a questionnaire and post-session evaluation form which participants were invited to complete. Approximately 6 months following attendance at a session, a sub-set of participants were further surveyed by postal questionnaire. Results: Approximately 3016 persons attended an information session and participants' responses revealed that a large proportion had either been personally bereaved by suicide (20%) or knew someone who had been so bereaved (58%). Evaluation immediately following the session found that the majority of respondents considered that the session had been useful (88%) and most (90%) reported that the session had enhanced their understanding of risk factors for suicide by older men. Conclusion: The information kit and presentations developed for use in the project appear to be useful tools for presenting sensitive material and encouraging people to discuss suicide. The use of existing community resources ensured that the project was highly cost-effective and sustainable.

One step forward, two steps back: advance care planning, Australian regulatory frameworks and the Australian Medical Association

Malcolm H. Parker et al. — Sun, 22 Mar 2009 19:21:14 PDT

The Australian Medical Association has recently adopted a policy position concerning advance care planning, which is generally supportive of extending patient self-determination beyond the loss of decision-making capacity. It calls for uniform national legislation for legally enforceable advance health directives (AHD), and statutory protection for practitioners who comply with valid AHD, or who do not comply on several grounds. Analysis of the grounds for non-compliance indicate that they undermine patient autonomy, and aspects of the policy are inconsistent with current common law and statutory regimes that allow an adult to complete a legally binding AHD. The policy therefore threatens the patient self-determination, which it endorses, and places doctors who participate in advance care planning at legal risk.

Physician discussions with terminally ill patients: a cross-national comparison

Colleen M. Cartwright et al. — Sun, 22 Mar 2009 19:21:10 PDT

A major issue in the care of terminally ill patients is communication and information provision. This paper reports the extent to which physicians in Australia, Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland discuss topics relevant to end of life care with terminally ill patients and their relatives (without first informing the patient), and possible associations between physician-specific characteristics and such discussions. Response rates to the postal survey ranged from 39% to 68% (n = 10139). Physicians in most of the countries except Italy `in principle, always' discuss issues related to terminal illness with their patients but not with patients' relatives without first informing the patient, unless the relatives ask. Cross-national differences remained strong after controlling for physician characteristics. The majority of physicians appeared to support the principle of patient-centred care to terminally ill patients, consistent with palliative care philosophy and with the law and/or professional guidelines in most of the countries studied.

Access to death certificates: What should research ethics committees require for approval?

Tore Nilstun et al. — Sun, 22 Mar 2009 19:21:09 PDT

Purpose: To present and discuss the reactions of research ethics committees (RECs) in a number of countries when asked for approval of a study requiring access to death certificates to identify the physicians signing the certificates and to send them a four-page questionnaire about medical decisions made at the patient's end-of-life that could possibly have hastened death. Methods: A simple questionnaire were sent to the responsible national investigator in an international study (Australia, Belgium, Denmark, Italy, the Netherlands, Sweden, Switzerland) asking about the interactions between the national research group and the national/regional REC(s). Results: Different laws or guidelines were used by the RECs. Denmark, the Netherlands, and Switzerland did not require an application to a REC. In Australia and Sweden, the RECs wanted changes in the research protocol, and one national research group had to refrain from publishing its results because the attrition rate became too high, probably due to the required changes in the protocol. Recommendations: Generally, similar demands from all RECs in relation to one project are strongly desirable. In epidemiological research, in which voluntary completion of an anonymous questionnaire demonstrates consent, additional prior informed consent about being approached should not be required.

Does being against euthanasia legislation equate to being anti-euthanasia?

Colleen M. Cartwright et al. — Sun, 22 Mar 2009 19:21:09 PDT

This study investigated issues raised in qualitative data from our previous studies of health professionals and community members, which suggested that being opposed to euthanasia legislation did not necessarily equate to being anti-euthanasia per se. A postal survey of 1002 medical practitioners, 1000 nurses and 1200 community members was undertaken. In addition to a direct question on changing the law to allow active voluntary euthanasia (AVE), four statements assessed attitudes to euthanasia with or without a change in legislation. Responses were received from 405 doctors (43%), 429 nurses (45%) and 405 community members (38%). Compared with previous studies there was a slight increase in support for a change in the law from medical practitioners, a slight decrease in support from community members and almost no change among nurses. Different interpretations of the results of the four attitude questions are possible, depending on the perspective of the interpreter.

Advance care planning: rights and responsibilities

Colleen M. Cartwright — Sun, 22 Mar 2009 19:21:08 PDT

Advance care planning allows competent patients to record their wishes for treatment they would or would not want if, at some future time, they are no longer competent. The purpose of advance directives and legislation affecting end-of-life issues are discussed.

End-of-life decision making in Europe and Australia: a physician survey

Bregje D. Onwuteaka-Philipsen et al. — Sun, 22 Mar 2009 19:21:08 PDT

Background: The frequencies with which physicians make different medical end-of-life decisions (ELDs) may differ between countries, but comparison between countries has been difficult owing to the use of dissimilar research methods. Methods: A written questionnaire was sent to a random sample of physicians from 9 specialties in 6 European countries and Australia to investigate possible differences in the frequencies of physicians' willingness to perform ELDs and to identify predicting factors. Response rates ranged from 39% to 68% (N = 10 139). Using hypothetical cases, physicians were asked whether they would (probably) make each of 4 ELDs. Results: In all the countries, 75% to 99% of physicians would withhold chemotherapy or intensify symptom treatment at the request of a patient with terminal cancer. In most cases, more than half of all physicians would also be willing to deeply sedate such a patient until death. However, there was generally less willingness to administer drugs with the explicit intention of hastening death at the request of the patient. The most important predictor of ELDs was a request from a patient with decisional capacity (odds ratio, 2.1-140.0). Shorter patient life expectancy and uncontrollable pain were weaker predictors but were more stable across countries and across the various ELDs (odds ratios, 1.1-2.4 and 0.9-2.4, respectively). Conclusion: Cultural and legal factors seem to influence the frequencies of different ELDs and the strength of their determinants across countries, but they do not change the essence of decision making.

How can we develop a leadership capability framework for non-profit Australian health and community care organisations?

Shankar Sankaran et al. — Sun, 22 Mar 2009 19:21:07 PDT

Purpose of the paper: To review the literature on leadership development in the for-proft sector and the Australian Public Sector in order to better understand how a leadership capability framework can be developed for the Australian non-profit sector. Methodology: Literature review Findings: There is a lack of research in leadership capability development in the health and community care sectors among NPOs in Australia. Implications for theory: An investigation into leadership capability development in the non-profit sector focusing on organisations involved in health and community care would be a contribution to knowledge that would be beneficial to all NPOs that are providing services to the public in an environment where both the private and public sectors also play a role in the Australian society. Value of the paper: This study is an important first step in creating a leadership capability framework for non-profit organisations who, along with for-profit and government organisations operating in the same sector, are key contributors to the social capital of Australia.

Mental health literacy in rural Queensland: results of a community survey

Helen Bartlett et al. — Sun, 22 Mar 2009 19:19:48 PDT

Objectives: The aim of this study was to assess the awareness of, and attitudes to, mental health issues in rural dwelling Queensland residents. A secondary objective was to provide baseline data of mental health literacy prior to the implementation of Australian Integrated Mental Health Initiative – a health promotion strategy aimed at improving the health outcomes of people with chronic or recurring mental disorders. Method: In 2004 a random sample of 2% (2132) of the estimated adult population in each of eight towns in rural Queensland was sent a postal survey and invited to participate in the project. A series of questions were asked based on a vignette describing a person suffering major depression. In addition, questions assessed respondents’ awareness and perceptions of community mental health agencies. Results: Approximately one-third (36%) of those surveyed completed and returned the questionnaire. While a higher proportion of respondents (81%) correctly identified and labelled the problem in the vignette as depression than previously reported in Australian community surveys, the majority of respondents (66%) underestimated the prevalence of mental health problems in the community. Furthermore, a substantial number of respondents (37%) were unaware of agencies in their community to assist people with mental health issues while a majority of respondents (57.6%) considered that the services offered by those agencies were poor. Conclusion: While mental health literacy in rural Queensland appears to be comparable to other Australian regions, several gaps in knowledge were identified. This is in spite of recent widespread coverage of depression in the media and thus, there is a continuing need for mental health education in rural Queensland.

Palliative care training: a survey among physicians in Australia and Europe

Tore Nilstun et al. — Sun, 22 Mar 2009 19:19:47 PDT

The purpose of this paper is to present data about the level and background characteristics of physicians' training in palliative care in Australia (AU), Belgium (BE), Denmark (DK), Italy (IT), the Netherlands (NL), Sweden (SE) and Switzerland (CH) (n=16,486). The response rate to an anonymous questionnaire differed between countries (39%-68%). In most countries approximately half of all responding physicians had any formal training in palliative care (median: 3-10 days). Exceptions were NL (78%) and IT (35%). The most common type of training was a postgraduate course. Physicians in nursing home medicine (only in NL), geriatrics, oncology (not in NL), and general practice had the most training. In all seven countries, physicians with such training discussed options for palliative care and options to forgo life-sustaining treatment more often with their patients than did physicians without. Irrespective of earlier palliative care training, 87%-98% of the physicians wanted extended training.

Physicians’ attitudes towards end-of-life decisions: a comparison between seven countries

Guido Miccinesi et al. — Sun, 22 Mar 2009 19:19:47 PDT

In the context of an European collaborative research project (EURELD), a study on attitudes towards medical end-of-life decisions was conducted among physicians in Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland. Australia also joined the consortium. A written questionnaire with structured questions was sent to practising physicians from specialties frequently involved in the care of dying patients. 10,139 questionnaires were studied. Response rate was equal to or larger than 50% in all countries except Italy (39%). Apart from general agreement with respect to the alleviation of pain and symptoms with possible life-shortening effect, there was large variation in support—between and within countries—for medical decision that may result in the hastening of death. A principal component factor analysis found that 58% of the variance of the responses is explained by four factors. ‘Country’ explained the largest part of the variation of the standardized factor scores.

Advance care planning and end of life decision making

Colleen M. Cartwright et al. — Sun, 22 Mar 2009 19:19:46 PDT

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.

PEG [percutaneous endoscopic gastrostomy] feeding, dementia and the need for policies and guidelines: opinion

Colleen M. Cartwright et al. — Sun, 22 Mar 2009 19:19:45 PDT

The author discusses the need for well structured policies and guidelines for the decision to commence or withhold percutaneous endoscopic gastrostomy feeding.

End-of-life decision-making: practical and ethical issues for health professionals

Colleen M. Cartwright — Sun, 22 Mar 2009 19:19:44 PDT

Life-extending changes in medical technology and an ageing population pose practical and ethical problems relating to end-of-life decision making. Health professionals need to understand the fears and concerns of their patients, their preferred place to die and to respect patient autonomy. Such wishes may be expressed verbally by a competent patient or through an advance directive (living will) or proxy by an incompetent patient. There is an urgent need for increased and improved training of health professionals in pain management and palliative care, and for the development of practical, ethical policies and guidelines with respect to withdrawing/withholding life-sustaining treatment. In addition, physician-assisted suicide and euthanasia, two of the important moral issues of the 90s, will continue to require open community debate as we move into the new millennium. Australia, in company with most other countries, has many challenges ahead in relation to end-of-life decision making.

A sustainable programme to prevent falls and near-falls in community-dwelling older people: results of a randomised trial

Margaret A. Steinberg et al. — Sun, 22 Mar 2009 19:19:44 PDT

STUDY OBJECTIVE---In the causative mechanism of falls among older community dwellers, slips and trips have been found to be significant precursors. The purpose of the two year trial was to assess the effectiveness of multi-component interventions targeting major risk factors for falls in reducing the incidence of slips, trips and falls among the well, older community. DESIGN---Four groups with approximately equal numbers of participants were randomly allocated to interventions. The prevention strategies included education and awareness raising of falls risk factors, exercise sessions to improve strength and balance, home safety advice to modify environmental hazards, and medical assessment to optimise health. The interventions combined the strategies in an add on approach. The first intervention group receiving the information session only was regarded as the control. The outcome of interest was the occurrence of a slip, trip or fall, monitored prospectively using a daily calendar diary. PARTICIPANTS AND SETTING---Two hundred and fifty two members of the National Seniors Association in the Brisbane district agreed to participate. National Seniors clubs provide a forum for active, community dwelling Australians aged 50 and over to participate in policy, personal development and recreation. MAIN RESULTS---Using Cox's proportional hazards regression model, adjusted hazard ratios comparing intervention groups with the control ranged from 0.35 (95% CI 0.17, 0.73) to 0.48 (0.25, 0.91) for slips; 0.29 (0.16, 0.51) to 0.45 (0.27, 0.74) for trips; and 0.60 (0.36, 1.01) to 0.82 (0.51, 1.31) for falls. While calendar monitoring recorded outcome, it was also assessed as a prevention strategy by comparing the intervention groups with a hypothetical non-intervened group. At one year after intervention, reductions in the probability of slips, trips and falls (61(95%CI 54, 66)%; 56 (49, 63)%; 29 (22, 36)% respectively) were demonstrated. CONCLUSIONS---This study makes an important contribution to the priority community health issue of falls prevention by showing that effective, sustainable, low cost programmes can be introduced through community-based organisations to reduce the incidence of slips, trips and falls in well, older people.

Advance health care planning and the GP. Is it time to move forward?

H Hawkins et al. — Sun, 22 Mar 2009 19:18:28 PDT

AIM: Legislation relating to advance health care planning was introduced into Queensland in 1998. All states and territories apart from Western Australia, New South Wales and Tasmania now have legislation relating to this issue. The aim of this pilot study was to: determine current usage of advance health directives (AHDs) in an individual general practice; and encourage appropriate use of AHDs in general practice. METHOD: One hundred clinical records were audited for evidence of advance health care planning and 100 adult patients were surveyed regarding advance care preferences. RESULTS: One percent of clinical records showed evidence of advance health care discussion and 5% of those surveyed stated they had a current AHD. Only 10% of those surveyed were aware of AHDs; 70% wanted to know more about them; 83% wished family members to be substitute decision makers regarding health matters if the individual was too ill to be involved; 54% nominated doctors to be among their preferred decision makers. CONCLUSIONS: Lack of familiarity with advance health care planning options was very common, however most patients wished to be involved in their own advance health care planning or wished to involve a family member. Legislation now exists in the majority of states and territories for this to occur. General practitioners could assist by having suitable information available in waiting rooms and including discussion in consultations where appropriate.