Competency and capacity : the legal and medical interface

Balancing the competing interests of autonomy and protection of individuals is an escalating challenge confronting an ageing Australian society. Legal and medical professionals are increasingly being asked to determine whether individuals are legally competent/capable to make their own testamentary and substitute decision-making, that is financial and/or personal/health care, decisions. No consistent and transparent competency/capacity assessment paradigm currently exists in Australia. Consequently, assessments are currently being undertaken on an ad hoc basis which is concerning as Australia’s population ages and issues of competency/capacity increase. The absence of nationally accepted competency/capacity assessment guidelines and supporting principles results in legal and medical professionals involved with competency/capacity assessment implementing individual processes tailored to their own abilities. Legal and medical approaches differ both between and within the professions. The terminology used also varies. The legal practitioner is concerned with whether the individual has the legal ability to make the decision. A medical practitioner assesses fluctuations in physical and mental abilities. The problem is that the terms competency and capacity are used interchangeably resulting in confusion about what is actually being assessed. The terminological and methodological differences subsequently create miscommunication and misunderstanding between the professions. Consequently, it is not necessarily a simple solution for a legal professional to seek the opinion of a medical practitioner when assessing testamentary and/or substitute decision-making competency/capacity. This research investigates the effects of the current inadequate testamentary and substitute decision-making assessment paradigm and whether there is a more satisfactory approach. This exploration is undertaken within a framework of therapeutic jurisprudence which promotes principles fundamentally important in this context. Empirical research has been undertaken to first, explore the effects of the current process with practising legal and medical professionals; and second, to determine whether miscommunication and misunderstanding actually exist between the professions such that it gives rise to a tense relationship which is not conducive to satisfactory competency/capacity assessments. The necessity of reviewing the adequacy of the existing competency/capacity assessment methodology in the testamentary and substitute decision-making domain will be demonstrated and recommendations for the development of a suitable process made.

Medical nutrition therapy and simple interventions can improve intake in patients who eat poorly in hospital

The Australasian Nutrition Care Day Survey (ANCDS) reported two-in-five patients in Australian and New Zealand hospitals consume ≤50% of the offered food. The ANCDS found a significant association between poor food intake and increased in-hospital mortality after controlling for confounders (nutritional status, age, disease type and severity)1. Evidence for the effectiveness of medical nutrition therapy (MNT) in hospital patients eating poorly is lacking. An exploratory study was conducted in respiratory, neurology and orthopaedic wards of an Australian hospital. At baseline, 24-hour food intake (0%, 25%, 50%, 75%, 100% of offered meals) was evaluated for patients hospitalised for ≥2 days and not under dietetic review. Patients consuming ≤50% of offered meals due to nutrition-impact symptoms were referred to ward dietitians for MNT with food intake re-evaluated on day-7. 184 patients were observed over four weeks. Sixty-two patients (34%) consumed ≤50% of the offered meals. Simple interventions (feeding/menu assistance, diet texture modifications) improved intake to ≥75% in 30 patients who did not require further MNT. Of the 32 patients referred for MNT, baseline and day-7 data were available for 20 patients (68±17years, 65% females, BMI: 22±5kg/m2, median energy, protein intake: 2250kJ, 25g respectively). On day-7, 17 participants (85%) demonstrated significantly higher consumption (4300kJ, 53g; p<0.01). Three participants demonstrated no improvement due to ongoing nutrition-impact symptoms. “Percentage food intake” was a quick tool to identify patients in whom simple interventions could enhance intake. MNT was associated with improved dietary intake in hospital patients. Further research is needed to establish a causal relationship.

An exploratory study to evaluate whether medical nutrition therapy can improve dietary intake in hospital patients who eat poorly

Background and aims The Australasian Nutrition Care Day Survey (ANCDS) reported two-in-five patients consume ≤50% of the offered food in Australian and New Zealand hospitals. After controlling for confounders (nutritional status, age, disease type and severity), the ANCDS also established an independent association between poor food intake and increased in-hospital mortality. This study aimed to evaluate if medical nutrition therapy (MNT) could improve dietary intake in hospital patients eating poorly. Methods An exploratory pilot study was conducted in the respiratory, neurology and orthopaedic wards of an Australian hospital. At baseline, percentage food intake (0%, 25%, 50%, 75%, and 100%) was evaluated for each main meal and snack for a 24-hour period in patients hospitalised for ≥2 days and not under dietetic review. Patients consuming ≤50% of offered meals due to nutrition-impact symptoms were referred to ward dietitians for MNT. Food intake was re-evaluated on the seventh day following recruitment (post-MNT). Results 184 patients were observed over four weeks; 32 patients were referred for MNT. Although baseline and post-MNT data for 20 participants (68±17years, 65% females) indicated a significant increase in median energy and protein intake post-MNT (3600kJ/day, 40g/day) versus baseline (2250kJ/day, 25g/day) (p<0.05), the increased intake met only 50% of dietary requirements. Persistent nutrition impact symptoms affected intake. Conclusion In this pilot study whilst dietary intake improved, it remained inadequate to meet participants’ estimated requirements due to ongoing nutrition-impact symptoms. Appropriate medical management and early enteral feeding could be a possible solution for such patients.

Encouraging, assisting, and time to eat : comparison of mealtime assistance interventions in elderly medical inpatients

BACKGROUND: The prevalence of protein-energy malnutrition in older adults is reported to be as high as 60% and is associated with poor health outcomes. Inadequate feeding assistance and mealtime interruptions may contribute to malnutrition and poor nutritional intake during hospitalisation. Despite being widely implemented in practice in the United Kingdom and increasingly in Australia, there have been few studies examining the impact of strategies such as Protected Mealtimes and dedicated feeding assistant roles on nutritional outcomes of elderly inpatients. AIMS: The aim of this research was to implement and compare three system-level interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged ≥65 years. This research also aimed to evaluate the sustainability of any changes to mealtime routines six months post-intervention and to gain an understanding of staff perceptions of the post-intervention mealtime experience. METHODS: Three mealtime assistance interventions were implemented in three medical wards at Royal Brisbane and Women's Hospital: AIN-only: Additional assistant-in-nursing (AIN) with dedicated nutrition role. PM-only: Multidisciplinary approach to meals, including Protected Mealtimes. PM+AIN: Combined intervention: AIN + multidisciplinary approach to meals. An action research approach was used to carefully design and implement the three interventions in partnership with ward staff and managers. Significant time was spent in consultation with staff throughout the implementation period to facilitate ownership of the interventions and increase likelihood of successful implementation. A pre-post design was used to compare the implementation and nutritional outcomes of each intervention to a pre-intervention group. Using the same wards, eligible participants (medical inpatients aged ≥65 years) were recruited to the preintervention group between November 2007 and March 2008 and to the intervention groups between January and June 2009. The primary nutritional outcome was daily energy and protein intake, which was determined by visually estimating plate waste at each meal and mid-meal on Day 4 of admission. Energy and protein intakes were compared between the pre and post intervention groups. Data were collected on a range of covariates (demographics, nutritional status and known risk factors for poor food intake), which allowed for multivariate analysis of the impact of the interventions on nutritional intake. The provision of mealtime assistance to participants and activities of ward staff (including mealtime interruptions) were observed in the pre-intervention and intervention groups, with staff observations repeated six months post-intervention. Focus groups were conducted with nursing and allied health staff in June 2009 to explore their attitudes and behaviours in response to the three mealtime interventions. These focus group discussions were analysed using thematic analysis. RESULTS: A total of 254 participants were recruited to the study (pre-intervention: n=115, AIN-only: n=58, PM-only: n=39, PM+AIN: n=42). Participants had a mean age of 80 years (SD 8), and 40% (n=101) were malnourished on hospital admission, 50% (n=108) had anorexia and 38% (n=97) required some assistance at mealtimes. Occasions of mealtime assistance significantly increased in all interventions (p<0.01). However, no change was seen in mealtime interruptions. No significant difference was seen in mean total energy and protein intake between the preintervention and intervention groups. However, when total kilojoule intake was compared with estimated requirements at the individual level, participants in the intervention groups were more likely to achieve adequate energy intake (OR=3.4, p=0.01), with no difference noted between interventions (p=0.29). Despite small improvements in nutritional adequacy, the majority of participants in the intervention groups (76%, n=103) had inadequate energy intakes to meet their estimated energy requirements. Patients with cognitive impairment or feeding dependency appeared to gain substantial benefit from mealtime assistance interventions. The increase in occasions of mealtime assistance by nursing staff during the intervention period was maintained six-months post-intervention. Staff focus groups highlighted the importance of clearly designating and defining mealtime responsibilities in order to provide adequate mealtime care. While the purpose of the dedicated feeding assistant was to increase levels of mealtime assistance, staff indicated that responsibility for mealtime duties may have merely shifted from nursing staff to the assistant. Implementing the multidisciplinary interventions empowered nursing staff to "protect" the mealtime from external interruptions, but further work is required to empower nurses to prioritise mealtime activities within their own work schedules. Staff reported an increase in the profile of nutritional care on all wards, with additional non-nutritional benefits noted including improved mobility and functional independence, and better identification of swallowing difficulties. IMPLICATIONS: The PhD research provides clinicians with practical strategies to immediately introduce change to deliver better mealtime care in the hospital setting, and, as such, has initiated local and state-wide roll-out of mealtime assistance programs. Improved nutritional intakes of elderly inpatients was observed; however given the modest effect size and reducing lengths of hospital stays, better nutritional outcomes may be achieved by targeting the hospital-to-home transition period. Findings from this study suggest that mealtime assistance interventions for elderly inpatients with cognitive impairment and/or functional dependency show promise.

Prevalence of depressive symptoms as elicited by Patient Health Questionnaire (PHQ-9) among medical trainees in Oman

Background Despite the increasing recognition that medical training tends to coincide with markedly high levels of stress and distress, there is a dearth of validated measures that are capable of gauging the prevalence of depressive symptoms among medical residents in the Arab/Islamic part of the world. Objective The aim of the present study is two-fold. First is to examine the diagnostic validity of the Patient Health Questionnaire (PHQ-9) using an Omani medical resident population in order to establish a cut-off point. Second is to compare gender, age, and residency level among Omani Medical residents who report current depressive symptomatology versus those who report as non-depressed according to PHQ-9 cut-off threshold. Results A total of 132 residents (42 males and 90 females) consented to participate in this study. The cut-off score of 12 on the PHQ-9 revealed a sensitivity of 80.6% and a specificity of 94.0%. The rate of depression, as elicited by PHQ-9, was 11.4%. The role of gender, age, and residency level was not significant in endorsing depression. Conclusion This study indicated that PHQ-9 is a reliable measure among this cross-cultural population. More studies employing robust methodology are needed to confirm this finding.

A preliminary study of the effects of Tai Chi and Qigong medical exercise on indicators of metabolic syndrome, glycaemic control, health-related quality of life, and psychological health in adults with elevated blood glucose

Objectives To evaluate the feasibility, acceptability and effects of a Tai Chi and Qigong exercise programme in adults with elevated blood glucose. Design, Setting, and Participants A single group pre–post feasibility trial with 11 participants (3 male and 8 female; aged 42–65 years) with elevated blood glucose. Intervention Participants attended Tai Chi and Qigong exercise training for 1 to 1.5 h, 3 times per week for 12 weeks, and were encouraged to practise the exercises at home. Main Outcome Measures Indicators of metabolic syndrome (body mass index (BMI), waist circumference, blood pressure, fasting blood glucose, triglycerides, HDL-cholesterol); glucose control (HbA1c, fasting insulin and insulin resistance (HOMA)); health-related quality of life; stress and depressive symptoms. Results There was good adherence and high acceptability. There were significant improvements in four of the seven indicators of metabolic syndrome including BMI (mean difference −1.05, p<0.001), waist circumference (−2.80 cm, p<0.05), and systolic (−11.64 mm Hg, p<0.01) and diastolic blood pressure (−9.73 mm Hg, p<0.001), as well as in HbA1c (−0.32%, p<0.01), insulin resistance (−0.53, p<0.05), stress (−2.27, p<0.05), depressive symptoms (−3.60, p<0.05), and the SF-36 mental health summary score (5.13, p<0.05) and subscales for general health (19.00, p<0.01), mental health (10.55, p<0.01) and vitality (23.18, p<0.05). Conclusions The programme was feasible and acceptable and participants showed improvements in metabolic and psychological variables. A larger controlled trial is now needed to confirm these promising preliminary results.

Mastering medical terminology online workbook

Key Features: "Aligns to Mastering Medical Terminology: Australia and New Zealand. Self-test to practise and revise combining forms, word roots, prefixes and suffixes. Crossword puzzles, anagrams and label-the-diagram exercises Also available iOS/Android app featuring audio glossary, flashcards and MCQs."--publisher website

Improving dental and medical students’ psychological health using a self-development coaching program : a pilot study

Introduction: Dental and medical students worldwide, including in Saudi Arabia, have been reported to have a high incidence of poor psychological health, such as depression, stress, anxiety, and lowlife satisfaction. Self-development coaching programs have become an increasingly popular way to improve individuals’ lives. However, few studies have evaluated the psychological effects of such programs among dental and medical students. Moreover, no studies have been conducted on self-development coaching programs in Saudi Arabia. Aims: The aim of this study was to assess the feasibility of a larger study via a pilot study and to acquire preliminary findings about the effectiveness of a self-development coaching program on psychological health among dental and medical students in Saudi Arabia. Methods: A pre-post interventional study design was used to test a self-development coaching program (How to be an Ultra-Super Student) with a sample of medical students (n=17) at Umm Al-Qura University at Saudi Arabia. The outcome measures were students’ psychological distress (depression, anxiety, and stress), life satisfaction, self-efficacy, the coach, and coaching program characteristics. Results: The study showed that there was a significant improvement in depression (p=0.04), self-efficacy (p=0.02), and satisfaction with life (p=0.04), which supported the feasibility of a large study in the future. Conclusions: The study’s findings encourage the implementation of a randomized, controlled trial study with a larger sample to further test the effectiveness of using self-development coaching programs with medical and dental students in Saudi Arabia to improve their psychological health.

Australian Medical Liability [Second Edition]

"Australian Medical Liability is a comprehensive handbook focusing on medical liability in the context of the civil liability legislation across Australia. This thoroughly revised second edition provides a detailed and in depth commentary on the elements of medical liability caselaw and legislation."--Libraries Australia

Tension between privacy and justice : ordering medical tests

Courts set guidelines for when genetic testing would be ordered - medical testing - life insurers - use of test results - confidentiality.

A 3D virtual medical imaging suite : bridging the academic-clinical training boundary

Aims The Medical Imaging Training Immersive Environment (MITIE) system is a recently developed virtual reality (VR) platform that allows students to practice a range of medical imaging techniques. The aim of this pilot study was to harvest user feedback about the educational value of the application and inform future pedagogical development. This presentation explores the use of this technology for skills training and blurring the boundaries between academic learning and clinical skills training. Background MITIE is a 3D VR environment that allows students to manipulate a patient and radiographic equipment in order to produce a VR-generated image for comparison with a gold standard. As with VR initiatives in other health disciplines (1-6) the software mimics clinical practice as much as possible and uses 3D technology to enhance immersion and realism. The software was developed by the Medical Imaging Course Team at a provider University with funding from a Health Workforce Australia “Simulated Learning Environments” grant. Methods Over 80 students undertaking the Bachelor of Medical Imaging Course were randomised to receive practical experience with either MITIE or radiographic equipment in the medical radiation laboratory. Student feedback about the educational value of the software was collected and performance with an assessed setup was measured for both groups for comparison. Ethical approval for the project was provided by the university ethics panel. Results This presentation provides qualitative analysis of student perceptions relating to satisfaction, usability and educational value as well as comparative quantitative performance data. Students reported high levels of satisfaction and both feedback and assessment results confirmed the application’s significance as a pre-clinical training tool. There was a clear emerging theme that MITIE could be a useful learning tool that students could access to consolidate their clinical learning, either during their academic timetables or their clinical placement. Conclusion Student feedback and performance data indicate that MITIE has a valuable role to play in the clinical skills training for medical imaging students both in the academic and the clinical environment. Future work will establish a framework for an appropriate supporting pedagogy that can cross the boundary between the two environments. This project was possible due to funding made available by Health Workforce Australia.

An exploratory study of staff nurses' knowledge of delirium in the medical ICU: An Asian perspective

Aim The aim of this study was to establish intensive care unit nurses’ knowledge of delirium within an acute tertiary hospital within South East Asia. Background Delirium is a common, life threatening and often preventable cause of morbidity and mortality among older patients. Undetected and untreated delirium is a catalyst to increased mortality, morbidity, functional decline and results in increased requirement for nursing care, healthcare expense and hospital length of stay. However, despite effective assessment tools to identify delirium in the acute setting, there still remains an inability of ICU nurses’ to accurately identify delirium in the critically ill patient especially that of hypoactive delirium. Method A purposive sample of 53 staff nurses from a 13-bedded medical intensive care unit within an acute tertiary teaching hospital in South East Asia were asked to participate. A 40 item 5-point Likert scale questionnaire was employed to determine the participants’ knowledge of the signs and symptoms; the risk factors and negative outcomes of delirium. Results The overall positively answered mean score was 27 (67.3%) out of a possible 40 questions. Mean scores for knowledge of signs and symptoms, risk factors and negative outcomes were 9.52 (63.5%, n = 15), 11.43 (63.5%, n = 17) and 6.0 (75%, n = 8), respectively. Conclusion Whilst the results of this study are similar to others taken from a western perspective, it appeared that the ICU nurses in this study demonstrated limited knowledge of the signs and symptoms, risk factors and negative outcomes of delirium in the critically patient. The implications for practice of this are important given the outcomes of untreated delirium.

Towards a visually enhanced medical search engine

This paper presents the prototype of an information retrieval system for medical records that utilises visualisation techniques, namely word clouds and timelines. The system simplifies and assists information seeking tasks within the medical domain. Access to patient medical information can be time consuming as it requires practitioners to review a large number of electronic medical records to find relevant information. Presenting a summary of the content of a medical document by means of a word cloud may permit information seekers to decide upon the relevance of a document to their information need in a simple and time effective manner. We extend this intuition, by mapping word clouds of electronic medical records onto a timeline, to provide temporal information to the user. This allows exploring word clouds in the context of a patient’s medical history. To enhance the presentation of word clouds, we also provide the means for calculating aggregations and differences between patient’s word clouds.

Promoting resilience and posttraumatic growth in medical professionals

Across the lifespan traumatic experiences are common with more people experiencing such events than not. Within the context of being a medical professional trauma may result from a direct experience (e.g., in a person’s personal life) but may also occur vicariously. For example, a medical professional may be traumatized during the course of their employ as they come to the aid of a trauma survivor. Although there can be long term negative sequale for trauma survivors (e.g., PTSD, depression), the majority of people who experience trauma, vicariously or otherwise, are resilient to long term effects and some people grow or develop beyond their pre-event level of functioning. Therefore, in addition to interest in antecedents and correlates of pathology, research examining the predictors and correlates of resilience and growth has gained notable attention. In this chapter the fundamental assumptions of the salutogenic theory are discussed. Salutogenisis refers to the study of the origins of health and to that end has a goal to determine factors involved in promoting and maintaining health. The chapter then goes on to describe posttraumatic growth, a term used to denote positive post-trauma changes as well as resilience including discussion of the similarities and differences between these two constructs. Ways of promoting growth and resilience in medical professionals are then identified. The chapter concludes with discussion of ways in which individuals can enhance their potential for growth and also of ways in which the organization they work for can best facilitate and promote resilience and growth in its employees.