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The current fallback position for the elderly frail nearing the end of life (less than 12 months to live) is hospitalisation. There is a reluctance to use the term 'terminally ill' for this population, resulting in overtreatment, overdiagnosis and management that is not consistent with the wishes of people. This is the major contributor to the so‐called hospital crisis, including decreased capacity of hospitals, reduced ability to conduct elective surgery, increased attendances at emergency departments and ambulance ramping. The authors recently conducted the largest randomised study, to their knowledge, attempting to inform specialist hospital medical teams about the terminally ill status of their admitted patients. This information did not influence their clinical decisions in any way. The authors discuss the reasons why this may have occurred, such as the current avoidance of discussing death and dying by society and the concentration of healthcare workers on actively managing the acute presenting problem and ignoring the underlying prognosis in the elderly frail. The authors discuss ways of improving the management of the elderly nearing the end of life, such as more detailed goals of care discussions using the concept of shared decision‐making rather than simply completing Advanced Care Decision documents. Empowering people in this way could become the most important driver of people's health care. [ABSTRACT FROM AUTHOR]

Introduction: Assisted dying (AD) has been legalised in a small but growing number of jurisdictions globally, including Canada and Australia. Early research in both countries demonstrates that, in response to access barriers, patients and caregivers take action to influence their individual experience of AD, as well as AD systems more widely. This study analyses how patients and caregivers suggest other decision‐makers in AD systems should address identified issues. Methods: We conducted semistructured, qualitative interviews with patients and caregivers seeking AD in Victoria (Australia) and three Canadian provinces (British Columbia, Ontario and Nova Scotia). Data were analysed using reflexive thematic analysis and codebook template analysis. Results: Sixty interviews were conducted with 67 participants (65 caregivers, 2 patients). In Victoria, this involved 28 interviews with 33 participants (32 caregivers, 1 patient) about 28 patient experiences. In Canada, this involved 32 interviews with 34 participants (33 caregivers, 1 patient) about 33 patient experiences. We generated six themes, corresponding to six overarching suggestions by patients and caregivers to address identified system issues: (1) improved content and dissemination of information about AD; (2) proactively develop policies and procedures about AD provision; (3) address institutional objection via top‐down action; (4) proactively develop grief resources and peer support mechanisms; (5) amend laws to address legal barriers; and (6) engage with and act on patient and caregiver feedback about experiences. Conclusion: AD systems should monitor and respond to suggestions from patients and caregivers with firsthand experience of AD systems, who are uniquely placed to identify issues and suggestions for improvement. To date, Canada has responded comparatively well to address identified issues, whereas the Victorian government has signalled there are no plans to amend laws to address identified access barriers. This may result in patients and caregivers continuing to take on the burdens of acting to address identified issues. Patient or Public Contribution: Patients and caregivers are central to this research. We interviewed patients and caregivers about their experiences of AD, and the article focuses on their suggestions for addressing identified barriers within AD systems. Patient interest groups in Australia and Canada also supported our recruitment process. [ABSTRACT FROM AUTHOR]

This article discusses the distinction between voluntary assisted dying and advance care planning in the context of end-of-life care discussions in Australia. It highlights the importance of incorporating voluntary assisted dying into advance care planning programs and practices, as it is now legal in all Australian states. The article emphasizes the need for training health practitioners to navigate discussions about voluntary assisted dying and adapt existing policies and guidelines. It also mentions the availability of resources and services to support health practitioners in these discussions. The authors stress the importance of a patient-centered approach that respects individuals' values and preferences. [Extracted from the article]

Introduction: Voluntary assisted dying (VAD) is increasingly being legalised internationally. In Australia, all six states have now passed such laws, with Victoria being the first in 2019. However, early research in Victoria on the patient experience of seeking VAD shows that finding a connection to the VAD system is challenging. This study analyses the causes of this 'point of access' barrier. Methods: We conducted semi‐structured qualitative interviews with family caregivers and a person seeking VAD, with participants recruited via social media and patient interest groups. Data were thematically analysed. We also undertook documentary analysis (content and thematic) of publicly available reports from the oversight body, the Voluntary Assisted Dying Review Board. Results: We interviewed 32 family caregivers and one patient across 28 interviews and analysed six Board reports. Finding a point of access to the VAD system was reported as challenging in both interviews and reports. Four specific barriers to connecting with the system were identified: (1) not knowing VAD exists as a legal option; (2) not recognising a person is potentially eligible for VAD; (3) not knowing next steps or not being able to achieve them in practice; and (4) challenges with patients being required to raise the topic of VAD because doctors are legally prohibited from doing so. Conclusion: Legal, policy and practice changes are needed to facilitate patients being able to find a connection to the VAD system. The legal prohibition on doctors raising the topic of VAD should be repealed, and doctors and institutions who do not wish to be involved in VAD should be required to connect patients with appropriate contacts within the system. Community awareness initiatives are needed to enhance awareness of VAD, especially given it is relatively new in Victoria. Patient or Public Contribution: Families and a patient were the focus of this research and interviews with them about the experience of seeking VAD were the primary source of data analysed. This article includes their solutions to address the identified point of access barriers. Patient interest groups also supported the recruitment of participants. [ABSTRACT FROM AUTHOR]

Objectives: To investigate barriers to and facilitators of access to voluntary assisted dying in Victoria under the Voluntary Assisted Dying Act 2017 (Vic). Design, setting, participants: Qualitative study; semi‐structured interviews with people who had applied for voluntary assisted dying or their family caregivers, recruited via social media and interested advocacy groups; interviews conducted 17 August – 26 November 2021. Main outcome measures: Barriers to and facilitators of access to voluntary assisted dying. Results: We interviewed 33 participants about 28 people who had applied for voluntary assisted dying; all but one of the interviews were with family caregivers after their relatives' deaths, and all but three were conducted via Zoom. The major barriers to access identified by participants were finding trained and willing doctors to assess eligibility for voluntary assisted dying; the time required for the application process (especially given how ill the applicants were); the prohibition of telehealth consultations; institutional objections to voluntary assisted dying; and the prohibition of health practitioners raising voluntary assisted dying with their patients. The major facilitators mentioned were care navigators (both the Statewide service and local navigators); finding a supportive coordinating practitioner; the Statewide Pharmacy Service; and system flow once the process had been initiated (although not during the early days of voluntary assisted dying in Victoria). Access was particularly difficult for people in regional areas or with neurodegenerative conditions. Conclusions: Access to voluntary assisted dying has improved in Victoria, and people generally felt supported while navigating the application process once they found a coordinating practitioner or a navigator. But this step, and other barriers, often still made patient access difficult. Adequate support for doctors, navigators and other facilitators of access is vital for the effective functioning of the overall process. [ABSTRACT FROM AUTHOR]

Despite widespread reform in Australia, the Australian Medical Association (AMA) remains ethically opposed to voluntary assisted dying (VAD). This article argues that the AMA should abandon its opposition to VAD to fulfil better its mandate of providing the best outcomes for doctors, patients and the community. A neutral stance enables peak bodies to engage more fully in implementation and support diverse perspectives. [ABSTRACT FROM AUTHOR]

Payment structure for voluntary assisted dying services Medical practitioners perceive that their VAD work is largely unremunerated, despite the significant time commitment involved.[[4]] Currently, there is no dedicated Medicare Benefits Schedule (MBS) item for VAD. Keywords: Euthanasia EN Euthanasia 8 10 3 01/17/23 20230116 NES 230116 Medical practitioners are poorly compensated for their time and services in supporting patients through the voluntary assisted dying process In six Australian states, voluntary assisted dying (VAD) is (or will be) a lawful end-of-life option for terminally ill competent adults. [Extracted from the article]

Keywords: Euthanasia EN Euthanasia 406 409 4 11/02/21 20211101 NES 211101 A Commonwealth law poses legal risks for practitioners acting under state and territory voluntary assisted dying laws November 2017 marked the start of a significant shift regarding voluntary assisted dying in Australia. Competing interests Lindy Willmott and Ben White were engaged by the Victorian and WA Governments to design and provide legislatively mandated training for doctors involved in voluntary assisted dying in those states. An alternative, although suboptimal, approach is for the Commonwealth Director of Public Prosecutions to issue guidelines barring prosecution of individuals acting lawfully under state or territory frameworks. [Extracted from the article]

Objectives: To investigate the perspectives of doctors involved with voluntary assisted dying in Victoria regarding the Voluntary Assisted Dying Act 2017 (Vic) and its operation.Design, Setting, Participants: Qualitative study; semi-structured interviews with 32 doctors who had participated in the voluntary assisted dying system during its first year of operation (commenced 19 June 2019). Doctors were interviewed during April-July 2020.Results: Three major themes related to problems during the first year of operation of the Act were identified: the statutory prohibition of health professionals initiating discussions with their patients about voluntary assisted dying; the Department of Health and Human Services guidance requirement that all doctor-patient, doctor-pharmacist, and pharmacist-patient interactions be face-to-face; and aspects of implementation, including problems with the voluntary assisted dying online portal, obtaining documentary evidence to establish eligibility, and inadequate resourcing of the Statewide Pharmacy Service.Conclusions: Doctors reported only limited concerns about the Victorian voluntary assisted dying legislation, but have had some problems with its operation, including implications for the accessibility of voluntary assisted dying to eligible patients. While legislative change may resolve some of these concerns, most can be ameliorated by improving the processes and systems. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The novel Coronavirus disease 2019 (COVID‐19) outbreak has led to rapid and profound changes in healthcare system delivery and society more broadly. Older adults, and those living with chronic or life‐limiting conditions, are at increased risk of experiencing severe or critical symptoms associated with COVID‐19 infection and are more likely to die. They may also experience non‐COVID‐19 related deterioration in their health status during this period. Advance care planning (ACP) is critical for this cohort, yet there is no coordinated strategy for increasing the low rates of ACP uptake in these groups, or more broadly. This paper outlines a number of key reasons why ACP is an urgent priority, and should form a part of the health system's COVID‐19 response strategy. These include reducing the need for rationing, planning for surges in healthcare demand, respecting human rights, enabling proactive care coordination and leveraging societal change. We conclude with key recommendations for policy and practice in the system‐wide implementation of ACP, to enable a more ethical, coordinated and person‐centred response in the COVID‐19 context. [ABSTRACT FROM AUTHOR]

Background: The community prevalence of advance care directives (ACD) is low despite known benefits of advance care planning for patients, families and health professionals. Aim: To determine the community prevalence of instructional and appointing ACD in New South Wales, Victoria and Queensland and factors associated with completion of these documents. Methods: A telephone survey of adults living in New South Wales, Victoria and Queensland (n = 1175) about completion of instructional ACD (making their own decisions about future healthcare) and appointing ACD (appointing another to decide). Quota sampling occurred based on population size by state, gender and age, with oversampling in smaller jurisdictions (Victoria and Queensland). Results: Overall response rate was 33%. Six per cent of respondents reported completing an instructional ACD while 12% reported completing an appointing ACD. Female gender, higher educational level, personal experience of a major health scare and being widowed were significant predictors of completing an instructional ACD. Older age, higher educational level and being widowed were significant predictors of completing an appointing ACD. Conclusions: Despite long‐standing efforts to increase advance care planning, community prevalence of ACD remains low, particularly for instructional ACD. This study found some different predictors for instructional ACD compared with appointing ACD, and also a potential role for experiential factors in triggering uptake. These findings suggest supplementing general community awareness campaigns with more nuanced and targeted efforts to improve ACD completion. [ABSTRACT FROM AUTHOR]

Arguably, deciding the timing and manner of one's death is the biggest decision of all. With the Victorian Voluntary Assisted Dying Act 2017 commencing in 2019, assessing capacity to choose Voluntary Assisted Dying (VAD) becomes a critical issue for clinicians in Victoria, and elsewhere with on‐going efforts to change the law across Australia and in New Zealand. We consider how capacity assessment and undue influence screening can be approached for VAD, the role and risks of supported decision‐making, and argue for the importance of training to ensure health care professionals are educated about their role. [ABSTRACT FROM AUTHOR]

Keywords: Legislation; medical; Suicide; assisted EN Legislation medical; Suicide assisted 47 47 1 01/17/23 20230116 NES 230116 Open access Open access publishing facilitated by The University of Sydney, as part of the Wiley - The University of Sydney agreement via the Council of Australian University Librarians. Nahm and colleagues[1] address this in their article on eligibility for Australia's voluntary assisted dying (VAD) laws.[1] However, in our opinion, the authors misinterpreted the relevant provisions, risking reduced access for eligible patients. Such an interpretation could, in practice, convert the 6 months test to 2 months for some patients, with the risk of narrowing access to VAD for patients the Parliament intended to be eligible. [Extracted from the article]

The article presents a study which aims to examine the knowledge level of doctors on withholding and withdrawing the life-sustaining medical treatment. The study uses a postal survey on all specialists in the field of emergency medicine, geriatric medicine, and medical oncology. Result shows that there is a significant knowledge gap on the law governing the withdrawal of life-sustaining treatment on adult patients with poor decision making capacity.

2 Willmott L, White B, Sellars M, Yates P. Participating doctors' perspectives on the regulation of voluntary assisted dying in Victoria: a qualitative study. Keywords: Euthanasia; Legislation; medical EN Euthanasia; Legislation medical 209 209 1 03/11/22 20220301 NES 220301 Acknowledgements We received a small amount of funding from the Queensland University of Technology to prepare the original manuscript (to which a letter to the editor and this response relate). [Extracted from the article]

The article focuses on the legal jurisprudence about withholding and withdrawing life-sustaining treatment decisions for adults who lack capacity in Australia. Overview of the six key themes upheld by the Supreme Court about life-sustaining treatment decisions is provided. Discussion of the court's consideration on the patient and family wishes, which also depend on the views of the medical practitioners, is offered.

Keywords: Disaster medicine; COVID-19; Infectious diseases; Respiratory tract infections EN Disaster medicine COVID-19 Infectious diseases Respiratory tract infections 71 71 1 07/29/21 20210715 NES 210715 A lack of clear protocols elevates risks for clinicians for the consequences of decisions that they have a professional duty to make in the interests of their community Clinicians, ethicists and lawyers have long debated the parameters of triage in response to the inevitable disasters that sporadically overwhelm the health care system. These issues have significant implications for clinicians: Absent a COVID-19 triage policy, not providing beneficial life-sustaining treatment is potentially risky because it may be harder to establish the professional practice defence in a negligence action. Disaster medicine, COVID-19, Infectious diseases, Respiratory tract infections Overseas, some governments have enacted immunity or indemnity laws to protect clinicians making COVID-19 triage decisions.14,15 No such laws exist in Australia, and they do not appear to have been considered. [Extracted from the article]

If a person dies at the time they have been prescribed appropriate doses of medicines (including opioids), they may feel they have promoted that person's death. But for all doctors providing end-of-life care, there should not be the risk of undertreatment and providing less than effective palliative care because of concerns about legal sanctions. Opioid-related disorders, Medicolegal, Euthanasia. [Extracted from the article]

Practitioner administration by a doctor is permitted only if the patient "has lost the physical capacity to self-administer or digest" the medication (section 53, VAD Act). The legislation also does not allow a doctor to assist a patient to die who has unsuccessfully attempted self-administration; for example, when a patient vomits the medication. In the Netherlands, while both euthanasia (practitioner-assisted) and assisted suicide (self-administration) is permitted, the incidence of self-administration is very low. Relatives' perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands. [Extracted from the article]

The article discusses the concerns of medical practitioners in Australia regarding potential litigation for the use of opioids in end of life care. Topics include the National Pain Strategy's emphasis on the importance of a multimodal approach to chronic pain due to differences between using opioids to treat chronic pain and in end of life care, concerns regarding the similarities between palliative care and assisted suicide, and the challenge for medical personnel to avoid suffering and hastening death.

The article focuses on the implementation of the Voluntary Assisted Dying Act 2017 in Victoria for encouraging the residents to be eligible for decision-making.

The article summarizes the case of patient June Woo of Queensland who died of hyperkalaemia and the findings of a coronial inquest. The family of Woo did not accept the cause of her death and referred the case to the Brisbane Coroner for investigation. The coroner cites several areas of concern relating to the process of making the not-for-resuscitation (NFR) order. An overview of the Guardianship and Administration Act 2000 (GAA) and the Powers of Attorney Act 1998 is provided.

Objective: To investigate how doctors define and use the terms "futility" and "futile treatment" in end-of-life care.Design, Setting, Participants: A qualitative study using semi-structured interviews with 96 doctors from a range of specialties which treat adults at the end of life. Doctors were recruited from three large Brisbane teaching hospitals and were interviewed between May and July 2013.Results: Doctors' conceptions of futility focused on the quality and prospect of patient benefit. Aspects of benefit included physiological effect, weighing benefits and burdens, and quantity and quality of life. Quality and length of life were linked, but many doctors discussed instances in which benefit was determined by quality of life alone. Most described assessing the prospects of achieving patient benefit as a subjective exercise. Despite a broad conceptual consensus about what futility means, doctors noted variability in how the concept was applied in clinical decision making. More than half the doctors also identified treatment that is futile but nevertheless justified, such as short term treatment that supports the family of a dying person.Conclusions: There is an overwhelming preference for a qualitative approach to assessing futility, which inevitably involves variability in clinical decision making. Patient benefit is at the heart of doctors' definitions of futility. Determining patient benefit requires discussing with patients and their families their values and goals as well as the burdens and benefits of further treatment. [ABSTRACT FROM AUTHOR]

A response from the author of an article on the medicolegal complexities of withholding and withdrawing medical treatment in end-of-life settings is presented.