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Objective: To measure compliance with Advance Care Directives (ACDs) for decedents in a rural setting. Design: Observational, cross‐sectional medical records audit comparing requests in ACDs with actual outcomes. Setting: Rural Australian coastal district. Participants: People who had an ACD, died during the study period (30 May 2020 to 15 December 2021) and participated in a local research project. Main Outcome Measure(s): Compliance was measured by comparing stated requests in the ACD with outcomes recorded in medical records. This included the place of death and a list of 'unacceptable interventions'. Results: Sixty‐eight people met the inclusion criteria (age range of 46–92 [mean 67 years; median 74 years]; 42 [62%] male). The main cause of death was cancer (n = 48; 71%). Preferred place of death was not stated in 16 ACDs. Compliance with documented preferred place of death was 63% (33/52): 48% (16/33) when the preferred place of death was home; 78% (7/9) when sub‐acute was preferred; and 100% (10/10) when hospital was preferred. Compliance was 100% with 'unacceptable interventions'. Conclusion: These results demonstrate strong compliance with rural patients' requests in ACDs, particularly 'unacceptable interventions'. Home was the most common preferred place of death, but the compliance measure (48%) was the lowest in this study. This requires further exploration. [ABSTRACT FROM AUTHOR]

Existence of Advance Care Planning (ACP) documents including contact details of Medical Treatment Decision Makers (MTDM), are essential patient care records that support Emergency Department (ED) clinicians in implementing treatment concordant with patients' expressed wishes. Based upon previous findings, we conducted a statewide study to evaluate the performance of Victorian public hospital emergency departments on reporting of availability of records for ACP. The study is a quantitative retrospective observational comparative design based upon ED tier levels as defined by the Australasian College for Emergency Medicine (ACEM) for the calendar year 2021. Of 1.8 million total Victorian ED attendances, 15,222 patients had an ACP alert status recorded. Of these, 7296 were aged ≥ 65 years (study group). Of the thirty-one public EDs that submitted data, 65 % were accredited and assigned a level of service tier. The presence of ACP alerts positively correlated to location, tier level, age and gender (MANOVA wilk's; p < 0.001, value=.981, F = (12, 15,300), partial ƞ2 =.006, observed power = 1.0 = 95.919). The identified rate of ACP reporting is low. Strategies to improve the result include synchronising ACP (generated at different points) electronically, staff education, training and further validation of the data at the sending and receiving agencies. [ABSTRACT FROM AUTHOR]

Consent is a fundamental ethical and legal principle in good medical practice. A patient must have capacity to provide informed consent. There are four key principles that need to be satisfied when establishing if a patient has capacity. For consent to be valid, the patient must be made aware of all associated risks to which they would attach significance. Information provided to patients should be individualized, objective and include all reasonable alternatives. It should be made clear if a procedure is optional, for example, an analgesic regional nerve block. Questions should be encouraged and answered honestly. Patients need adequate time to consider all the information provided. The consent process should be documented but a separate signed consent form is not required for most anaesthetic interventions. Some patients may have an advance care directive or a legally appointed power of attorney and these must be respected. When a patient has not made such arrangements and does not have capacity, treatment should be provided in accordance with their best interests. This must be individualized and consider multiple factors. Specialist advice should be sought in circumstances where there is uncertainty. [ABSTRACT FROM AUTHOR]

The prevalence and factors associated with advance care planning (ACP) documents for Australian public hospital inpatients were determined through cross‐sectional study of 123 Victorian hospitals between July 2016 and December 2018. Of the 611 786 included patients, 2.9% had an ACP document. Odds increased significantly in those comorbid, unpartnered, regional and >5 admissions, which supports future ACP conversations and document creation. [ABSTRACT FROM AUTHOR]

The registered nurse has crucial preventative, therapeutic, sociocultural, and advocacy roles in promoting quality holistic patient-centred palliative care. This paper examines, describes, and analyses this multifaceted role from an antipodean perspective. We conducted systematic searches using PubMed, Google Scholar, government guidelines, authoritative body regulations, quality control guidelines, and government portals pertaining to palliative care nursing in Australia. This paper relies upon the information garnered from publications, reports, and guidelines resulting from these searches and analyses. The fundamental principles and guiding values of palliative care (and nursing) and the raison d’etre for palliative care as a discipline are underscored and expanded on. Australian Clinical Practice Guidelines (CPGs) pertaining to palliative end-of-life (EOL) nursing care and associated services are discussed. The relevant NMBA nursing standards that RNs need to have to administer opioids/narcotics in palliative care are summarised. The identification of patients who need EOL care, holistic person-centred care planning for them, and consultative multidisciplinary palliative clinical decision making are discussed in the palliative care context. Several components of advance care planning apropos health deterioration and conflicts are discussed. Several aspects of EOL care, especially palliative nursing care, are analysed using research evidence, established nursing and palliative care standards, and the Australian EOL CPGs.

The registered nurse has crucial preventative, therapeutic, sociocultural, and advocacy roles in promoting quality holistic patient-centred palliative care. This paper examines, describes, and analyses this multifaceted role from an antipodean perspective. We conducted systematic searches using PubMed, Google Scholar, government guidelines, authoritative body regulations, quality control guidelines, and government portals pertaining to palliative care nursing in Australia. This paper relies upon the information garnered from publications, reports, and guidelines resulting from these searches and analyses. The fundamental principles and guiding values of palliative care (and nursing) and the raison d'etre for palliative care as a discipline are underscored and expanded on. Australian Clinical Practice Guidelines (CPGs) pertaining to palliative end-of-life (EOL) nursing care and associated services are discussed. The relevant NMBA nursing standards that RNs need to have to administer opioids/narcotics in palliative care are summarised. The identification of patients who need EOL care, holistic person-centred care planning for them, and consultative multidisciplinary palliative clinical decision making are discussed in the palliative care context. Several components of advance care planning apropos health deterioration and conflicts are discussed. Several aspects of EOL care, especially palliative nursing care, are analysed using research evidence, established nursing and palliative care standards, and the Australian EOL CPGs. [ABSTRACT FROM AUTHOR]

Abstract 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 Background A growing body of international literature concurs that comprehensive and complex Advance Care Planning (ACP) programs involving specially qualified or trained healthcare professionals are effective in increasing documentation of Advance Care Directives (ACDs), improving compliance with patients’ wishes and satisfaction with care, and quality of care for patients and their families. Economic analyses of ACDs and ACP have been more sporadic and inconclusive. This study aimed to contribute to the evidence on resource use associated with implementation of ACP and to inform key decision-makers of the resource implications through the conduct of a cost-consequence analysis of the Normalised Advance Care Planning (NACP) trial. Methods The outcomes for the economic evaluation included the number of completed “legally binding” ACDs and the number of completed Conversation Cards (CC). The cost analysis assessed the incremental difference in resource utilisation between Usual Practice and the Intervention. Costs have been categorised into: 1) Contract staff costs; 2) Costs associated with the development of the intervention; 3) Implementation costs; 4) Intervention (delivery) costs; and 5) Research costs. Results The cost incurred for each completed ACD was A$13,980 in the hospital setting and A$1248 in the community setting. The cost incurred for each completed Conversation Card was A$7528 in the hospital setting and A$910 in the community setting. Conclusions The cost-consequence analysis does not support generalisation of the specified intervention within the hospital setting. The trial realised an estimated incremental cost per completed ACD of $1248, within the community setting. This estimate provides an additional benchmark against which decision-makers can assess the value of either 1) this approach towards the realisation of additional completed ACDs; and/or 2) the value of ACP and ACDs more broadly, when this estimate is positioned within the potential health outcomes and downstream health service implications that may arise for people with or without a completed ACD. Trial registration The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record.

Background: Although primary care is a well suited context for conducting advance care planning (ACP), there are many barriers to initiating discussions regarding future health preference and end-of-life conversations. Methods: This qualitative study conducted 30 detailed individual interviews with senior administrators, medical and nurse practitioners of a local health district, NSW Ambulance, e-Health NSW, general practitioners and practice nurses to find out about barriers to ACP in South Western Sydney. Results: Thematic analysis was conducted on the interviews. Six major themes were identified: Prevalence; Empowerment of roles and responsibilities; Lack of training/knowledge/confidence; Fragmentation of care; Patient/family readiness; and Prognostication. Half of the participants were willing to use a prognostic tool to identify when a patient was likely to be at the end of their life and provide a prompt to initiate ACP. Conclusion: In addition to addressing training and acknowledging resource constraints, these findings suggest that if a prognostic tool was validated and practical in a primary care setting, it may provide valuable assistance to encourage everyone in society to begin discussing this issue and completing ACP. Previous research indicates that ACP can facilitate care consistent with the patient's attitudes, beliefs and priorities, and reduce the chance of people receiving non-beneficial or inappropriate care at the end-of-life. This study conducted detailed individual interviews with senior administrators, medical and nurse practitioners of a local health district, and general practitioners and practice nurses to understand the barriers to conducting advance care planning in primary care. [ABSTRACT FROM AUTHOR]

Abstract Background Advance Care Planning (ACP) enables healthcare professionals to embrace the important process where patients think about their values in life and goals for health care, and discuss their future health care preferences with family members for a time when they are not able to make health care decisions. Despite the promotion of ACP last two decades, and well-known benefits of ACP and a written Advance Care Directive (ACD), they are still underutilised in Australia and across the world. Previous studies have provided some insights, however, an uptake of ACP and prevalence of ACDs in community settings is rarely reported. Methods The aim of this study was to determine the uptake of ACP and prevalence of ACDs among people with chronic diseases in hospital and community settings. A retrospective medical record audit of eligible patients looking for evidence of ACP was conducted in 16 research sites in eight hospital and eight community care settings. Participants included those who were admitted to one of the research sites, and who were aged 18 years and over with at least one of nine nominated chronic diseases. The primary outcome measures included the number of patients with evidence of ACP through the following practices: completion of an ACD, appointment of an Enduring Guardian (EG), or completion of a resuscitation plan. Results The overall prevalence of ACD was 2.8% (n = 28) out of 1006 audited records, and only 10 (1%) of them were legally binding. The number of EGs appointed was 39 (3.9%) across the sites. A total of 151 (15.4%) resuscitation plans were found across the eight hospital sites. 95% (n = 144) of the resuscitation plans indicated ‘Not-for-resuscitation’. Conclusions The uptake of ACP is very low. Current medical recording system reveals the challenges in ACP lie in the process of storage, access and execution of the ACDs. Given that having an ACD or Enduring Guardian in place is only useful if the treating physician knows how and where to access the information, it has implications for policy, information system, and healthcare professionals’ education. Trial registration The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx

As the population ages, so does the prevalence of dementia, a condition in which timely advance care planning (ACP) is recommended. This study explored the barriers and enablers of ACP for Australian GPs caring for people with dementia. Semi-structured qualitative telephone interviews informed by the theoretical domains framework (TDF) were conducted with 16 GPs from the south-east region of metropolitan Melbourne. The most prevalent domains of the TDF were: (1) environmental context and resources; (2) beliefs about consequences; and (3) social/professional role and identity. Further thematic analysis found that: (1) ACP was felt to be within the scope of general practice, but more so before the onset of dementia because lack of confidence in capacity assessment acted as a barrier once a diagnosis was made; (2) beliefs about the perceived benefits of ACP motivated GPs to engage patients in ACP; and (3) doctors felt that patients were often reluctant to discuss ACP, especially in the time-pressured context of the standard consultation. This study's use of the TDF provides direction for potential interventions to alleviate challenges faced by Australian GPs with ACP in dementia. Improving ACP in general practice may require a focus on public health campaigns to educate patients about the benefits of ACP before the onset of dementia. GPs' difficulty assessing a patient's decisional capacity may be addressed through skills development workshops. Advance care planning (ACP) leads to better outcomes for patients and is particularly relevant for people with dementia who eventually lose the capacity to take part in their own medical treatment planning. This study found that GPs see themselves as having an important role in ACP for those with dementia, but are hindered by barriers at the patient, practitioner and system level. The results of this study have implications for improving the quality of care for patients with dementia by increasing the uptake of ACP. [ABSTRACT FROM AUTHOR]

Little is known about advance care planning among young adults with congenital heart defects (CHD). Congenital Heart Survey to Recognize Outcomes, Needs, and well-beinG (CH STRONG) participants were born with CHD between 1980 and 1997, identified using active, population-based birth defects surveillance systems in Arkansas, Arizona and Atlanta, and Georgia, and surveyed during 2016–2019. We estimated the percent having an advance care directive standardized to the site, year of birth, sex, maternal race, and CHD severity of the 9312 CH STRONG-eligible individuals. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for characteristics associated with having advance care directives. Of 1541 respondents, 34.1% had severe CHD, 54.1% were female, and 69.6% were non-Hispanic white. After standardization, 7.3% had an advance care directive (range: 2.5% among non-Hispanic blacks to 17.4% among individuals with "poor" perceived health). Individuals with severe CHD (10.5%, aOR = 1.6, 95% CI: 1.1–2.3), with public insurance (13.1%, aOR = 1.7, 95% CI: 1.1–2.7), with non-cardiac congenital anomalies (11.1%, aOR = 1.9, 95% CI: 1.3–2.7), and who were hospitalized in the past year (13.3%, aOR = 1.8, 95% CI: 1.1–2.8) were more likely than their counterparts to have advance care directives. Individuals aged 19–24 years (6.6%, aOR = 0.4, 95% CI: 0.3–0.7) and 25–30 years (7.6%, aOR = 0.5, 95% CI: 0.3–0.8), compared to 31–38 years (14.3%), and non-Hispanic blacks (2.5%), compared to non-Hispanic whites (9.5%, aOR = 0.2, 95% CI: 0.1–0.6), were less likely to have advance care directives. Few young adults with CHD had advance care directives. Disparities in advance care planning may exist. [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]

Background: A growing body of international literature concurs that comprehensive and complex Advance Care Planning (ACP) programs involving specially qualified or trained healthcare professionals are effective in increasing documentation of Advance Care Directives (ACDs), improving compliance with patients' wishes and satisfaction with care, and quality of care for patients and their families. Economic analyses of ACDs and ACP have been more sporadic and inconclusive. This study aimed to contribute to the evidence on resource use associated with implementation of ACP and to inform key decision-makers of the resource implications through the conduct of a cost-consequence analysis of the Normalised Advance Care Planning (NACP) trial.Methods: The outcomes for the economic evaluation included the number of completed "legally binding" ACDs and the number of completed Conversation Cards (CC). The cost analysis assessed the incremental difference in resource utilisation between Usual Practice and the Intervention. Costs have been categorised into: 1) Contract staff costs; 2) Costs associated with the development of the intervention; 3) Implementation costs; 4) Intervention (delivery) costs; and 5) Research costs.Results: The cost incurred for each completed ACD was A$13,980 in the hospital setting and A$1248 in the community setting. The cost incurred for each completed Conversation Card was A$7528 in the hospital setting and A$910 in the community setting.Conclusions: The cost-consequence analysis does not support generalisation of the specified intervention within the hospital setting. The trial realised an estimated incremental cost per completed ACD of $1248, within the community setting. This estimate provides an additional benchmark against which decision-makers can assess the value of either 1) this approach towards the realisation of additional completed ACDs; and/or 2) the value of ACP and ACDs more broadly, when this estimate is positioned within the potential health outcomes and downstream health service implications that may arise for people with or without a completed ACD.Trial Registration: The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record. [ABSTRACT FROM AUTHOR]

Purpose: To explore advance care planning (ACP) awareness, experiences, and preferences of people with cancer and support people of someone with cancer, in Australia.Methods: Descriptive analysis and independent group t tests were used to examine data from a national, online cross-sectional survey.Results: Of 705 respondents (440 people with cancer, 265 support people), 48.5% of participants had heard of ACP prior to the survey and 65% had discussed their values or preferences with someone. Significantly more people aged under 65 years had discussed their preferences than their older counterparts. Most (93%) discussions occurred with family or friends, but only 3.7% occurred with a health professional. A total of 33% had documented their preferences, with support people, women, and people aged under 65 years significantly more likely to have signed a legal document appointing someone to make medical decisions on their behalf. Views varied about the preferred timing of ACP and end-of-life care discussions (38.3% when cancer is incurable compared to 20% at diagnosis). Only 3.0% did not want to discuss ACP at all. Topics discussed were significantly different based on cohort, gender, age group, treatment status, and region.Conclusion: Despite increasing community awareness of ACP, understanding remains low amongst cancer patients and support people, who generally rely on discussions with family and friends rather than health professionals. ACP should be introduced early across multiple interactions with health professionals, discuss a broad range of ACP relevant topics, and involve the cancer patient and their support person. [ABSTRACT FROM AUTHOR]

Objective: Substitute decision makers (SDMs) can be required to make difficult health care decisions on behalf of individuals lacking decision-making capacity. Online resources may be helpful in preparing and supporting SDMs. This study systematically explored the frequency, content and usability of Australian online resources containing health care substitute decision-making content written for consumers. Methods: In April 2019, Google searches were conducted to identify online resources containing health care substitute decision-making content for consumers. Analysis comprised mapping resource characteristics, including target audience (individual-specific, SDM-specific, mixed) and thematic analysis of content. Usability was assessed using the Patient Education Materials Assessment Tool (PEMAT). Results: Of the 61 resources identified, the most frequent were webpages (57%), individual-specific (43%) and those produced by government organisations (31%). Only 15 resources (24%) were written for SDMs. Content themes identified were: defining the scope of the SDM role (93%); recommended traits or characteristics of SDMs (80%); instructions or principles regarding standards for decision making (75%); duties of SDMs (70%); and supports (46%), rights (16%), barriers (8%) and benefits (5%) for SDMs. The median (interquartile range) PEMAT scores (out of 100) were 66 (27) for understandability and 60 (55) for actionability. Conclusions: SDMs have a vital role in making decisions for people lacking decision-making capacity. Online resources are a potential source of information and support for SDMs in Australia. This study identified key gaps in availability, content and usability of existing SDM resources, highlighting the need for the further development of such resources. We suggest that future resource development include SDMs in the design and evaluation processes. What is known about the topic?: An aging population and a greater need for decisions to be made on behalf of others who lack capacity means that health care substitute decision-making is occurring more frequently. Appointing one or more SDMs may occur as part of the advance care planning process. However, being a healthcare SDM can be difficult and stressful. People frequently use the Internet to search for health-related information. What does this paper add?: This paper systematically examined the frequency, content and usability of existing Australian online resources with substitute decision-making content written for a consumer audience in English, and identified key gaps in online resources available to support SDMs. What are the implications for practitioners?: Although there is a need for resources written for SDMs, authors of online resources need to pay careful attention to the purpose, content and usability of their resource. Future resource development should include input from SDMs and involve them in evaluation to assess whether the resources meet target audience needs. [ABSTRACT FROM AUTHOR]

Background: Advance Care Planning (ACP) enables healthcare professionals to embrace the important process where patients think about their values in life and goals for health care, and discuss their future health care preferences with family members for a time when they are not able to make health care decisions. Despite the promotion of ACP last two decades, and well-known benefits of ACP and a written Advance Care Directive (ACD), they are still underutilised in Australia and across the world. Previous studies have provided some insights, however, an uptake of ACP and prevalence of ACDs in community settings is rarely reported.Methods: The aim of this study was to determine the uptake of ACP and prevalence of ACDs among people with chronic diseases in hospital and community settings. A retrospective medical record audit of eligible patients looking for evidence of ACP was conducted in 16 research sites in eight hospital and eight community care settings. Participants included those who were admitted to one of the research sites, and who were aged 18 years and over with at least one of nine nominated chronic diseases. The primary outcome measures included the number of patients with evidence of ACP through the following practices: completion of an ACD, appointment of an Enduring Guardian (EG), or completion of a resuscitation plan.Results: The overall prevalence of ACD was 2.8% (n = 28) out of 1006 audited records, and only 10 (1%) of them were legally binding. The number of EGs appointed was 39 (3.9%) across the sites. A total of 151 (15.4%) resuscitation plans were found across the eight hospital sites. 95% (n = 144) of the resuscitation plans indicated 'Not-for-resuscitation'.Conclusions: The uptake of ACP is very low. Current medical recording system reveals the challenges in ACP lie in the process of storage, access and execution of the ACDs. Given that having an ACD or Enduring Guardian in place is only useful if the treating physician knows how and where to access the information, it has implications for policy, information system, and healthcare professionals' education.Trial Registration: The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx. [ABSTRACT FROM AUTHOR]

Objectives This study explored associations between birth region, sociodemographic predictors, and advance care planning (ACP) uptake. Methods A prospective, multicenter, cross-sectional audit study of 100 sites across 8 Australian jurisdictions. ACP documentation was audited in the health records of people aged 65 years or older accessing general practice (GP), hospital, and long-term care facility (LTCF) settings. Advance care directives (ACDs) completed by the person ("person completed ACDs") and ACP documents completed by a health professional or other person ("health professional or someone else ACP") were counted. Hierarchical multilevel logistic regression assessed associations with birth region. Results From 4,187 audited records, 30.0% (1,152/3,839) were born outside Australia. "Person completed ACDs" were less common among those born outside Australia (21.9% vs 28.9%, X 2 (1, N = 3,840) = 20.3, p <.001), while "health professional or someone else ACP" was more common among those born outside Australia (46.4% vs 34.8%, X 2 (1, N = 3,840) = 45.5, p <.001). Strongest associations were found for those born in Southern Europe: "person completed ACD" (odds ratio [OR] = 0.56, 95% confidence interval [CI] = 0.36–0.88), and "health professional or someone else ACP" (OR = 1.41, 95% CI = 1.01–1.98). English-language proficiency and increased age significantly predicted both ACP outcomes. Discussion Region of birth is associated with the rate and type of ACP uptake for some older Australians. Approaches to ACP should facilitate access to interpreters and be sensitive to diverse preferences for individual and family involvement in ACP. [ABSTRACT FROM AUTHOR]

Emergency departments routinely offer cardiopulmonary resuscitation and endotracheal intubation to patients in resuscitative states. With increasing longevity and prevalence of chronic conditions in Australia, there has been growing need to uptake and implement advance care directives and resuscitation plans. This study investigates the frequency of the presence of advance care directives and resuscitation plans and its utilisation in cardiopulmonary and endotracheal intubation decision making. Retrospective audit of electronic patients' medical records aged ≥65 years presenting over a 3-month period. Data collected included demographics, triage categories, advance care directive and/or resuscitation plans/orders status. A total of 6439 patients were included representing 29% of the total patient population during the study period. Participants were randomly selected (N = 300); mean age was 78.7 (±8.1) years. An advance care directive was present in only 8% and one in three patients (37%) had a previous resuscitation plan/order. Senior consultant was present at the department for consultation by junior doctors for most of the patients (82%). Acknowledgment of either advance care directive or resuscitation plans/orders in clinical notes was only 9.5% (n = 116). Advance care directive prevalence was low with resuscitation plans/orders being more common. However, clinician acknowledgement was infrequent for both. [ABSTRACT FROM AUTHOR]

Context: Advance care planning (ACP) documentation needs to be available at the point of care to guide and inform medical treatment decision-making.Objective: To examine concordance between self-reported completion of ACP documentation and self-reported storage of the documentation at the person's current point of care with the availability of the documentation in that person's health record.Methods: A national multicenter audit of health records and a self-report survey of eligible audit participants in 51 Australian health and residential aged care services. The audit assessed availability of ACP documentation in the health record, whereas the survey assessed self-reported completion and storage of the ACP documentation at the person's current place of care. To ascertain concordance, survey and audit data were cross-tabulated and concordance rates and kappa statistics were calculated overall and by health care sector and ACP documentation type.Results: The audit included 2285 people, of whom 1082 were eligible for the survey. Of 507 who completed the survey (response rate = 47%), 272 (54%) reported completing ACP documentation, of whom 130 (48%) had documentation identified in the audit. Conversely, 39 of 235 people (17%) who reported not completing ACP documentation had documentation identified (concordance rate = 64%; κ = 0.303, P < .001). The concordance rate increased to 79% when self-reported storage of ACP documentation at the person's current point of care was compared with the existence of the document in their health record (κ = 0.510, P < .001). Concordance varied by health care setting and type of ACP documentation.Conclusion: Discrepancies exist between self-reported completion of ACP documentation and the presence of these documents in the health records of older adults, representing a significant patient safety issue. Public education campaigns and improvements to systems for document storage and accessibility are required to support person-centered medical and end-of-life care. [ABSTRACT FROM AUTHOR]

Objective: To examine the views and experiences of patients and their health care providers on developing advance care planning (ACP) and advance care directives (ACD); and determine barriers and facilitators to ACD development, storage, and use, including implications for people with communication disability.Method: An integrative review of 93 studies, analysed according to their content themes.Results: Content themes encapsulated the initiation, documentation, and implementation stages of ACP/ACD. Lack of guidance for initiating and supporting ACP/ACD impedes discussions, and both patients and healthcare providers avoid discussions owing to fear of dying and reluctance to think about end-of-life.Conclusions: There are several barriers and facilitators to the initiation of ACP discussions, documentation and implementation of ACD, and little research exploring the views of legal professionals on the development, storage, or use of ACP documents. Further research is needed to explore the timing and responsibility of both legal and health professionals in initiating and supporting ACP discussions.Practice Implications: It is important for healthcare providers to raise ACP discussions regularly so that patients have time to make informed advance care decisions. Storage of the document in an electronic health record might facilitate better access to and implementation of patients' end-of-life care decisions. [ABSTRACT FROM AUTHOR]

The need for appropriate mechanisms guiding end-of-life care is increasingly vital. This commentary compares the use of Advance Care Directives (ACD) in New South Wales and South Australia in order to highlight the inconsistency in Australian legislation, before exploring common problems, legal concerns and ethical issues associated with their application in an adult population. The benefits and detriments of statutory legislation for ACD are also evaluated. [ABSTRACT FROM AUTHOR]

Do-not-resuscitate (DNR) orders are necessary if resuscitation, the default option in hospitals, should be avoided because a patient is known to be dying and attempted resuscitation would be inappropriate. To avoid inappropriate resuscitation at night, if no DNR order has been recorded, after-hours medical staff are often asked to have a DNR discussion with patients whose condition is deteriorating, but with whom they are unfamiliar. Participants in two qualitative studies of cancer patients' views on how to present DNR discussions recognized that such patients are at different stages of understanding of their situation and may not be ready for a DNR discussion; therefore, a one-policy-fits-all approach was thought to be inappropriate. To formulate a policy that incorporates the patient's views, we propose that a standard form which mandates a DNR discussion is replaced by a "blank sheet" with instructions to record the progress of the discussion with the patient, and a medical recommendation for a DNR decision to guide the nursing staff in case of a cardiac arrest. Such an advance care directive would have to honor specifically expressed patient or guardian wishes whilst allowing for flexibility, yet would direct nurses or other staff so that they can avoid inappropriate cardiopulmonary resuscitation of a patient dying of cancer. [ABSTRACT FROM AUTHOR]

An advance care directive is a person's oral or written instructions about his or her future medical care, if he or she becomes unable to communicate. It may be in written or oral form. Africans ordinarily do not encourage the contemplation of death or any discussion about their own or their loved ones' death. According to the African belief system, life does not end with death, but continues in another realm. Becoming an ancestor after death is a desirable goal of every individual, a feat which cannot be achieved if an individual asks for an unnatural death by attempting to utilize advance care directives. Advance care directives are considered to be too individualistic for communitarian societies such as Africa. Coupled with the communitarian nature of African societies are issues such as lack of awareness of advance directives, fear of death and grief, and the African cultural belief system, which are potential barriers to the utilization of advance care directives in the African setting. Hence, the need for culture sensitivity which makes it imperative that patient's family and loved ones are carried along as far as possible, without compromising the autonomy of the patient in question when utilizing advance care directives. [ABSTRACT FROM AUTHOR]

Objective This report will present the case of an elderly woman with rapidly declining health admitted to hospital from a nursing home. It will discuss benefits of advance care planning for residents of aged care facilities who have expressed opinions/wishes regarding their end-of-life care, and identify barriers, varying legal status, the need for documentation of discussion outcomes specifying residents' wishes, and the importance of education and expert support for nursing staff. Setting Nursing home and acute tertiary referral hospital. Subject Female resident of a nursing home, aged 97 years, with acute onset of abdominal pain and multiple co-morbidities. Primary Argument The majority of nursing home residents do not have advance care planning initiated, nor is this routinely raised by nursing staff. While wishes may be discussed with family, they may not be fully respected if undocumented. Acutely ill residents are frequently hospitalised, especially when death is imminent, and often die alone in unfamiliar surroundings, tended by strangers. Many of these admissions could be avoided with Advance Care Planning, as could the resultant medical interventions which may cause the resident acute pain and discomfort. Conclusion Advance Care Planning can lead to avoidance of non-essential hospital transfers and their inherent risks and is likely to facilitate a dignified, peaceful death in familiar surroundings for nursing home residents, averting medical interventions which may cause needless pain and prolonged suffering. [ABSTRACT FROM AUTHOR]

This research examined the quality of resuscitation decisions documented in the clinical notes of 99 older patients within 48 h of admission. Only 34 had current documentation that was frequently inconsistent and ambiguous, leaving patients at risk of receiving inappropriate and unwanted resuscitation. Clear guidelines with community input to guide the implementation and documentation of end-of-life decisions are essential. [ABSTRACT FROM AUTHOR]

Objectives: Quantify rates of awareness about, and ownership of, End-of-Life Planning (ELP) instruments. Examine whether this rate is increased by brief education during routine team care. Measure the time required by this exercise. Design: Quality Improvement Activity. Setting: General Practice on Mid-North Coast, New South Wales. Participants: Forty-two consecutive, consenting elderly patients undertaking a Home Health Assessment. Main outcome measures: This study assessed rates of ELP instruments at baseline, at 2 weeks, at 2 months and at 2 years following the provision and discussion of a fact sheet while measuring the clinicians' time required. Results: This education exercise increased the number of patients with ELP instruments from one to ten (24%). On average it took 5.6 min of nursing time and 3.9 min for the GP. Conclusions: Brief education during Home Health Assessments may empower patients to prepare for a scenario where they lost competency to make fully informed decisions. This may alleviate patient's fears about causing problems between those close to them and having treatments against their wishes. [ABSTRACT FROM AUTHOR]

Introduction: Advance care planning (ACP), an ongoing communication and planning process, aims to clarify a person's values and preferences, so these guide decision-making if the person becomes unable to make his or her own decisions. Ideally, ACP results in completion of advance care directives (ACD), documents completed by competent people outlining their values, treatment preferences and/or appointment of a substitute decision-maker (SDM). ACDs are most effective at the point of care, where they can be used to inform treatment decisions. Australian governments fund initiatives and have developed policy to increase ACD completion rates. However, little is known about the prevalence of ACDs at the point of care in Australian health services, making ACP evaluation efforts difficult. This study aims to determine the prevalence of ACDs in records of older people in Australian hospitals, aged care facilities and general practices., Methods and Analysis: This is a national multicentre cross-sectional prevalence study in selected aged care facilities, hospitals and general practices. Following a 2017 feasibility study, a new protocol incorporating key learnings was developed. Sites will be recruited via expression of interest process. Health records of people aged ≥65 years, admitted to or attending services on study day(s) will be audited by trained staff from sites. Site-level data will be collected during the expression of interest. The primary outcome is the presence of at least one ACD in the health record. Secondary outcomes include prevalence of other documented outcomes of ACP (by health practitioner(s)/family/SDM), assessment of ACD quality and content and concordance between the person's documented preferences and any medical treatment orders. Individuals and sites characteristics where ACDs are present will be explored., Ethics and Dissemination: Protocol approval by Austin Health Human Research Ethics Committee, Melbourne, Australia (reference: HREC/18/Austin/109). Results will be disseminated via peer-reviewed journals and conferences. Participating sites and jurisdictions will receive individualised reports of findings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

An advance care directive (ACD) is a written expression of a person's preferences in relation to health care, which can appoint a trusted substitute decision-maker, describe personal values, and make explicit decisions consenting to, or refusing, certain treatments. When a person with a directive refusing life-sustaining treatments attempts suicide, opinions are divided as to the degree to which health care staff are bound by such a directive. In this section, I will provide an example of a patient who presents to hospital after attempting suicide who has a valid ACD refusing life-sustaining treatment. I will then describe the legislation relevant to ACDs in Victoria, Australia and ethical arguments relating to the application of an ACD in this context. I will present a decision-making algorithm for health care staff faced with the difficult decisions arising from such a presentation.