Withholding and withdrawing life-sustaining treatment : criminal responsibility for established medical practice?

The law recognises the right of a competent adult to refuse medical treatment even if this will lead to death. Guardianship and other legislation also facilitates the making of decisions to withhold or withdraw life-sustaining treatment in certain circumstances. Despite this apparent endorsement that such decisions can be lawful, doubts have been raised in Queensland about whether decisions to withhold or withdraw life-sustaining treatment would contravene the criminal law, and particularly the duty imposed by the Criminal Code (Qld) to provide the “necessaries of life”. This article considers this tension in the law and examines various arguments that might allow for such decisions to be made lawfully. It ultimately concludes, however, that criminal responsibility may still arise and so reform is needed.

Identification of alcohol involvement in injury-related hospitalisations using routine data compared to medical record review

Objective: To quantify the extent to which alcohol related injuries are adequately identified in hospitalisation data using ICD-10-AM codes indicative of alcohol involvement. Method: A random sample of 4373 injury-related hospital separations from 1 July 2002 to 30 June 2004 were obtained from a stratified random sample of 50 hospitals across 4 states in Australia. From this sample, cases were identified as involving alcohol if they contained an ICD-10-AM diagnosis or external cause code referring to alcohol, or if the text description extracted from the medical records mentioned alcohol involvement. Results: Overall, identification of alcohol involvement using ICD codes detected 38% of the alcohol-related sample, whilst almost 94% of alcohol-related cases were identified through a search of the text extracted from the medical records. The resultant estimate of alcohol involvement in injury-related hospitalisations in this sample was 10%. Emergency department records were the most likely to identify whether the injury was alcohol-related with almost three-quarters of alcohol-related cases mentioning alcohol in the text abstracted from these records. Conclusions and Implications: The current best estimates of the frequency of hospital admissions where alcohol is involved prior to the injury underestimate the burden by around 62%. This is a substantial underestimate that has major implications for public policy, and highlights the need for further work on improving the quality and completeness of routine administrative data sources for identification of alcohol-related injuries.

Lifting the lifegiving dollar : case samples of creative practice in health and medical research philanthropy

This study aims to stimulate thought, debate and action for change on this question of more vigorous philanthropic funding of Australian health and medical research (HMR). It sharpens the argument with some facts and ideas about HMR funding from overseas sources. It also reports informed opinions from those working, giving and innovating in this area. It pinpoints the range of attitudes to HMR giving, both positive and negative. The study includes some aspects of Government funding as part of the equation, viewing Government as major HMR givers, with particular ability to partner, leverage and create incentives. Stimulating new philanthropy takes active outreach. The opportunity to build more dialogue between the HMR industry and the wider community is timely given the ‘licence to practice’ issues and questioned trust that applies currently somewhat both to science and to the charitable sector. This interest in improving HMR philanthropy also coincides with the launch last year by the Federal Government of Nonprofit Australia Limited (NAL), a group currently assessing infrastructure improvements to the charitable sector. History suggests no one will create this change if Research Australia does not. However, interest in change exists in various quarters. For Research Australia to successfully change the culture of Australian HMR giving, the process will drive the outcomes. Obviously stakeholder buy-in and partners will be needed and the ultimate blueprint for greater philanthropic HMR funding here will not be this document. Instead it will be the one that wears the handprint and ‘mindprint’ of the many architects and implementers interested in promoting HMR philanthropy, from philanthropists to nonprofit peaks to government policy arms. As the African proverb says, ‘If you want to go fast, go alone; but if you want to go far, go with others’.

QUT Medical Engineering Research Facility (MERF) annual report 2009

DIRECTOR’S OVERVIEW by Professor Mark Pearcy This report for 2009 is the first full year report for MERF. The development of our activities in 2009 has been remarkable and is testament to the commitment of the staff to the vision of MERF as a premier training and research facility. From the beginnings in 2003, when a need was identified for the provision of specialist research and training facilities to enable close collaboration between researchers and clinicians, to the realisation of the vision in 2009 has been an amazing journey. However, we have learnt that there is much more that can be achieved and the emphasis will be on working with the university, government and external partners to realise the full potential of MERF by further development of the Facility. In 2009 we conducted 28 workshops in the Anatomical and Surgical Skills Laboratory providing training for surgeons in the latest techniques. This was an excellent achievement for the first full year as our reputation for delivering first class facilities and support grows. The highlight, perhaps, was a course run via our video link by a surgeon in the USA directing the participants in MERF. In addition, we have continued to run a small number of workshops in the operating theatre and this promises to be an avenue that will be of growing interest. Final approval was granted for the QUT Body Bequest Program late in 2009 following the granting of an Anatomical Accepting Licence. This will enable us to expand our capabilities by provide better material for the workshops. The QUT Body Bequest Program will be launched early in 2010. The Biological Research Facility (BRF) conducted over 270 procedures in 2009. This is a wonderful achievement considering less then 40 were performed in 2008. The staff of the BRF worked very hard to improve the state of the old animal house and this resulted in approval for expanded use by the ethics committees of both QUT and the University of Queensland. An external agency conducted an Occupational Health and Safety Audit of MERF in 2009. While there were a number of small issues that require attention, the auditor congratulated the staff of MERF on achieving a good result, particularly for such an early stage in the development of MERF. The journey from commissioning of MERF in 2008 to the full implementation of its activities in 2009 has demonstrated the potential of this facility and 2010 will be an exciting year as its activities are recognised and further expanded building development is pursued.

Withholding and withdrawing life-sustaining medical treatment

• At common law, a competent adult can refuse life-sustaining medical treatment, either contemporaneously or through an advance directive which will operate at a later time when the adult’s capacity is lost. • Legislation in most Australian jurisdictions also provides for a competent adult to complete an advance directive that refuses life-sustaining medical treatment. • At common law, a court exercising its parens patriae jurisdiction can consent to, or authorise, the withdrawal or withholding of life-sustaining medical treatment from an adult or child who lacks capacity if that is in the best interests of the person. A court may also declare that the withholding or withdrawal of treatment is lawful. • Guardianship legislation in most jurisdictions allows a substitute decision-maker, in an appropriate case, to refuse life-sustaining medical treatment for an adult who lacks capacity. • In terms of children, a parent may refuse life-sustaining medical treatment for his or her child if it is in the child’s best interests. • While a refusal of life-sustaining medical treatment by a competent child may be valid, this decision can be overturned by a court. • At common law and generally under guardianship statutes, demand for futile treatment need not be complied with by doctors.

Evaluation of distributed control signaling protocols in GMPLS

GMPLS is a generalized form of MPLS (MultiProtocol Label Switching). MPLS is IP packet based and it uses MPLS-TE for Packet Traffic Engineering. GMPLS is extension to MPLS capabilities. It provides separation between transmission, control and management plane and network management. Control plane allows various applications like traffic engineering, service provisioning, and differentiated services. GMPLS control plane architecture includes signaling (RSVP-TE, CR-LDP) and routing (OSPF-TE, ISIS-TE) protocols. This paper provides an overview of the signaling protocols, describes their main functionalities, and provides a general evaluation of both the protocols.

IT-enhanced communication protocols for building project management

Purpose – Building project management requires real time flow of information between all the project team members or the supply chain members. In the present scenario, when project participants are geographically separated, adoption of Information Communication Technology (ICT) enables such effective communication. But strategic adoption of ICT requires that all the supply chain members follow the accepted methods of communication or the communication protocols. The majority of the construction organizations are small and medium enterprises (SMEs). This research, therefore, proposes to focus on developing IT-enhanced communication protocols for building project management by SMEs. Design/methodology/approach – The research adopts a sequential mixed methods approach, where data collection and analysis are conducted in both the quantitative and qualitative phases of research. Findings – The protocols are proposed as a “Strategic Model for Enhancing ICT Diffusion in Building Projects”. The framework for the model is discussed at three levels of study, i.e industry, organization, and people. Practical implications – While the research was conducted in an Indian context, the research outcome is envisaged to be widely applicable in other countries with due considerations. Originality/value – The developed framework has implications for national level bodies and academic institutions, organizations, people or project managers and is applicable at the international level after due considerations.

Securing medical research data with a rights management system

We propose a digital rights management approach for sharing electronic health records for research purposes and argue advantages of the approach. We give an outline of our implementation, discuss challenges that we faced and future directions.

An empirical study of data collection protocols for wireless sensor networks

In the past few years, numerous data collection protocols have been developed for wireless sensor networks (WSNs). However, there has been no comparison of their relative performance in realistic environments. Here we report the results of an empirical study using a Fleck3 sensor network testbed for four different data collection protocols: One phase pull Directed Diffusion (DD), Expected Number of Transmissions (ETX), ETX with explicit acknowledgment (ETX-eAck), and ETX with implicit acknowledgment (ETX-iAck). Our empirical study provides useful insights for future sensor network deployments. When the required application end-to-end reliability is not strict (e.g., 70%) and link quality is good, DD and ETX are the best options because of their simplicity and low routing overhead. Both ETX-eAck and ETX-iAck achieve more than 90% end-to-end reliability when the link quality is reasonable (less than 25% packet loss). When the link quality is good, ETX-iAck introduces significantly less routing overhead (up to 50%) than ETX-eAck. However, if the radio transceiver supports variable packet length, ETX-eAck can outperform ETX-iAck when the link quality is poor. The important message from this paper is that choice of data collection protocol should come after the operating environment is understood. This understanding must include the characteristics of the radio transceiver, and link loss statistics from a long-term (across seasons and weather variation) radio survey of the site.

Image acquisition and manipulation protocols for CT-PET fusion to improve the accuracy of gross tumour volume localisation for 3D conformal radiotherapy for lung cancer

Aims: To develop clinical protocols for acquiring PET images, performing CT-PET registration and tumour volume definition based on the PET image data, for radiotherapy for lung cancer patients and then to test these protocols with respect to levels of accuracy and reproducibility. Method: A phantom-based quality assurance study of the processes associated with using registered CT and PET scans for tumour volume definition was conducted to: (1) investigate image acquisition and manipulation techniques for registering and contouring CT and PET images in a radiotherapy treatment planning system, and (2) determine technology-based errors in the registration and contouring processes. The outcomes of the phantom image based quality assurance study were used to determine clinical protocols. Protocols were developed for (1) acquiring patient PET image data for incorporation into the 3DCRT process, particularly for ensuring that the patient is positioned in their treatment position; (2) CT-PET image registration techniques and (3) GTV definition using the PET image data. The developed clinical protocols were tested using retrospective clinical trials to assess levels of inter-user variability which may be attributed to the use of these protocols. A Siemens Somatom Open Sensation 20 slice CT scanner and a Philips Allegro stand-alone PET scanner were used to acquire the images for this research. The Philips Pinnacle3 treatment planning system was used to perform the image registration and contouring of the CT and PET images. Results: Both the attenuation-corrected and transmission images obtained from standard whole-body PET staging clinical scanning protocols were acquired and imported into the treatment planning system for the phantom-based quality assurance study. Protocols for manipulating the PET images in the treatment planning system, particularly for quantifying uptake in volumes of interest and window levels for accurate geometric visualisation were determined. The automatic registration algorithms were found to have sub-voxel levels of accuracy, with transmission scan-based CT-PET registration more accurate than emission scan-based registration of the phantom images. Respiration induced image artifacts were not found to influence registration accuracy while inadequate pre-registration over-lap of the CT and PET images was found to result in large registration errors. A threshold value based on a percentage of the maximum uptake within a volume of interest was found to accurately contour the different features of the phantom despite the lower spatial resolution of the PET images. Appropriate selection of the threshold value is dependant on target-to-background ratios and the presence of respiratory motion. The results from the phantom-based study were used to design, implement and test clinical CT-PET fusion protocols. The patient PET image acquisition protocols enabled patients to be successfully identified and positioned in their radiotherapy treatment position during the acquisition of their whole-body PET staging scan. While automatic registration techniques were found to reduce inter-user variation compared to manual techniques, there was no significant difference in the registration outcomes for transmission or emission scan-based registration of the patient images, using the protocol. Tumour volumes contoured on registered patient CT-PET images using the tested threshold values and viewing windows determined from the phantom study, demonstrated less inter-user variation for the primary tumour volume contours than those contoured using only the patient’s planning CT scans. Conclusions: The developed clinical protocols allow a patient’s whole-body PET staging scan to be incorporated, manipulated and quantified in the treatment planning process to improve the accuracy of gross tumour volume localisation in 3D conformal radiotherapy for lung cancer. Image registration protocols which factor in potential software-based errors combined with adequate user training are recommended to increase the accuracy and reproducibility of registration outcomes. A semi-automated adaptive threshold contouring technique incorporating a PET windowing protocol, accurately defines the geometric edge of a tumour volume using PET image data from a stand alone PET scanner, including 4D target volumes.