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Background: The number of Australians dying each year is predicted to double in the next 25 years and there is an urgent need to establish sustainable models for providing high quality end-of-life care. An innovative community care model (Bupa Palliative Care Choices Program or BPCCP) was developed and piloted with the purpose of supporting patients in achieving their choices surrounding end-of-life care., Aims: This study evaluates whether BPCCP patients were more likely to die in their place of choice compared with patients receiving standard care. Additional aims were evaluating patient and carer satisfaction and insurer cost., Methods: This prospective, comparative cohort study comprises a clinical chart audit and survey of patient and carer experience., Results: More BPCCP participants preferred to die at home (53% vs 31%). A lower proportion of BPCCP patients died in acute hospitals (10% vs 19%) and more of this cohort died at home (46% vs 26%). In both cohorts, nearly 90% of patients were able to die in their preferred location. Patient and carer satisfaction with the programme was very high in the small cohort who responded to the survey. There was a decrease in average claims spend per patient enrolled in the programme during the first 12-month period of implementation compared with historical claims spend for inpatients only., Conclusions: This evaluation of an innovative community palliative care intervention indicates that the extra services available to patients support the choice of dying at home and the ability to do so while generating claims cost efficiencies., (© 2019 Royal Australasian College of Physicians.)

Cirrhosis with decompensation has a poor prognosis, high symptom burden and causes carer stress. This pilot research in one tertiary hospital found that patients with cirrhosis with decompensation were infrequently referred to specialist palliative care. Despite this, they had a heavy symptom burden, high predicted mortality, frequent unplanned readmissions, long admissions and intensive care unit admissions. Few had adequate advance care planning., (© 2019 Royal Australasian College of Physicians.)

The antibiotic optimisation imperative is now ubiquitous, with national policy frameworks in Organisation for Economic Co-operation and Development (OECD) countries incorporating the requirement for antimicrobial stewardship within healthcare services. Yet in practice, the optimisation agenda often raises complex ethical- and practice-based dilemmas. Antibiotic use at the end of life is multidimensional. It includes balancing complex issues, such as accuracy of prognostic estimates, benevolence to the individual versus the broader public health, personalised value judgement of time and quality of life and the right to treatment versus the right to die. It also occurs in an emotional context where the clinician and patient (and their family) collectively confront mortality. This provides a scenario where amplification of the already strong social and behavioural forces that drive overuse of antibiotics in many other clinical settings may occur. It therefore offers an important case for illustrating how antibiotic optimisation may be limited by social, value-based and ethical dilemmas., (© 2019 Royal Australasian College of Physicians.)

Background: There is little research and no clear guidelines for clinicians to follow when instructing patients with advanced disease about driving., Aims: To investigate current practice in providing advice to patients with advanced disease and identify areas of consensus or variation with the Australian driving guidelines., Methods: An online survey was distributed to Australian members of the Australian and New Zealand Society of Palliative Medicine. Responses were analysed using descriptive statistics., Results: The survey was distributed to 322 Australian and New Zealand Society of Palliative Medicine members and received 92 responses (29% response rate). Most respondents were aware of the driving guidelines (76%) and about half of the respondents had read the driving guidelines (55%). The majority of respondents had been asked to provide advice about driving to their patient or patient's caregiver (91%). Most respondents had asked a patient to stop driving (94%), but only 27% had reported a patient to the Driver Licensing Authority. Only 14% of respondents were in consensus with the guidelines in providing driving advice to a patient with asymptomatic brain metastases. Most doctors (64%) advise patients to refrain temporarily from driving post-short-acting oral morphine, with 4 h (36%) being the most common time period for not driving., Conclusions: This is the first survey investigating the practice of Australian doctors in assessing fitness to drive of patients with advanced disease. The survey found wide variability in practice and substantial discordance with current driving guidelines., (© 2017 Royal Australasian College of Physicians.)