Volume 169 Issue 3

Decision making in CPR: attitudes of hospital patients and healthcare professionals Ian H Kerridge, Sallie-Anne Pearson, Isobel E Rolfe and Michael Lowe MJA 1998; 169: 128-131 For editorial comment, see Ryan Abstract - Introduction - Methods - Results - Discussion - Acknowledgments - References - Authors' details - - ©MJA1998 Abstract Objective: To examine the opinions of patients and healthcare professionals regarding the process of making decisions about cardiopulmonary resuscitation (CPR). Design and participants: A cross-sectional survey of 511 healthcare professionals (doctors, nurses and allied health professionals) (64% response rate) and 152 patients (58% response rate) at the John Hunter Hospital, Newcastle, New South Wales, in June 1994. Main outcome measures: Opinions on who should be involved in CPR decision making; what issues are important when making the decision; and how these decisions should be communicated. Results: 80% (95% confidence interval [CI], 72%-86%) of patients and 99% (95% CI, 98%-100%) of healthcare professionals (P < 0.001) thought patients' views should be taken into account when making CPR decisions. More patients (29%; 95% CI, 22%-38%) than healthcare professionals (14%; 95% CI, 11%-17%) indicated that doctors should be the main decision makers. Two-thirds of respondents regarded the patient's wishes, diagnosis and quality of life as important factors. Most respondents (82%) felt comfortable discussing CPR, but only 29% (95% CI, 22%-37%) of patients and 57% (95% CI, 52%-61%) of healthcare professionals had actually discussed CPR with others (P < 0.001). More than half of all respondents preferred to express their wishes about CPR in writing (47% [95% CI, 39%-55%] of patients, 69% [95% CI, 64%-73%] of healthcare professionals; P < 0.01); the others preferred to tell a family member or close friend. Most patients (60%; 95% CI, 52%-68%) and healthcare professionals (85%; 95% CI, 81%-88%) wanted their views in their medical records (P < 0.001). Conclusion: Most patients want to be involved in CPR decision making and many want some form of advance directive. Although there are some differences in opinions between patients and healthcare professionals, both perceive decision making at the end of life as a shared process, primarily involving the patient and doctor. Introduction Cardiopulmonary resuscitation (CPR) has been used in hospitals for about 30 years.1 Early studies of CPR in highly selected populations demonstrated its effectiveness and CPR soon became routine for any patient who died in hospital. However, as experience accumulated it became apparent that many patients, particularly those with chronic diseases, did not benefit from CPR. Hospitals responded by developing procedures for withholding CPR through the documentation of "do-not-resuscitate" orders. Decisions to initiate or withhold CPR were originally taken by doctors, but changing attitudes towards the doctor-patient relationship and the rise of medical consumerism have challenged this form of unilateral decision making. Indeed, respect for patient autonomy suggests that patients should have the right to contribute to such decisions. No Australian studies reported to date have examined patient preferences regarding CPR decision making. International studies suggest that most patients do not consider discussions about CPR preferences to be cruel or insensitive,2 and most wish to participate in decisions regarding CPR and other life-sustaining therapies.3 However, many patients are unable to participate during the final stages of life-threatening illnesses.4 The use of advance directives has been proposed as a means by which competent patients may ensure that their wishes will be carried out. Advance directives are written or verbal statements in which patients set out their preferences regarding life-sustaining treatment in case they later become incompetent. Advance directives have received considerable attention in the United States,5 where they have widespread legal recognition,6 but have received less publicity in Australia. In the absence of advance directives, CPR decisions are generally made by healthcare professionals in consultation with patients' families.7 The aim of this study was to compare the opinions of patients and healthcare professionals about several aspects of CPR: who should be involved in making the decision, what issues are considered important, and how these decisions should be communicated. Methods Survey We carried out a cross-sectional survey of healthcare professionals (doctors, nurses and allied health professionals) and patients at the John Hunter Hospital, Newcastle, New South Wales, in June 1994. The John Hunter Hospital is a 700-bed teaching hospital in an urban area. The survey formed part of a larger study that aimed to compare patients' and healthcare professionals' attitudes and knowledge about CPR. Survey questions were developed by reviewing published articles, incorporating questions from previously administered surveys,8,9 and consulting experts in the fields of ethics and questionnaire development. After pilot testing, the questionnaire was modified to incorporate the suggestions of a sample of patients and healthcare professionals at a local district hospital. The questionnaire included questions on sociodemographic information (age, sex, marital status, educational, religious and ethnic background) and self-reported health status. Respondents were then asked: whether doctors should ask patients if they would like CPR should they require it; whether patients have the right to choose or refuse resuscitation; who (from a list of people) should be involved in CPR decision making and who should be the main decision maker; which of eight issues listed were important in CPR decision making; whether discussing CPR was cruel or insensitive; whether they had discussed CPR and, if so, with whom; whether they would like patients' views about CPR to be expressed in writing before or soon after admission to hospital; and whether they would like patients' views about CPR to be included in medical records. The survey was administered to all healthcare professionals working over a two-day period at the John Hunter Hospital and to all eligible inpatients over an adjacent two-day period. Self-complete questionnaires were delivered by hand and collected as soon as they had been completed. Patients were initially screened by one of the principal investigators in consultation with a nursing unit manager and excluded if they were regarded as unable to complete the questionnaire or could not understand English. The remaining patients were asked by trained interviewers to participate. After consent was obtained, a Mini Mental State Examination (MMSE) was carried out to assess cognitive status. Patients with an MMSE score less than 24 were excluded, as this may indicate incompetence.10 Statistical analysis Data were analysed with SPSS for Windows.11 Continuity-corrected chi-square analysis was used to compare the sociodemographic variables and the responses of patients and healthcare professionals for each questionnaire item. Ethical approval The Hunter Area Health Service Research Ethics Committee and the University of Newcastle Research Ethics Committee approved the study. Results Respondents Of the 803 questionnaires delivered to hospital staff, 511 were returned -- a response rate of 64%. Of these respondents, 148 were doctors, 312 were nurses and 51 were from other healthcare professions, including physiotherapy, social work, occupational therapy, speech therapy and nutrition and dietetics. There were 443 adult patients in the John Hunter Hospital at the time of the study; 183 were excluded because of dementia, neurological impairment or delirium (110 of those excluded), incompetence (35), visual problems (24), psychiatric illness (9), or because they were undergoing procedures (5). Of the 260 remaining patients, 152 completed the questionnaire -- a response rate of 58%. Healthcare professionals were more likely than patients to be younger, female, have tertiary qualifications and report being healthy. Healthcare professionals and patients did not differ in terms of marital status, religion or ethnic background. Patient involvement in CPR decision making Patients and healthcare professionals differed significantly in their responses to whether doctors should ask patients if they would like CPR should they require it (P < 0.001): 23% (95% confidence interval [CI], 16%-30%) of patients and less than 1% (95% CI, 0-2%) of healthcare professionals thought that doctors should never ask patients, whereas 30% (95% CI, 22%-37%) of patients and 41% (95% CI, 37%-46%) of healthcare professionals thought that they should always ask patients. The remaining respondents were unsure or thought it depended on the patient's circumstances. There was also a significant difference in the way healthcare professionals and patients responded regarding the right to choose or refuse CPR (P < 0.001): 32% (95% CI, 25%-40%) of patients and 1% (95% CI, 0-2%) of healthcare professionals felt that patients should never have this right. Fewer patients (34%; 95% CI, 26%-42%) than healthcare professionals (67%; 63%-71%) believed that patients should always have the right to choose or refuse resuscitation, and the remaining respondents thought it depended on the patient's circumstances. Who should be involved in decision making More than 80% of patients and healthcare professionals indicated that patients and their doctors are important in CPR decision making (Table). Approximately half the respondents regarded the patient's partner and family members as important, but only a third regarded nursing staff as important decision makers. Interestingly, 47% (95% CI, 41%-52%) of nurses believed that they should be involved, whereas only 23% (95% CI, 16%-31%) of doctors and 24% (95% CI, 13%-37%) of allied health professionals believed that nurses should be involved. A significantly lower proportion of patients than healthcare professionals indicated that patients and their partners are important in making the decision. Approximately two-thirds of respondents identified the patient and less than one-third identified the doctor as the person who should be the main decision maker. There was a significant difference in the way healthcare professionals and patients responded. Fewer patients (55%; 95% CI, 47%-63%) than healthcare professionals (85%; 95% CI, 82%-88%) thought the patient should be the main decision maker, whereas 29% (95% CI, 22%-38%) of patients but only 14% (95% CI, 11%-17%) of healthcare professionals thought the doctor should be the main decision maker. The other respondents identified nurses, partners or family members. Important factors in the decision The patient's wishes, diagnosis and quality of life were identified by at least two-thirds of all respondents as important factors in CPR decision making (Figure). Patients were less likely than healthcare professionals to regard patient's wishes (P < 0.001), diagnosis (P < 0.001) and quality of life (P < 0.001) as important, but were more likely to regard age (P < 0.001), family wishes (P < 0.01), mental state (P < 0.03) and social circumstances (P < 0.01) as important. Discussing CPR Most respondents (82% in both groups) did not think discussing CPR was cruel or insensitive. Although 92% (95% CI, 86%-96%) of patients and 96% (95% CI, 94%-97%) of healthcare professionals (P < 0.001) indicated that they had family members who could make decisions for them if they were unable to, only 29% (95% CI, 22%-37%) of patients and 57% (95% CI, 52%-61%) of healthcare professionals (P < 0.001) had discussed with others whether they would like CPR. For all respondents, any discussions that had taken place were with partners (37%; 95% CI, 33%-41%), and/or family members (26%; 95% CI, 23%-30%) and/or doctors (3%; 95% CI, 2%-4%). Advance directives More than half the respondents (47% [95% CI, 39%-55%] of patients, 69% [95% CI, 64%-73%] of healthcare professionals; P < 0.01) preferred to express their wishes about CPR in writing before or soon after being hospitalised. The remaining respondents preferred to tell a family member or close friend about their wishes. About two-thirds of all respondents indicated that they would like their views about CPR to be part of their medical records. Fewer patients (60%; 95% CI, 52%-68%) than healthcare professionals (85%; 95% CI, 81%-88%) wanted their views in their medical records (P < 0.001). The remaining respondents were either uncertain or did not wish to have their views as part of their records. Discussion We found that many patients want to be involved in CPR decision making and many want some form of advance directive. Patients and healthcare professionals generally think that decisions about CPR should be shared by doctors and patients, with patients more likely to feel that doctors should be the main decision maker in such circumstances. This study has several flaws. The study uses a self-report questionnaire, and the low response rate among patients suggests that the group may not have been representative of the population as a whole. Indeed, there is likely to have been a systematic bias towards those who were willing to discuss CPR. Despite this, the findings of this study are of interest, particularly as the study sampled inpatients and had methodological strengths, including a process for the assessment of patient competence and the use of trained interviewers who were not members of the patients' own healthcare team, and thus less likely to influence their participation in the study or their responses to the questions about CPR. International studies have demonstrated that most patients would like to be involved in CPR decision making.12 Layson et al, reviewing international published studies, found that 52%-87% of patients had considered their preferences for life-sustaining therapy (CPR and admission to intensive care) and wished to discuss their preferences with their doctors, but few did so.13 We found that 80% of patients believed they should be involved in CPR decisions, but only 29% had discussed CPR with their doctors or their families. Forty-seven per cent of patients in this study would have liked to express their wishes regarding CPR in writing, either before admission or shortly after. The remainder preferred to tell a family member or a close friend. However, very few patients reported giving advance directives. There are few data to validate routine use of advance directives in hospitals. In the largest study to date that looked at the introduction of advance directives in routine care, their use did not affect patient-physician communication, physician's knowledge of patient preferences, the number of patients receiving ventilation or the use of hospital resources.14 Interestingly, that study was based upon the extensive use of nurses to assess patient preferences and communicate these results to physicians. Hospital staff appear to place more importance upon the role of patients in CPR decision making than patients do. This has been noted in previous studies of patient preferences about decision making,15,16 leading commentators such as Ende et al to suggest that the current emphasis upon patient autonomy arises more from normative ethical reasoning than from patients' actual preferences.16 Other researchers suggest that this is a misconception arising from combining several different aspects of decision making into a single question. Deber and Baumann suggest that shared decision making has two parts:17 problem solving, in which an expert identifies diagnostic and treatment options and expected risks and benefits, and decision making per se, in which the doctor and patient together determine an appropriate course of action.18 According to Deber et al, "given the choice between abiding by the decisions of a paternalistic provider and being handed a stack of medical books and being told to figure out what they wish to do, most patients unsurprisingly opt to hand over control to a trusted provider".18 Both these options are probably inappropriate, and if given a wider choice patients are unlikely to opt for unilateral decision making. Our study suggests that, despite differences between the views of healthcare professionals and patients, the overwhelming majority of both groups support patient and doctor involvement in shared decision making about CPR. Who else should be involved in CPR decision making? Both patients and healthcare professionals believe that partners and some family members should be involved. Surprisingly, only 36% of patients believed that nurses should be involved in these decisions. The reasons for this are likely to be complex. There is no doubt that nurses have a genuine stake in discussions about resuscitation. When a patient has a cardiac arrest, nurses are faced with an ethical decision: to follow their own ethical standards, or to follow the protocols documented in patient notes and hospital procedures, if such documentation exists. Within this context it is interesting to note that in a recent study of American critical care nurses 16% reported that they had participated in euthanasia or assisted suicide, many without the knowledge of physicians, patients or patients' surrogates, and 4% reported that they had hastened a patient's death by only pretending to apply life-sustaining treatment ordered by a physician.19 Nurses are independent moral agents, and there are good reasons for nurses to be involved in CPR decision making. However, there are considerable practical difficulties as nurses care for patients in shifts, and it is not possible to involve every nurse who looks after a patient. It is clearly inadequate to include only one nurse, and then to document "nursing staff in agreement". Perhaps some of this uncertainty filters through to patients. Without continuity of nursing care, patients are unlikely to consider nurses to be major participants in CPR decision making. In addition, the professional image of nurses as moral agents in their own right may not have been communicated adequately to patients or other healthcare professionals. Either way, this finding challenges the notion of "nurse as patient advocate". Differences between staff and patients in preferences about CPR decision making may influence the way decisions are made in hospital and limit the capacity for healthcare professionals to act as patient advocates. This suggests that the proper role for advance directives and the process of CPR decision making requires further study. The effect of determinants such as age, health status, education and religion on CPR decision making also requires further research. Simplistic assertions of autonomy or of the theoretical moral or legal value of advance directives without consideration of the importance of care, compassion or clinical context are clearly inappropriate. This study suggests that both healthcare professionals and patients see decision making at the end of life as a complex, shared process rather than a sterile abstraction of expert information disclosure followed by patient self-determination. Acknowledgements We wish to acknowledge student research assistants from the Faculty of Medicine and Health Sciences for their assistance with data collection and the staff and patients of the John Hunter Hospital for their generous participation in this study. References Robertson GS. Resuscitation and senility: a study of patients' opinions. J Med Ethics 1993; 19: 104-107. Stolman CJ, Gregory OJ, Dunn D, Levine JL. Evaluation of patient, physician, nurse and family attitudes toward do not resuscitate orders. Arch Intern Med 1990; 150: 653-658. Reilly BM, Magnassen R, Ross J, et al. Can we talk? Inpatient discussions about advance directives in a community hospital. Arch Intern Med 1994; 154: 2299-2308. Bedell SE, Pelle D, Maher PL, et al. Do-not-resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact? JAMA 1986; 256: 233-237. Council on Ethical and Judicial Affairs. American Medical Association. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA 1991; 265: 1868-1871. Fisher RH, Meslin EM. Should living wills be legalised? CMAJ 1990; 142: 23-26. Hare J, Pratt C, Nelson C. Agreement between patients and their self-selected surrogates on difficult medical decisions. Arch Intern Med 1992; 152: 1049-1054. Frankl D, Oye RK, Bellamy P. Attitudes of hospitalised patients toward life support: a survey of 200 inpatients. Am J Med 1989; 86: 645-648. Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival on patient's preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994; 330: 545-549. Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189-198. SPSSx statistical package for the social sciences [computer program]. Version 6.0. Chicago, Ill: SPSS Inc, 1990. Morgan R, King D, Prajapati C, Rowe J. Views of elderly patients and their relatives on cardiopulmonary resuscitation. BMJ 1994; 308: 1677-1678. Layson RT, Adelman HM, Wallach PM, et al. Discussions about the use of life-sustaining treatments: a literature review of physicians' and patients' attitudes and practices. J Clin Ethics 1994; 5: 195-199. The SUPPORT Principle Investigators. A controlled trial to improve care for seriously ill hospitalised patients. JAMA 1995; 274: 1591-1592. Strull WM, Lo B, Charles G. Do patients want to participate in medical decision making? JAMA 1984; 252: 2990-2994. Ende J, Kazis L, Ash AB. Measuring patients' desire for autonomy: decision making and information seeking preferences among medical patients. J Gen Intern Med 1989; 4: 23-30. Deber RB, Baumann AO. Clinical reasoning in medicine and nursing: decision-making versus problem-solving. Teach Learn Med 1992; 4: 140-146. Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making? Arch Intern Med 1996; 156: 1414-1420. Asch DA. The role of critical-care nurses in euthanasia and assisted suicide. N Engl J Med 1996; 334: 1374-1379. (Received 14 Jul 1997, accepted 1 Apr 1998) Authors' details Faculty of Medicine and Health Sciences, University of Newcastle, NSW. Ian H Kerridge, BMed, MPhil, Lecturer in Clinical Ethics, Clinical Unit in Ethics and Health Law, and Haematology Registrar, John Hunter Hospital; Sallie-Anne Pearson, BSc(Hons), Professional Officer, Programme Evaluation Committee; Isobel E Rolfe, FRACP, MRCP, Senior Lecturer in Medical Education; Michael Lowe, BMed, Tutor in Clinical Ethics, and Medical Registrar, John Hunter Hospital. Reprints will not be available from the authors. Correspondence: Dr I H Kerridge, Clinical Unit in Ethics and Health Law, John Hunter Hospital, Locked Bag 1, Hunter Regional Mail Centre, Newcastle, NSW 2310. E-mail: ikerridgeATmail.newcastle.edu.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Ian H Kerridge · Sallie-Anne Pearson · Isobel E Rolfe · Michael Lowe

The stress of metropolitan general practice Peter L Schattner and Greg J Coman MJA 1998; 169: 133-137 For editorial comment, see Douglas & Sibthorpe Abstract - Introduction - Methods - Results - Sex differences - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To identify the work-related stressors of Australian metropolitan general practitioners (GPs). Design and setting: A descriptive postal survey of metropolitan GPs from all States and Territories selected at random from the Health Insurance Commission database. Participants: 296 of 464 GPs (64%) surveyed in June 1996; 67% were male; 87% worked full-time (more than 6 sessions per week). Main outcome measures: Frequency and severity of work stresssors in general practice; overall feelings of stress at work in the past 12 months; effects of the stressors on work satisfaction; contribution of work stress to overall life stress; responses to the 12-item General Health Questionnaire (GHQ) as potential correlates of occupational stress. Results: "Time pressure to see patients" was the most frequently reported stressor. Threat of litigation was perceived as the most severe stressor. Of the top 10 severe stressors, seven were also in the top 10 for stressor frequency. Work was the major stressor in GPs' lives. The GHQ scores did not correlate significantly with major stress outcome measures, but 12.8% of GPs had scores indicative of severe psychiatric disturbance. Fifty per cent of respondents had considered leaving their current workplace and 53% had considered abandoning general practice because of occupational stress. GPs working 6 or more sessions per week were more likely to be moderately or severely stressed than those working part-time (P < 0.02, Fisher's exact test). Those who had considered leaving their current workplace or careers were also more likely to be moderately or severely stressed (P < 0.0001, Fisher's exact test). Conclusions: The most frequent and relatively severe stressful events in general practice involved time pressures. There are implications for government, which, through remuneration policies, might influence GPs to work at a rate beyond their capacity to cope. Strategies are required to manage or prevent stress in metropolitan GPs. Introduction Stress has been defined as a response to challenging events.1 It is usually thought of as "distress" or an inability to cope with an external factor (the "stressor"). In the workplace it is generally referred to as occupational stress. Australian and international studies suggest that general practice is a stressful occupation.2-7 The extent to which GPs feel stressed by various aspects of their occupation may affect the quality of patient care and may also affect practitioners' health. Health problems experienced by GPs include alcohol and drug abuse,8-10 marital disruption and divorce,3,11,12 anxiety,3,13 burnout,14 depression,15 as well as suicide and attempted suicide.16,17 The specific characteristics that make general practice so stressful are largely unknown, although anecdotal evidence would suggest that time and financial issues are major stress factors for Australian GPs. In our study we aimed to identify the sources, frequency and severity of occupational stress experienced by metropolitan GPs; the importance of occupational stress compared with other life stressors; the effects of the work stressors on GPs' job satisfaction; and the possible effects of these stressors on GPs' psychological health. Rural GPs were not included, as factors such as isolation and difficulty in obtaining locum relief suggest this group should be studied separately.18 Methods General practitioner recruitment and survey distribution A list of 500 potential survey participants was obtained from the Health Insurance Commission database of the Commonwealth Department of Human Services and Health (now the Department of Health and Family Services). Potential participants were randomly selected from the population of GPs in all States and Territories who had capital city practices only and more than 1500 consultations annually (the number generally accepted by the General Practice Evaluation Programme as the definition of "active" GPs). The Department advised that potential participants had not recently been surveyed through this database. Questionnaires were mailed to all 500 GPs in June 1996. Non-respondents to the first mailout were sent a second questionnaire in July 1996, and non-respondents to this prompter were telephoned to request their participation in August 1996. Survey instrument We used a four-part questionnaire to collect data on:(1) GPs' demographic and practice information. (2) The frequency and severity of potentially stressful events in general practice, using a 28-item list developed from an extensive literature review which included validated stress-screening instruments,4,5,6,18 and input from a Melbourne-based GP focus group. A four-point Likert-like scale was used, with 3 representing "frequently, at least weekly"; 2, "occasionally, at least monthly"; 1, "rarely, a few times a year"; and 0, "does not occur". Another four-point Likert-like scale, with 3 representing "severe stress"; 2, "moderate stress"; 1, "mild stress"; and 0, "no stress", was used to assess stress severity for each item. (3) The effects of stressors on GPs' job satisfaction, including asking them to (a) indicate on a four-point scale (from 0 = none to 4 = severe) their overall work stress levels in the previous 12 months; (b) rank six aspects of general practice in order of contribution to work stress levels, from 1 for the greatest contribution to 6 for the least; (c) distinguish between stressors related to job content (ie, clinical duties) and job context (ie, environmental and organisational factors) (see Box 1); (d) rank six potential sources of life stress in order from 1 for the greatest source of stress to 6 for the least stressful. (4) The 12-item General Health Questionnaire (GHQ),19 used to determine the presence of psychiatric disturbance, anxiety or depression as potential correlates of occupational stress. GHQ items have four response options, which were scored 0, 0, 1 or 1. This provides a GHQ score range from 0 to 12. Using this method, scores of less than four represent negligible psychiatric disturbance, scores between four and eight suggest moderate disturbance, and scores greater than eight indicate severe psychiatric disturbance. Data entry and analysis Data were computer-coded and analysed using the Statistical Package for the Social Sciences for Windows.20 Analyses included cross-tabulations of stress outcome measures with the demographic data shown in Box 2. Non-parametric tests were used to test for significant differences at the P = 0.05 level. Potential work stressors were ranked in order of reported frequency and severity. Ethical approval Ethical approval was granted by the Monash University Standing Committee on Ethics in Research on Humans. Results Characteristics of respondents Of the 500 questionnaires mailed, 36 were returned unopened; 296 of the remaining 464 GPs participated (response rate, 64%). Box 2 shows their demographic characteristics, which are similar to the demographic profile of Australian metropolitan general practice.21 General practice stressors Frequency of general practice stressors The most frequent stressors were related to perceived lack of time. "Time pressure to see patients", "phone interruptions during consultations" and "too much work to do in a limited time" were ranked 1, 3 and 4, respectively, in frequency, with "paperwork" the second most frequent stressor (Box 3). Severity of general practice stressors The threat of litigation (actual involvement in litigation proceedings was not an item), although perceived as one of the most stressful events in general practice, was reported relatively infrequently. However, seven of the 10 most stressful events (Box 4) were also in the top 10 for frequency. The GPs appeared to experience a number of stressors which were perceived as mild to moderate, but which occurred frequently. The mean ratings for the three most severe stressors -- "threat of litigation", "too much work to do in a limited time" and "earning enough money in general practice" -- were between "mild" and "moderate". Effects of stress Overall work stress The Figure shows that most GPs (273/296; 92%) reported some feelings of stress, with 241 (81%) labelling it "mild" or "moderate" and 32 (10.8%) "severe". When asked about levels of stress in the past 12 months, 121 (41%) of GPs said they had increased, 118 (40%) said they had stayed the same, and 33 (11%) said they had decreased. Fifty per cent of GPs surveyed had considered leaving their current workplace, and 157 (53%) had considered abandoning general practice because of occupational stress. Factors associated with high overall work stress levels When the GPs' reported experience of work stress was cross-tabulated with the demographic variables reported in Box 2, the only significant association was that GPs working six or more sessions per week were more likely to be moderately or severely stressed than those working part-time (P < 0.02, Fisher's exact test). Those who had considered leaving their current workplace or abandoning their careers were also more likely to be moderately or severely stressed (P < 0.0001, Fisher's exact test). Six major causes of occupational stress Of the six most stressful aspects of general practice high workload was rated worst, followed, in descending order, by economic factors (income, running a business) and "medicopolitical" factors (involvement with professional associations, government pressures). Clinical factors and the effect of work on outside life were rated fourth and fifth, respectively, and the physical working environment was considered the dimension which contributed the least to the stresses of general practice (Box 5). These rankings were based on the means of rank scores; the first two items ranked significantly ahead of the other factors (P < 0.05). Sixty per cent of the GPs said that their experience of stress arose mainly from "job context" rather than from "job content". Comparisons with other life stresses Work was the major source of overall stress in GPs' lives, followed closely by financial concerns (Box 6). General Health Questionnaire data The 12-item GHQ was used to assess respondents' levels of psychiatric morbidity, especially depression and anxiety. The mean GHQ score was 3.01 (95% confidence interval, 2.66-3.35), suggesting that, on average, GPs experience low levels of psychiatric disturbance. However, almost a third (30.7%) of respondents recorded GHQ scores of 4 or more and 38 (12.8%) recorded scores of 8 or more, suggesting that many GPs are clinically depressed, anxious, or experiencing other psychiatric symptoms. The responses to three GHQ questions were of concern. These were Item 5 ("Have you recently felt constantly under strain?"), to which 7.1% responded "much more than usual"; Item 9 ("Have you recently been feeling unhappy and depressed?"), to which 5.1% responded "much more than usual"; and Item 11 ("Have you recently been thinking of yourself as a worthwhile person?"), to which 6.1% responded "not at all". Box 7 shows that, while significant, correlations between GHQ scores and the stress measures were not high. The highest correlation (0.53) was with GPs' overall perception of stress in the past 12 months. Sex differences There were small but statistically insignificant differences in the responses of men and women. Discussion Our study indicates that, while the worst stressors in general practice are perceived to be of only mild to moderate severity, many occur frequently. The study cannot determine whether there is a cumulative effect, in which a series of minor frustrations leads to a pervasive level of significant stress in GPs, but this may be an explanation as to why so many GPs have considered leaving their practices or abandoning general practice altogether. Apart from the threat of litigation, work overload issues, such as time pressure to see patients, phone interruptions and too much work to do in a limited time, were the most common stressors for GPs. Both GPs and their patients have been reported to be dissatisfied with the amount of time spent in consultations.4,7,22-25 Time pressure may be a reason for patients' reporting that GPs are not listening to what they are saying and not explaining things to them properly.26 Effects of time constraints on GPs may include irritability, frustration and, possibly, mistakes in diagnosis and treatment.4 Practice administration issues, which have not been traditionally taught to undergraduates, were rated as causing much more stress than issues of clinical competence. This may add to the pressure of high patient loads. The intrusion of work on family life was a significant stressor. Presumably, GPs would be less stressed if work did not impinge on family time or if they could see more of their family by working fewer hours. Although our list of potential sources of life stress was not exhaustive, we have not found a similar ranking attempt in the other stress studies reviewed. It would be interesting to see how this group of GPs compares with other occupational groups and the community at large in this regard. Concerns about remuneration and other financial concerns, such as the cost of practice overheads, were considered to be among the most frequent and severe stressors in this study (although they were not rated as highly as some might expect). This should be of interest to governments, which continue to emphasise cost-cutting in healthcare expenditure. It is of concern that almost a third of the respondents (91; 30.7%) had GHQ scores of 4 or more, suggesting moderate psychiatric disturbance, and that 38 (12.8%) scored 8 or more, suggesting severe disturbance. To some extent this is an independent finding; work stress cannot be blamed entirely for the presence of psychiatric disturbance in GPs, although it is likely to be a contributing factor. Our 64% response rate and the similarity of our sample's demographic profile to that of Australian metropolitan general practice21 suggest that the survey results are generalisable to urban GPs. It is possible that highly stressed GPs are under-represented because they were too stressed to comply with yet another demand on their time (the completion of a questionnaire). General practice may be no more or less stressful than many other "caring professions".4 However, the specific stressors highlighted in this study do suggest that government, healthcare policymakers, organisers of vocational training and GPs themselves should be aware of the high levels of stress experienced by doctors who choose this vocation, and steps should be taken to institute stress prevention and management. Acknowledgements Our thanks to the administrative staff at the Department of Community Medicine and General Practice at Monash University, as well as Dr Lynne Ham and Dr Chris Peterson for their expert advice on occupational stress, and Dr Con Tsalamandris for statistical analysis. This project was funded by a grant from the General Practice Evaluation Program of the Department of Human Services and Health. References Selye H. The stress of life. New York: McGraw Hill, 1976. Mawardi B. Satisfactions, dissatisfactions and causes of stress in medical practice. JAMA 1979; 241: 1483-1486. Roeske N. Stress and the physician. Psychiatr Ann 1981; 11: 245-258. Porter A, Howie J, Levinson A. Stress and the general practitioner. In: Payne R, Firth-Cozens J, editors. Stress in health professionals. Chichester: Wiley, 1987: 45-70. Makin P, Rout U, Cooper C. Job satisfaction and occupational stress among general practitioners -- a pilot study. J R Coll Gen Pract 1988; 38: 303-306. Sutherland V, Cooper C. Job stress, satisfaction and mental health among general practitioners before and after introduction of new contract. BMJ 1992; 304: 1545-1548. Sutherland V, Cooper C. Identifying distress among general practitioners: predictors of psychological ill health and job dissatisfaction. Soc Sci Med 1993; 37: 575-581. Ball J. Alcohol and drug use and related problems in the medical profession. Aust Drug Alcohol Rev 1986; 5: 29-32. Baldwin D, Hughes P, Conrad S, et al. Substance abuse among senior medical students. JAMA 1991; 265: 2074-2078. Serry N, Bloch S, Ball R, Anderson K. Drug and alcohol abuse by doctors. Med J Aust 1994; 160: 402-407. Bird H. The physician's marriage: joys and sorrows: life transition points. Facets 1979; Summer: 18-20. Miles J, Krell R, Lin T. The doctor's wife: mental illness and marital pattern. Int J Psychiatry Med 1975; 6: 481-487. Cramond W. Anxiety in medical practice: the doctor's own anxiety. Aust N Z J Psychiatry 1969; 3: 324-328. Lemkau J, Purdy R, Rafferty J, Rudisill J. Correlates of burnout among family practice residents. J Med Educ 1988; 63: 682-691. Smith M, Andrasik F, Quinn S. Stressors and psychological symptoms of family practice residents and spouses. J Med Educ 1988; 63: 397-405. Craig A, Pitts F. Suicide by physicians. Dis Nerv Syst 1968; 219: 763-772. Steppacher R, Mausner J. Suicide in male and female physicians. JAMA 1974; 228: 323-328. Dua J. Development of a scale to assess occupational stress in rural general practitioners. Int J Stress Manage 1996; 3: 117-128. Goldberg D, Williams P. Manual of the General Health Questionnaire. Windsor (UK): Nfer-Nelson, 1988. Statistical Package for the Social Sciences [computer program] release 6.0. SPSS, Chicago, Ill, USA, 1996. Commonwealth Department of Health and Human Services. General practice in Australia: 1996. Canberra: AGPS, 1996. Cartwright A, Anderson R. General practice revisited. London: Tavistock, 1981. Bates E. Doctors and their spouses speak: stress in medical practice. Sociol Health Illness 1982; 4: 25-39. Richardson IM, Howie J, Durno D, et al. A study of general practitioner consultations in North-East Scotland. J R Coll Gen Pract 1973; 23: 132-142. Brooks M, Stewart-Weeks M. Integrating consumer views about quality in general practice. Canberra: Consumers' Health Forum of Australia, 1996. Myerson S. Doctors' methods of dealing with "on going" stress in general practice. Med Sci Res 1991; 19: 267-269. (Received 7 Oct 1997, accepted 31 Mar 1998) Authors' details Department of Community Medicine and General Practice, Monash University, Melbourne, VIC Peter L Schattner, MMed BS, FRACGP, Director, Research Unit; Greg J Coman, GradDipAppPsych, MSc, Psychologist. Reprints will not be available from the authors. Correspondence: Dr P L Schattner, Department of Community Medicine and General Practice, Monash University, 867 Centre Road, East Bentleigh, Melbourne, VIC 3165. E-mail: peter.schattnerATmed.monash.edu.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Peter L Schattner · Greg J Coman

Emergency department telephone advice Daniel M Fatovich, Ian G Jacobs, Jill P McCance, Kerry L Sidney and Rod J White MJA 1998; 169: 143-146 For editorial comment, see Oberklaid Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To evaluate telephone advice given in an emergency department. Design: Prospective, observational study. Setting: A community-based emergency department in a semi-rural/outer metropolitan setting, between August and November 1995. Participants: All people telephoning the emergency department for medical advice. Methods: Details of all calls, callers and patients were recorded. Within 72 hours, a follow-up call was initiated seeking replies to a series of standardised questions. Main outcome measures: Number, timing and duration of calls; appropriateness of the advice given; compliance with the advice; and callers' satisfaction with the service. Results: Over the four-month period, 1682 calls were received, 58% between 4 pm and midnight. There were 33 telephone calls per 100 emergency department attendances. The mean call duration was 3.9 minutes (range, 0.25-25 minutes); 49% of patients were less than 14 years old, and 72% of callers phoned because of spontaneous illness. The advice given was considered inappropriate in only 1.4% of calls. Follow-up calls were made to 1132 people (67%), revealing a non-compliance rate of only 6.9% and a high level of caller satisfaction, with 99% of callers affirming a need for such a service. Conclusions: The provision of telephone advice by emergency department staff is rated highly by the community and compliance with the advice is strong. Paediatric problems, arising as a result of spontaneous illness, predominate and there is a large bias towards after-hours use of the service. Experienced staff provide better advice. Introduction Emergency department (ED) staff are frequently telephoned by members of the community who seek medical advice. Little is known about who calls and why, how much professional time is required, what problems people call about and the quality of the advice given.1 In particular, caller compliance has seldom been assessed. This study was conducted to provide a detailed analysis of emergency department telephone advice. A prospective, observational study, it was undertaken at Swan District Hospital, which is situated 20 km northeast of the central business district of Perth. The hospital has 148 beds, is community based and over 15 000 patients attend its ED each year. It serves a population of over 142 000 residents in a metropolitan and semi-rural setting. There are approximately 160 general practitioners in the area who provide some after-hours care. The catchment population was more socioeconomically disadvantaged than that of the metropolitan area. Methods Data collection The survey took place from 1 August to 30 November 1995. All telephone calls from people seeking medical advice were answered by an ED registered nurse who was responsible for triage and later reviewed. Details of the call, including the date, time, patient's name, age and sex, caller's name, relationship of the caller to the patient, patient's telephone number, presenting problem and advice given, were recorded on a telephone advice form during the call. Each call was timed using a stopwatch and problems were divided into four categories: spontaneous illness, injury, poisoning, and drug-related. Evaluation of the calls To establish the quality and appropriateness of the telephone advice given, each completed telephone advice form was assessed independently by at least two authors. Disputes were settled by a third author. The authors deemed the advice to be either appropriate or inappropriate and, in cases where the advice was considered to be inappropriate, defined it as potentially life threatening, at risk of causing serious sequelae or not serious. Caller feedback At the completion of each call, permission was sought for a follow-up call to determine the caller's response to the advice given. Where permission was given, a research nurse telephoned the caller within 72 hours of the initial call. The nurse asked each caller how he/she had acted upon the advice, how helpful the advice had been, if the caller had sought advice elsewhere, if he/she had used an ambulance when advised, and his/her overall perception of the telephone advice service. Callers were also encouraged to freely make comments about the service. Statistical analysis Data were analysed using the Statistical Package for Social Sciences (SPSS).2 Ethical approval Approval for the study was obtained from the Ethics Committee of the Swan Area Health Service. Results Number, timing and content of calls During the four-month period 1682 calls were received. The average number of calls per day was 14 (range, 3-32). Given that there were 5127 attendances at the ED during the same period, the ratio of calls to ED attendances was 1:3 (33 calls per 100 attendances). The mean age of the patients was 22 years (range, 1 week-95 years), although 49% were under 14 years (Figure 1). Fifty-five percent of patients were female. Comparison of the age and sex distribution of patients who called the telephone advice service with that of patients who attended the ED showed that callers were more likely to be younger and female (Box). Almost a quarter (24%) of all calls were received on Sunday, 17% were received on Saturday, and Monday was the busiest weekday (Figure 2). Calls between 4 pm and midnight constituted 58% of all calls received (Figure 3). The mean call duration was 3.9 minutes (± 2.5 minutes), with the longest call taking 25 minutes (allowing also for a brief request for a follow-up call). The patient was the caller in 32% of cases. Where the caller was not the patient, 63% and 17% of calls, respectively, were made by a parent or spouse. Eighty-two percent of calls were from the Swan Area Health Service catchment area. The others were from the city of Perth and its surrounds. Spontaneously occurring illness accounted for 72% of calls (1175). The most common problems were fever in children, pain (especially earache in children), and shortness of breath. A further 22% of calls were for injuries. Advice given Advice was considered inappropriate in 23 cases (1.4%). Of these, 11 (48%) were assessed as potentially life threatening (eg, a 42-year-old man with chest pain who had previously had a coronary angioplasty was not advised to attend hospital by ambulance). Four (17%) were considered at possible risk of serious sequelae (eg, an 18-month-old child with a two-week history of lethargy, fever and vomiting was not advised to see a doctor). Staff with less than two years' relevant ED experience were responsible for 78% of the inappropriate advice given (18 of 23 calls) and 100% of potentially life-threatening advice. No advice was given in 97 cases (6%) as the caller rang merely to inform the ED of their impending arrival. Only one call was prompted by an imminently life-threatening situation (a 40-year-old man with insulin-dependent diabetes who could not be roused by the caller). The patient was making a "funny noise breathing" and the caller was unable to give him sugar. The caller was correctly advised to ring for an ambulance. A Dextrostix test performed by ambulance officers indicated a low blood sugar level of 1.4 mmol/L. They administered glucagon intramuscularly, which raised his blood sugar level to 4.2 mmol/L. Caller feedback A total of 1132 patients (67%) consented to follow-up. Of these, 42% had previously used the service and 89% considered the advice to be useful or very useful. Almost a third (30%) had sought advice elsewhere before calling the ED, 43% of these from their general practitioner. The level of compliance with advice was established in 1205 cases (72%). This included 73 cases where the caller later attended the ED and compliance was able to be determined from the medical record. Eighty-three people (6.9%) did not comply with the advice received, including 34 who were advised to call an ambulance but failed to do so. The main reasons for this were the anticipated cost of the ambulance journey, the caller's perception that the problem did not require an ambulance (despite being advised to call one), and the belief that travelling to the ED would be faster by private transport. Other reasons for non-compliance ranged from lack of transport and unwillingness to wait, to simple refusal to follow the advice because the caller believed that they knew better. About a quarter of callers (26%) subsequently attended their general practitioner, and 13% elected to monitor their problem. Five hundred and ninety-nine patients (50%) attended an ED, 92% attending the Swan District Hospital ED. The distribution of problems which warranted attendance was similar to that of the problems which had prompted the original call. Of those attending an ED, 94 patients (16%) were admitted to hospital. Each caller who was followed up was asked to rate the telephone advice service on a scale of one to 10, with 10 being "excellent". The mean score was 8.9, with only 1.5% of respondents giving a score of less than five. There was overwhelming support for a telephone advice service, with 99% of those contacted affirming the need. The majority of respondents (86%) also indicated that they would be disappointed if the telephone advice service were discontinued. Discussion Throughout the world, it is common practice for ED staff to provide telephone advice. This is almost unavoidable because patients require access to health information and medical advice at all times. Health authorities need to consider this when planning health services. The American College of Emergency Physicians3 and the British Association of Emergency Medicine4 have position statements on giving telephone advice, and the British government has announced plans for a 24-hour patient helpline staffed by nurses.5 Pilot schemes have already commenced. We found that the ED in our study received 33 telephone calls for advice per 100 ED attendances. This is consistent with the results of a survey of 130 Australian EDs which reported a national figure of 28 calls per 100 attendances.6 The same study calculated an annual volume of almost 1.2 million ED telephone advice calls (almost two every minute) and found that two-thirds of Australian EDs provide telephone advice, with rural EDs more likely to provide this service than metropolitan EDs. This may reflect rural isolation from medical care. Some metropolitan hospitals have developed specialised advice lines for people with sick children.7 An unavoidable limitation of this study was that a third of callers were lost to follow-up. Seasonal factors may have been another source of bias. Other limitations were that the social desirability of giving an acceptable answer may have contributed to the degree of compliance reported, and that the performance of the nurses giving the advice may have been influenced by the fact that a study was being undertaken (the "Hawthorne effect"). Most Australian households have a telephone and are aware of their nearest public hospital: in our consumer- oriented society, it is little wonder that EDs are frequently telephoned for advice.8 The bias towards after-hours use probably reflects a lack of alternative resources. Previous studies have concluded that ED telephone advice is inexpensive, safe, allows public access to health information and encourages consultation with a doctor as appropriate.9 According to Verdile et al,10 telephone advice should be considered an outreach program of the ED. However, EDs are rarely funded to provide this service. Our finding of a 93.1% compliance rate is high, but consistent with the only other study of compliance. Egleston et al9 found that 99 of 104 callers (95.2%) were compliant with the telephone advice. The commonest scenario in which advice was not followed involved the use of an ambulance. This result should be considered by providers of prehospital care. It was apparent from our study that people telephoned the ED not just for medical advice, but also as a last resort in social crises. These included problems ranging from domestic violence and child abuse to suicide and social isolation. The advice included direction of callers to appropriate community resources, advising medical assessment or simply providing empathy. At times, telephoning the emergency department may be the only option of which the caller is aware. This reflects the ED's function as society's healthcare "safety net" 24 hours a day, seven days a week. Most calls lasting over 15 minutes were in this category. The longest call, which lasted 25 minutes, was from a woman who was anxious about her five-month-old baby being difficult to settle due to "colic" after having been vaccinated the previous day. The call was made during a quiet period in the ED and the nurse who took it took the time to listen and empathise. Nurses have traditionally been, and are described in other reports as, the predominant ED staff members responsible for answering medical advice telephone calls. Often, however, nurse training in this important component of ED work is absent. Protocols for telephone triage have been assessed and found to be effective.11,12 The protocols have checklists which assist the user in gathering essential data from the caller, provide built-in guidelines for patient management and facilitate documentation.10 Such protocols should be standardised as the literature reveals that the quality of medical advice varies and that inappropriate advice can be harmful. Aitken et al13 found the advice to be inadequate in 16 of 36 institutions assessed when given a theoretical case of a 5-week-old infant with a fever of 38.5¡C. When Verdile et al10 surveyed EDs using a scenario that may have been myocardial ischaemia, only 4 of 46 respondents recommended that the patient be brought to the nearest ED by ambulance. Their findings indicate that the telephone advice given by some EDs is inconsistent and may be inadequate to the point of jeopardising the health of those seeking advice. Medicolegal concerns are frequently raised in relation to telephone advice, although an estimate of the exact magnitude of the problem of litigation is difficult to ascertain.10 However, it is possible that hospitals could be held accountable for giving either poor advice or refusing to help. The literature suggests that, although questioning a caller about a problem is acceptable, once any advice is offered over the telephone the ED staff member has assumed a legal obligation to the caller and is responsible for any advice given.14 Hence, it is important to have guidelines and to document all calls. Telephone advice is a difficult skill to perform well but one that is important to master. The consequences of error can be serious, and hence the use of experienced and trained staff who are aware of the limitations and ramifications of providing the service is mandatory. A basic rule is that diagnosis via the telephone is not possible and that the best advice is to recommend a face-to-face consultation. With common sense, the proper use of the telephone can both facilitate patient care and maximise the available human resources. It fulfils a genuine community need and helps promote better community relations. We found that the provision of telephone advice by ED staff is rated highly by the community and that compliance with the advice is strong. Calls regarding children with spontaneous illnesses predominate, and there is a strong bias towards after-hours use of the service. Experienced nursing staff provide better advice. The provision of telephone advice is an under-recognised function of the emergency department of which healthcare planners should be aware. Acknowledgements This study was made possible by a research grant from the Commonwealth Department of Human Services and Health (Ambulatory Care Research and Pilot Program) and the support of the Health Department of Western Australia, Health System Policy Branch. The authors are grateful to all ED staff who participated, especially Sheila Penman, RN. References Knowles PJ, Cummins RO. Emergency department medical advice calls: who calls and why? J Emerg Nurs 1984; 10: 283-286. SPSS Inc, release 6 [computer program]. Chicago,Illinois: SPSS, 1993. American College of Emergency Physicians. Providing telephone advice from the emergency department. Ann Emerg Med 1990; 19: 600. British Association for Emergency Medicine Clinical Services Committee. Guidelines on the handling of telephone enquiries in emergency departments. London: British Association for Emergency Medicine, 1992. Horton R. The realpolitik of a new National Health Service for the UK. Lancet 1998; 351: 76-77. Fatovich DM, Jacobs IG. Emergency department telephone advice: a survey of Australian Emergency Departments. Emerg Medi 1998; 10: 117-121. Best Practice in NSW Health 1994 Sydney. 49-52. Crouch R, Patel A, Williams S, Dale J. An analysis of telephone calls to an inner city accident and emergency department. J R Soc Med 1996; 89: 324-328. Egleston CV, Kelly HC, Cope AR. Use of a telephone advice line in an accident and emergency department. BMJ 1994; 308: 31. Verdile VP, Paris PM, Stewart RD, Verdile LA. Emergency department telephone advice. Ann Emerg Med 1989; 18: 278-282. Levy JC, Rosekrans J, Lamb GA, Friedman M, et al. Development and field testing of protocols for the management of pediatric telephone calls: protocols for pediatric telephone calls. Pediatrics 1979; 64: 558-563. Strasser PH, Levy JC, Lamb GA, Rosekrans J. Controlled clinical trial of pediatric telephone protocols. Pediatrics 1979; 64: 553-557. Aitken ME, Carey MJ, Kool B. Telephone advice about an infant given by after-hours clinics and emergency departments. N Z Med J 1995; 108: 315-317. Dunn JM. Warning: giving telephone advice is hazardous to your professional health. Nursing 1985; 8: 40-41. (Received 7 Oct 1997, accepted 26 Mar 1998) Authors' details Swan District Hospital, Middle Swan, Perth, WA Daniel M Fatovich, MB BS, FACEM, Director of Emergency Medicine; Jill P McCance, RN, Clinical Nurse; Kerry L Sidney, RN, Clinical Nurse Specialist; Rod J White, RN, Clinical Nurse. School of Public Health, Department of Epidemiology & Biostatistics, Curtin University. Ian G Jacobs, PhD, RN, Senior Lecturer. Reprints will not be available from the authors. Correspondence: Dr D M Fatovich, Department of Emergency Medicine, Swan District Hospital, Eveline Road, Middle Swan, WA 6056. E-mail: daniel.fatovichAThealth.wa.gov.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Daniel M Fatovich · Ian G Jacobs · Jill P McCance · Kerry L Sidney · Rod J White