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

Emergency department and intensive care unit health professionals' knowledge and application of the law that applies to end-of-life decision-making for adults: A scoping review of the literature

BACKGROUND

Laws that regulate healthcare practice at the end of life reflect the values of the society where they apply. Traditionally, healthcare professionals rely on their clinical knowledge to inform treatment decisions, but the extent to which the law also informs health professionals' decision-making at the end of life is uncertain.

OBJECTIVE

The objective of this study was to describe what healthcare professionals working in emergency departments and intensive care units know about the law that relates to end-of-life decision-making for hospitalised adults and what affects its application.

REVIEW METHOD

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

DATA SOURCES

Data were sourced by searching the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL [via EBSCOhost]), Nursing and Allied Health and Health and Medical Collection (via ProQuest Central), Excerpta Medica dataBASE (Embase), PubMed, PsycINFO, and HeinOnline.

RESULTS

Systematic screening of the search results and application of inclusion criteria resulted in the identification of 18 quantitative and three qualitative articles that were reviewed, summarised, and reported. Ten of the quantitative studies assessed knowledge and attitudes to law or end-of-life decision-making using hypothetical scenarios or vignettes. Qualitative studies focussed on how the law was applied when end-of-life decisions were made. End-of-life decision-making is mostly based on the clinical needs of the patient, with the law having a secondary role.

CONCLUSION

Around the world, there are significant gaps in healthcare professionals' legal knowledge. Clinical factors are considered more important to end-of-life decision-making than legal factors. End-of-life decision-making is perceived to carry legal risk, and this results in the provision of nonbeneficial end-of-life care. Further qualitative research is needed to ascertain the clinician-related factors that affect the integration of law with end-of-life decision-making.

Junior Medical Officers' knowledge of advance care directives and substitute decision making for people without decision making capacity: a cross sectional survey

Background

For the benefits of advance care planning to be realised during a hospital admission, the treating team must have accurate knowledge of the law pertaining to implementation of advance care directives (ACDs) and substitute decision making.

Aims

To determine in a sample of Junior Medical Officers (JMOs): (1) knowledge of the correct order to approach people as substitute decision makers if a patient does not have capacity to consent to treatment; (2) knowledge of the legal validity of ACDs when making healthcare decisions for persons without capacity to consent to treatment, including the characteristics associated with higher knowledge; and (3) barriers to enacting ACDs.

Methods

A cross-sectional survey was conducted at five public hospitals in New South Wales, Australia. Interns, residents, registrars, and trainees on clinical rotation during the recruitment period were eligible to participate. Consenting participants completed an anonymous pen-and-paper survey.

Results

A total of 118 JMOs completed a survey (36% return rate). Fifty-five percent of participants were female and 56.8% were aged 20–29 years. Seventy-five percent of JMOs correctly identified a Guardian as the first person to approach if a patient did not have decision-making capacity, and 74% correctly identified a person’s spouse or partner as the next person to approach. Only 16.5% identified all four persons in the correct order, and 13.5% did not identify any in the correct order. The mean number of correct responses to the questions assessing knowledge of the legal validity of ACDs was 2.6 (SD = 1.1) out of a possible score of 6. Only 28 participants (23.7%) correctly answered four or more knowledge statements correctly. None of the explored variables were significantly associated with higher knowledge of the legal validity of ACDs. Uncertainty about the currency of ACDs and uncertainty about the legal implications of relying on an ACD when a patient’s family or substitute decision maker disagree with it were the main barriers to enacting ACDs.

Conclusion

JMOs knowledge of the legal validity of ACDs for persons without decision making capacity and the substitute decision making hierarchy is limited. There is a clear need for targeted education and training to improve knowledge in this area for this cohort.

Junior medical doctors' decision making when using advance care directives to guide treatment for people with dementia: a cross-sectional vignette study

Background

Junior medical doctors have a key role in discussions and decisions about treatment and end-of-life care for people with dementia in hospital. Little is known about junior doctors’ decision-making processes when treating people with dementia who have advance care directives (ACDs), or the factors that influence their decisions. To describe among junior doctors in relation to two hypothetical vignettes involving patients with dementia: (1) their legal compliance and decision-making process related to treatment decisions; (2) the factors influencing their clinical decision-making; and (3) the factors associated with accurate responses to one hypothetical vignette.

Method

A cross-sectional survey of junior doctors, including trainees, interns, registrars and residents, on clinical rotation in five public hospitals located in one Australian state. The anonymous, investigator-developed survey was conducted between August 2018 and June 2019. Two hypothetical vignettes describing patients with dementia presenting to hospital with an ACD and either: (1) bacterial pneumonia; or (2) suspected stroke were presented in the survey. Participants were asked to indicate whether they would commence treatment, given the ACD instructions described in each vignette.

Results

Overall, 116 junior doctors responded (35% consent rate). In Vignette 1, 58% of respondents (n = 67/116) selected the legally compliant option (i.e. not commence treatment). Participants who chose the legally compliant option perceived ‘following patient wishes’ (n = 32/67; 48%) and ‘legal requirements to follow ACDs’ (n = 32/67; 48%) as equally important reasons for complying with the ACD. The most common reason for not selecting the legally compliant option in Vignette 1 was the ‘ACD is relevant in my decision-making process, but other factors are more relevant’ (n = 14/37; 38%). In Vignette 2, 72% of respondents (n = 83/116) indicated they would commence treatment (i.e. not follow the ACD) and 18% (n = 21/116) selected they would not commence treatment. (i.e. follow the ACD). Similar reasons influenced participant decision-making in Vignette 2, a less legally certain scenario.

Conclusions

There are critical gaps in junior doctors’ compliance with the law as it relates to the implementation of ACDs. Despite there being differences in relation to the legal answer and its certainty, clinical and ethical factors guided decision-making over and above the law in both vignettes. More education and training to guide junior doctors’ clinical decision-making and ensure compliance with the law is required.

Knowledge of end-of-life law: A cross-sectional survey of general practitioners working in aged care

OBJECTIVE

To describe the knowledge of end-of-life law and experiences in practice at the end of life amongst Australian general practitioners (GPs).

METHODS

A cross-sectional online survey of GPs practising in aged care settings in Queensland (QLD), New South Wales (NSW) and Victoria (VIC).

RESULTS

From 521 potential GPs, 160 (response rate 30.7%) were included in the final sample. Most participants (62%) reported experience with six key end-of-life areas at least 'a few times', including 74% administering medication for pain and symptom relief, and 67% facilitating advance care planning 'several' or 'many times' and perceiving they had 'some' knowledge of end-of-life law (53%, n = 84). However, low-to-moderate actual levels of end-of-life legal knowledge were identified (mean correct response of 5.24 out of 9).

CONCLUSION

Australian GPs working in aged care may have low-to-moderate knowledge about end-of-life law despite frequently making end-of-life decisions in clinical practice.

Advance care directive prevalence among older Australians and associations with person-level predictors and quality indicators

BACKGROUND

Advance care planning (ACP) conversations may result in preferences for medical care being documented.

OBJECTIVE

To explore the uptake and quality of advance care directives (ACDs) among older Australians accessing health and aged care services, by overall ACP documentation prevalence, person-level predictors and ACD quality indicators.

DESIGN AND SETTING

National multi-centre health record audit in general practices (GP), hospitals and residential aged care facilities (RACF).

PARTICIPANTS

A total of 4187 people aged ≥65 years attending their GP (n = 676), admitted to hospital (n = 1122) or residing in a RACF (n = 2389).

MAIN OUTCOME MEASURES

ACP documentation prevalence by setting and type including person-completed ACDs and non-ACD documents (completed by a health professional or someone else); person-level predictors and quality indicators of ACDs.

RESULTS

Overall ACP documentation prevalence was 46.5% (29.2% weighted). ACD prevalence was 25.3% (14.2% weighted). Unweighted ACD prevalence was higher in RACFs (37.7%) than in hospitals (11.1%) and GPs (5.5%). 35.8% of ACP documentation was completed by a health professional (9.7% weighted), and 18.1% was completed by someone else (10.6% weighted). Having an ACD was positively associated with being female, older, having two or more medical conditions, receiving palliative care, being divorced/separated and being in a RACF. Only 73% of ACDs included full name, signature, document date and witnessing.

CONCLUSIONS AND CONTRIBUTION

Low ACP documentation prevalence and a lack of accessible, person-completed and quality ACDs represent an important ACP implementation issue. Low prevalence is complicated by poor document quality and a higher prevalence of documents being completed by someone other than the person.

Perceptions of optimal end-of-life care in hospitals: A cross-sectional study of nurses in three locations

AIM

To examine whether nurses' location of employment, demographics, or training influences their perceptions of what constitutes optimal care for dying patients in hospital.

DESIGN

Questionnaire-based, cross-sectional study.

METHODS

Between December 2016-June 2018, 582 registered or enrolled nurses from Australia (N = 153), South Korea (N = 241), and Hong Kong (N = 188) employed in a variety of hospital care units rated the extent to which they agreed with 29 indicators of optimal end-of-life care across four domains: patient, family, healthcare team, and healthcare system. Latent class analysis identified classes of respondents with similar responses.

RESULTS

Top five indicators rated by participants included: 'physical symptoms managed well'; 'private rooms and unlimited visiting hours'; 'spend as much time with the patient as families wish'; 'end-of-life care documents stored well and easily accessed' and 'families know and follow patient's wishes'. Four latent classes were generated: 'Whole system/holistic' (Class 1); 'Patient/provider-dominated' (Class 2); 'Family-dominated' (Class 3) and 'System-dominated' (Class 4). Class 1 had the highest proportion of nurses responding positively for all indicators. Location was an important correlate of perceptions, even after controlling for individual characteristics.

CONCLUSION

Nurses' perceptions of optimal end-of-life care are associated with location, but perhaps not in the direction that stereotypes would suggest. Findings highlight the importance of developing and implementing location-specific approaches to optimize end-of-life care in hospitals.

IMPACT

The findings may be useful to guide education and policy initiatives in Asian and Western countries that stress that end-of-life care is more than symptom management. Indicators can be used to collect data that help quantify differences between optimal care and the care actually being delivered, thereby determining where improvements might be made.

Where would acute care nurses prefer to receive end-of-life care? a cross-sectional survey

BACKGROUND

Hospital-based nurses can offer a unique perspective about factors that can contribute to a good end-of-life experience, including the location in which end-of-life care is delivered.

OBJECTIVES

To examine in a sample of hospital-based nurses, the location in which they personally would most and least prefer to be cared for at the end of life, and the reasons for these preferences.

DESIGN

Questionnaire-based, cross-sectional study.

SETTING AND PARTICIPANTS

170 registered and enrolled nurses employed in acute care wards of three metropolitan hospitals in Australia between April 2016 and February 2017.

RESULTS

Nurses would most prefer to be cared for at home (53%) or in a hospice/palliative care unit (41%) at the end-of-life. Being in a familiar environment and feeling like dying is a more normal process were the main reasons reported for choosing these settings. The main reasons given by nurses for choosing a hospice/palliative care unit were that being cared for at home may place a burden on family/friends and hinder appropriate symptom management. Nurses would least prefer being cared for in an emergency department (49%) due to a perceived lack of privacy and adverse impact on the family; and residential aged care facilities (25%) due to perceived suboptimal symptom management and reduced likelihood of wishes being respected.

CONCLUSION

Nurses in this study value familiarity of environment and normalising the dying process. The majority do not wish to burden their family and friends at the end of their lives. Important next steps in providing services that meet the needs of people facing the end of their lives include understanding how nurses' personal views may influence decision-making conversations with patients and families about location of care at the end-of-life, as well as determining the capacity of available services to meet patient and family needs.

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.

Doctors' perspectives on adhering to advance care directives when making medical decisions for patients: an Australian interview study

OBJECTIVE

Advance care planning (ACP) assists people to identify their goals, values and treatment preferences for future care. Ideally, preferences are documented in an advance care directive (ACD) and used by doctors to guide medical decision-making should the patient subsequently lose their decision-making capacity. However, studies demonstrate that ACDs are not always adhered to by doctors in clinical practice. We aim to describe the attitudes and perspectives of doctors regarding ACD adherence and the utility of ACDs in clinical practice.

DESIGN

Face-to-face semistructured interviews were conducted using three case-based vignettes to explore doctors' decision-making and attitudes towards ACDs. Transcripts were analysed using a thematic analysis.

SETTING

Doctors from a variety of medical specialties and with varying experience levels were recruited from a large tertiary hospital in Melbourne, Australia.

PARTICIPANTS

A total of 21 doctors were interviewed, 48% female (10/21). Most (19/21) reported having experience using ACDs.

RESULTS

Four themes were identified: aligning with patient preferences (avoiding unwanted care, prioritising autonomy and anticipating family opposition), advocating best interests (defining futile care, relying on clinical judgement, rejecting unreasonable decisions and disregarding legal consequences), establishing validity (doubting rigour of the decision-making process, questioning patients' ability to understand treatment decisions, distrusting outdated preferences and seeking confirmation) and translating written preferences into practice (contextualising patient preferences, applying subjective terminology and prioritising emergency medical treatment).

CONCLUSIONS

ACDs provide doctors with opportunities to align patient preferences with treatment and uphold patient autonomy. However, doctors experience decisional conflict when attempting to adhere to ACDs in practice, especially when they believe that adhering to the ACD is not in the patients' best interests, or if they doubt the validity of the ACD. Future ACP programmes should consider approaches to improve the validity and applicability of ACDs. In addition, there is a need for ethical and legal education to support doctors' knowledge and confidence in ACP and enacting ACDs.

Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis

OBJECTIVES

How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice?

DESIGN

A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting.

SETTING

Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews.

RESULTS

The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging.

CONCLUSION

Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice.

PROSPERO REGISTRATION NUMBER

CRD42018088838.

Are older and seriously ill inpatients planning ahead for future medical care?

Background

Despite the perceived ethical, personal and health service benefits of advance care planning (ACP), the extent to which older and seriously ill Australian inpatients have considered future health decisions remains uncertain. This study aimed to determine in a sample of older and seriously ill inpatients, the proportion who had: 1) engaged in four advance care planning (ACP) activities; 2) not engaged in ACP activities but wanted to; and 3) reasons why they had not engaged.

Methods

Cross-sectional face-to-face standardised interview survey with inpatients in a tertiary referral centre who were either: aged 80+ years; aged 55+ years with progressive chronic disease(s); or judged by treating clinicians as having a life expectancy of less than 12 months. Patients indicated whether they had engaged in four ACP activities: (1) appointed medical substitute-decision-maker(s), (2) recorded end-of-life wishes in an advance directive or care plan; and talked about their end-of-life wishes with their: (3) support persons and/or (4) doctors. Patients who had not engaged in activities were asked whether they wished this to occur and reasons why.

Results

One hundred eighty-six inpatients consented to the study (80% of approached). Of these, 9% (n = 16) had engaged in four ACP activities; 27% (n = 50) had not engaged in any. Half (n = 94, 52%) had appointed a medical substitute-decision-maker, 27% (n = 50) had recorded wishes in an advance directive or care plan, 51% (n = 90) had talked about their end-of-life wishes with support persons and 27% (n = 48) had talked with their doctor. Patients who wanted to, but had not, engaged in the four ACP activities were unaware they could record wishes or appoint decision-makers, or indicated providers had not initiated conversations.

Conclusion

Relatively few inpatients had engaged in all four ACP activities. More inpatients had discussed end of life issues with family and appointed substitute decision makers, than completed written documents or talked with doctors. Community education and a more active role for community and hospital-based providers in supporting patients and families to collaboratively resolve end-of-life decisions may increase the probability wishes are known and followed.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1211-2) contains supplementary material, which is available to authorized users.

An integrative review of stakeholder views on Advance Care Directives (ACD): Barriers and facilitators to initiation, documentation, storage, and implementation

OBJECTIVE

To examine the views and experiences of patients and their health care providers on developing advance care planning (ACP) and advance care directives (ACD); and determine barriers and facilitators to ACD development, storage, and use, including implications for people with communication disability.

METHOD

An integrative review of 93 studies, analysed according to their content themes.

RESULTS

Content themes encapsulated the initiation, documentation, and implementation stages of ACP/ACD. Lack of guidance for initiating and supporting ACP/ACD impedes discussions, and both patients and healthcare providers avoid discussions owing to fear of dying and reluctance to think about end-of-life.

CONCLUSIONS

There are several barriers and facilitators to the initiation of ACP discussions, documentation and implementation of ACD, and little research exploring the views of legal professionals on the development, storage, or use of ACP documents. Further research is needed to explore the timing and responsibility of both legal and health professionals in initiating and supporting ACP discussions.

PRACTICE IMPLICATIONS

It is important for healthcare providers to raise ACP discussions regularly so that patients have time to make informed advance care decisions. Storage of the document in an electronic health record might facilitate better access to and implementation of patients' end-of-life care decisions.

Do medical oncology patients and their support persons agree about end-of-life issues?

BACKGROUND

The perceptions of those called on to make decisions on behalf of patients who lack capacity at the end of life must accurately reflect patient preferences.

AIMS

To establish the extent to which the views of medical oncology outpatients are understood by their support persons, specifically with regards to (i) preferred type and location of end-of-life care, (ii) preferred level of involvement in end-of-life decision-making and (iii) whether the patient has completed an advance care plan or appointed an enduring guardian.

METHODS

Adults with a confirmed cancer diagnosis and their nominated support persons were approached between September 2015 and January 2016 in the waiting room of an Australian tertiary referral clinic. Consenting participants completed a pen-and-paper survey. Nominated support persons answered the same questions from the patient's perspective.

RESULTS

In total, 208 participants (39% of eligible dyads) participated. Observed agreement across the five outcomes ranged from 54% to 84%. Kappa values for concordance between patient-support person responses were fair to moderate (0.24-0.47) for enduring guardian, decision-making, advance care plan and care location outcomes. A slight level of concordance (k = 0.15; 95% confidence interval: -0.02, 0.32) was found for the type of care outcome.

CONCLUSION

Relying on support persons' views does not guarantee that patients' actual preferences will be followed. Strategies that make patient preferences known to healthcare providers and support persons while they still have the capacity to do so is a critical next step in improving quality cancer care.

[Knowledge and attitudes of health care professionals in advance healthcare directives]

BACKGROUND AND OBJECTIVE

The advanced healthcare directive is a new style of health care relationship, based on the respect of the patientś autonomous decisions: as well as a valuable tool that enables a proper management of the decisions made at the end of life. The objective of this study was to explore the knowledge and attitudes of the health care professionals regarding the advance directives, as well as the resources for advanced care planning in a municipality of Madrid during 2016-2017.

MATERIAL AND METHODS

A cross-sectional descriptive study was carried out on a population of Health care professionals of Primary and Specialised Care. The knowledge and attitudes questionnaire about the advance directives was used. Sociodemographic and knowledge variables related to resources for the advanced care planning. Statistical-descriptive analysis was performed.

RESULTS

A total of 431 professionals were included, with a mean age of 44.55 years (SD: 11.1). As regards knowledge about advance directives, the mean score was 5.08 (SD 2.4), with statistically significant differences being found between professional groups. A small percentage (4.6%) of the professionals had their document of Advance directives ready, and 42% of professionals did not know if they were regulated by the Community of Madrid. Less than half (41.5%) of the professionals knew the palliative resources of their institution.

CONCLUSIONS

The health care professional's knowledge about advance directives, as well as the resources for the advanced care planning, show deficiencies at training and information level. Almost half of the professionals did not know if these are regulated in the Community of Madrid. They also believe that it would be useful to plan, and very useful to have the Advance directives document ready.

General practice palliative care: patient and carer expectations, advance care plans and place of death-a systematic review

BACKGROUND

With an increasing ageing population in most countries, the role of general practitioners (GPs) and general practice nurses (GPNs) in providing optimal end of life (EoL) care is increasingly important.

OBJECTIVE

To explore: (1) patient and carer expectations of the role of GPs and GPNs at EoL; (2) GPs' and GPNs' contribution to advance care planning (ACP) and (3) if primary care involvement allows people to die in the place of preference.

METHOD

Systematic literature review.

DATA SOURCES

Papers from 2000 to 2017 were sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases.

RESULTS

From 6209 journal articles, 51 papers were relevant. Patients and carers expect their GPs to be competent in all aspects of palliative care. They valued easy access to their GP, a multidisciplinary approach to care and well-coordinated and informed care. They also wanted their care team to communicate openly, honestly and empathically, particularly as the patient deteriorated. ACP and the involvement of GPs were important factors which contributed to patients being cared for and dying in their preferred place. There was no reference to GPNs in any paper identified.

CONCLUSIONS

Patients and carers prefer a holistic approach to care. This review shows that GPs have an important role in ACP and that their involvement facilitates dying in the place of preference. Proactive identification of people approaching EoL is likely to improve all aspects of care, including planning and communicating about EoL. More work outlining the role of GPNs in end of life care is required.

Knowledge of, and participation in, advance care planning: A cross-sectional study of acute and critical care nurses' perceptions

BACKGROUND

Nurses have a core role in facilitating discussions and enacting decisions about end-of-life issues for patients in hospitals. Nurses' own knowledge and attitudes may influence whether they engage in meaningful end-of-life conversations with patients.

AIMS

To determine in a sample of nurses working in acute and critical care hospital wards: 1) their knowledge of advance care planning, including the authority of substitute decision-makers and legal validity of advance directives; 2) their own participation in advance care planning decision-making practices; and 3) associations between nurses' socio-demographic characteristics; clinical expertise; and knowledge and behaviour in relation to advance care planning practices.

DESIGN

Questionnaire-based, cross-sectional study.

SETTING AND PARTICIPANTS

The study was conducted with 181 registered and enrolled nurses employed in acute and critical care wards of three metropolitan hospitals in Australia.

RESULTS

Nurses were least knowledgeable about items relating to the authority of medical (56%) and financial (42%) substitute decision-makers. Few nurses had prepared advance directives (10%) or appointed medical (23%) or financial (27%) decision-makers, when compared to discussing end-of-life wishes (53%) or organ donation (75%). Overall, 15% of nurses had not engaged in any advance care planning practices. Nurses who had cared for 11-30 dying patients in the last six months were more likely to have an increased knowledge score. Older nurses were more likely to participate in a greater number of advance care planning practices and an increase in shifts worked per week led to a significant decrease in nurses' participation.

CONCLUSION

Nurses have a key role in providing advice and engaging dying patients and their families in advance care planning practices. Nurses' own knowledge and rates of participation are low. Further education and support is needed to ensure that nurses have an accurate knowledge of advance care planning practices, including how, when and with whom wishes should be discussed and can be enacted.

Increasing advance personal planning: the need for action at the community level

BACKGROUND

Advance personal planning is the process by which people consider, document and communicate their preferences for personal, financial and health matters in case they lose the ability to make decisions or express their wishes in the future.

DISCUSSION

Advance personal planning is most often undertaken by individuals who are seriously ill, often in the context of a medical crisis and/or at the time of admission to hospital. However, the clinical utility and legal validity of the planning process may be compromised in these circumstances. Patients may lack sufficient capacity to meaningfully engage in advance personal planning; there may be insufficient time to adequately reflect on and discuss wishes with key others; and there may also be limited opportunity for inter-professional input and collaboration in the process. Here, we propose an agenda for research to advance the science of advance personal planning by promoting a 'whole community' approach. Adoption of advance personal planning at a community level may be achieved using a variety of strategies including public media campaigns, intervening with professionals across a range of health care and legal settings, and mobilising support from influential groups and local government. One potentially promising method for encouraging earlier adoption of advance personal planning among a broader population involves a community action approach, whereby multiple evidence-based strategies are integrated across multiple access points. Community action involves calling on community members, professionals, community and/or government organisations to work collaboratively to design and systematically implement intervention strategies with the aim of bringing about desired behaviour change. An example of a community action trial to improving uptake and quality of advance personal planning is described.

CONCLUSION

While promising, there is a need for rigorous evidence to demonstrate whether a community action approach is effective in establishing whole community adoption of advance personal planning.

The role of law in decisions to withhold and withdraw life-sustaining treatment from adults who lack capacity: a cross-sectional study

OBJECTIVES

To determine the role played by law in medical specialists' decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed.

DESIGN

Cross-sectional postal survey of medical specialists.

SETTING

The two largest Australian states by population.

PARTICIPANTS

649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting.

MAIN OUTCOME MEASURES

Compliance with law and the impact of legal knowledge on compliance.

RESULTS

649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge.

CONCLUSIONS

Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care.

Supporting a good life and death in residential aged care: an exploration of service use towards end of life

BACKGROUND

The concept of a 'good death' involves end-of-life care in an appropriate setting and in keeping with the person's preferences. Limited research has examined the circumstances and place of death for older people living in residential aged care.

OBJECTIVE

This exploratory study investigated the nature of health service use and place of death of older people living in aged care to identify factors that lead to transfer of end-of-life care to other settings and poorer outcomes.

METHODS

Retrospective review of residential aged care client records between July 2014 and June 2015.

CONCLUSION

The majority of people in this study died in their home setting of residential care and a number were in receipt of palliative care prior to their deaths. The study proposes a national approach to the use of terminology and documents related to palliative and end-of-life care and education in assessment and recognition of nearing the end of life.

Factors Influencing Australian General Practitioners' Clinical Decisions Regarding Advance Care Planning: A Factorial Survey

CONTEXT

Primary care physicians are well placed to identify patients in need of advance care planning (ACP) and initiate ACP in advance of an acute situation.

OBJECTIVES

This study aimed to understand Australian general practitioner (GP) clinical decision making relating to a patient's "need for ACP" and the likelihood of initiating ACP.

METHODS

An experimental vignette study pseudorandomly manipulated factors thought to influence decision making regarding ACP. Patient-level factors included gender, age, type of disease, medical severity, openness to ACP, doctor-patient relationship, and family support. An accompanying demographic survey assessed health professional-level factors, including gender, years of experience, place of training, place of practice, caseload of patients with ACP, direct personal experience in ACP, and self-reported attitudes toward ACP. Seventy GPs were recruited, and each completed six unique vignettes, providing ratings of patient need for ACP, importance of initiating ACP in the coming months, and likelihood of initiating ACP at the next consultation.

RESULTS

Older patients, with malignant or cardiovascular disease, severe clinical presentations, good doctor-patient relationship, female gender, and poor family support were more likely to receive prompt ACP. Positive GP attitudes toward ACP were associated with greater likelihood of initiating ACP promptly.

CONCLUSION

Patients with presentations suggesting higher mortality risk were identified as being in need of ACP; however, the likelihood of initiating ACP was sensitive to GP attitudes and psychosocial aspects of the doctor-patient interaction. Training materials aimed at encouraging GP involvement in ACP should target attitudes toward ACP and communication skills, rather than focusing solely on prognostic risk.