Ethics

Keeping the doctor’s bag relevant to needs

Gerard F Gill

South Australians are more likely to settle their financial affairs than their health care and lifestyle advance directives

Sandra L Bradley BSc, BN, MSc · Richard J Woodman PhD · Jennifer J Tieman BSc(Hons), MBA, PhD · Paddy A Phillips MB BS, DPhil, FRACP

A case study highlights the complexities of assessing a patient’s capacity to consent to treatment

Hayden A Snow MB BS · Bill R Fleming MB BS, FRACS, FRCS

Mandatory detention is a form of child abuse and paediatricians strongly disagree with offshore processing

Elizabeth J M Corbett BA, LLB(Hons), GDipLegalP · Hasantha Gunasekera MIPH(Hons), FRACP, PhD · Alanna Maycock MA, BSc, DipHE · David Isaacs MD, FRACP, FRCPCH

An expression of support for Bruce Hall and his significant contributions to the field of transplantation

Jeremy R Chapman · Geoffrey W McCaughan · Philip J O’Connell

How to manage challenging doctor–patient relationships

Michael Jefford MB BS, PhD, FRACP · John R Zalcberg MB BS, PhD, FRACP

Obligations don’t end at the last consultation

Loane L C Skene LLB, LLM, LLD

Asylum seekers are not receiving acceptable standards of medical care. Should doctors boycott the system?

John-Paul Sanggaran MB BS, MHMed, BHSc · Grant M Ferguson BSc(Hons), MB BS · Bridget G Haire PhD, MBioethics

A first step towards understanding how Australia’s notifiable conduct law is working

Marie M Bismark MB ChB, LLB, MBHL · Matthew J Spittal PhD, MBio · Tessa M Plueckhahn BA(Hons), JD · David M Studdert LLB, ScD, MPH

In reply: The emergency principle may be applied legally without any prior approval or documentation

Kerri Eagle · Christopher J Ryan

Objectives: To examine doctors' level of knowledge of the law on withholding and withdrawing life-sustaining treatment from adults who lack decision-making capacity, and factors associated with a higher level of knowledge. Design, setting and participants: Postal survey of all specialists in emergency medicine, geriatric medicine, intensive care, medical oncology, palliative medicine, renal medicine and respiratory medicine on the AMPCo Direct database in New South Wales, Victoria and Queensland. Survey initially posted to participants on 18 July 2012 and closed on 31 January 2013. Main outcome measures: Medical specialists' levels of knowledge about the law, based on their responses to two survey questions. Results: Overall response rate was 32%. For the seven statements contained in the two questions about the law, the mean knowledge score was 3.26 out of 7. State and specialty were the strongest predictors of legal knowledge. Conclusions: Among doctors who practise in the end-of-life field, there are some significant knowledge gaps about the law on withholding and withdrawing life-sustaining treatment from adults who lack decision-making capacity. Significant consequences for both patients and doctors can flow from a failure to comply with the law. Steps should be taken to improve doctors' legal knowledge in this area and to harmonise the law across Australia.

Ben White LLB(Hons), DPhil · Lindy Willmott BCom LLB, LLM, PhD · Colleen Cartwright PhD, MPH, BSW(Hons) · Malcolm H Parker MB BS, MHMedLaw, MD · Gail Williams MSc, MSc(Lond), PhD

Cardiopulmonary resuscitation (CPR) is the default treatment in hospital unless there is a decision to the contrary and this is documented in the patient record. The outcome of CPR in older chronically ill patients is very poor and discharge home is unlikely. Fewer not-for-resuscitation (NFR) orders are written than there are patients who would not benefit from CPR. NFR orders appear to be a marker of death, rather than the result of informed discussion about end-of-life care. There is a legal and ethical framework for the consideration of the suitability of CPR. Discussions about CPR are challenging, and uncertainty is introduced because of the lack of consensus around futility, the emotionally charged nature of the topic, misconceptions about the success of CPR and the failure to recognise that not offering CPR will allow a peaceful and supported death. Discussion around CPR can be misconstrued as a need for consent. A focus on patient and family involvement may result in an expectation that CPR is an entitlement. As part of evidence-based patient-centred care, CPR should only be offered to those for whom it is beneficial. CPR should no longer be the universal default. We propose an opt-in model, which will drive discussion and evaluation of the efficacy and suitability of CPR for the individual. A CPR discussion should occur on admission for all elderly hospital inpatients.

Michele Levinson MD, FRACP, FCICM · Amber Mills PhD, BA(Hons)

Linkage is arduous and prone to errors

Jessica L Harding · Jonathan E Shaw · Dianna J Magliano

Guiding principles of the Council of Australian Therapeutic Advisory Groups should inform off-label prescribing

Madlen Gazarian · Steve Morris

Australian researchers are proving the usefulness of data linkage, but their access to data is hindered

Ian N Olver MB BS, MD, PhD

Through our language, we are unthinkingly privileging doctors’ views over those of parents

Rosalind J McDougall BSc/BA(Hons), BPhil, PhD · Lynn Gillam BA(Hons), MA, PhD

Government should take the lead in trialling and evaluating new strategies for tackling disease prevention

Roger S Magnusson

Government should take the lead in trialling and evaluating new strategies for tackling disease prevention

Jane M Young · David Currow · Sally Dunlop

How should we treat patients who may lack the capacity to decide in their own best interests?

Joanne F Bradbury BNat(Hons), BA(Psych), PhD · Matt Ireland BA(Psych)(Hons) · Helen Stasa BA(Hons), PhD

How should we treat patients who may lack the capacity to decide in their own best interests?

Kerri Eagle LLB(Hons), LLM, FRANZCP · Christopher J Ryan MB BS, MHL, FRANZCP

Universal advance care directives may not solve the current problems surrounding end-of-life discussions

Adrian M J Pokorny BMed

Waiving the requirement for participant consent in low-risk research may provide important community benefits

Ian N Olver MD, PhD, FRACP

Is the researcher held to a higher standard than the clinician?

Ian A Harris MB BS, MMed(ClinEpi), PhD · Justine M Naylor BAppSc(Phty), PhD

Doctors may be liable for failing to diagnose atypical presentations of melanoma

Melody R Abikhair MB BS(Hons) · Patrick D Mahar MB BS(Hons), LLB(Hons), MBA · Adrian R Cachia FRCPA, LLB(Hons), FACLM · John W Kelly MB BS, MD, FACD