Roman concept of mental capacity to make end-of-life decisions

When assessing decisional competence of patients, psychiatrists have to balance the patients' right to personal autonomy, their condition and wishes against principles of medical ethics and professional discretion. This article explores the age-old legal and ethical dilemmas posed by refusal of vital medical treatment by patients and their mental capacity to make end-of-life decisions against the background of philosophical, legal and medical approaches to these issues in the time of the Younger Pliny (c62–c113 CE). Classical Roman discourse regarding mental competency and "voluntary death" formed an important theme of the vast corpus of Greco-Roman writings, which was moulded not only by legal permissibility of suicide but also by philosophical (in modern terms, moral or ethical) considerations. Indeed, the legal and ethical issues of evaluating the acceptability of end of life decisions discussed in the Letters are as pertinent today as they were 2000 years ago. We may gain valuable insights about our own methodologies and frames of reference in this area of the law and psychiatry by examining Classical Roman approaches to evaluating acceptability of death-choices as described in Pliny's Letters and the writings of some of his peers.

Managing patient deterioration : a protocol for enhancing undergraduate nursing students’ competence through web-based simulation and feedback techniques

Aims: To describe a funded proposal for the development of an on-line evidence based educational program for the management of deteriorating patients.
Background: There are international concerns regarding the management of deteriorating patients with issues around the ‘failure to rescue’. The primary response to these issues has been the development of medical emergency teams with little focus on the education of primary first responders.
Design/Methods: A mixed methods triangulated convergent design. In this four phase proposal we plan to 1. examine nursing student team ability to manage deteriorating patients and based upon these findings 2. develop web based educational material, including interactive scenarios. This educational material will be tested and refined in the third Phase 3, prior to evaluation and dissemination in the final phase.
Conclusion: This project aims to enhance knowledge development for the management of deteriorating patients through rigorous assessment of team performance and to produce a contemporary evidence-based online training program.

General practitioners' perspectives regarding competence and confidentiality in an adolescent with suspected anorexia nervosa: legal and ethical considerations

In Victoria, Australia, the legal position regarding young people's competence to make medical treatment decisions has not been clarified in legislation, and a number of often vague common law decisions must be relied on for guidance. This situation produces a degree of uncertainty about appropriate professional practice, while also potentially impeding young people's rights claims in health care settings. With this in mind, the present research explored general practitioners' competence and confidentiality decisions regarding a 17-year-old female who presented with symptoms of an eating disorder. Questionnaires were sent to a random sample of 500 Victorian general practitioners, of whom 190 responded. After reading a case vignette, general practitioners indicated whether they would find the hypothetical patient competent and if they would maintain her confidentiality. Seventy-three per cent of respondents found the patient competent and most would have maintained confidentiality, at least initially. However, subsequent analysis of the rationales supplied for these decisions revealed a wide diversity in general practitioners' understandings and implementations of extant legal authority. This research highlights the need for general practitioners to be exposed to up-to-date and clinically relevant explanations of contemporary legal positions.

General practitioners' competence and confidentiality determinations with a minor who requests the oral contraceptive pill

The right of minors to make medical treatment decisions is an issue that is not explicitly addressed in the legislation of most Australian jurisdictions. While recent common law decisions allow competent minors to consent to treatment, current legislation in Victoria does not provide adequate guidelines on how competence is to be measured. It is also unclear whether the duty of confidentiality is extended to competent minors. The current study explored general practitioners' competence and confidentiality decisions with a hypothetical 14-year-old patient who requests the oral contraceptive pill (OCP). Questionnaires were sent to 1,000 Victorian general practitioners, 305 of whom responded. General practitioners were asked to determine whether "Liz" was competent to request the OCP, and whether they would maintain her confidentiality. A total of 81% of respondents found the patient competent, while 91% would have maintained her confidentiality. Results indicate that the majority of general practitioners used rationales that generally did not conform to current legal principles when making competence and confidentiality determinations regarding this patient.

A metasynthesis of patient-provider communication in hospital for patients with severe communication disabilities: informing new translational research

Poor patient-provider communication in hospital continues to be cited as a possible causal factor in preventable adverse events for patients with severe communication disabilities. Yet to date there are no reports of empirical interventions that investigate or demonstrate an improvement in communication in hospital for these patients. The aim of this review was to synthesize the findings of research into communication in hospital for people with severe communication disabilities arising from lifelong and acquired stable conditions including cerebral palsy, autism, intellectual disability, aphasia following stroke, but excluding progressive conditions and those solely related to sensory impairments of hearing or vision. Results revealed six core strategies suggested to improve communication in hospital: (a) develop services, systems, and policies that support improved communication, (b) devote enough time to communication, (c) ensure adequate access to communication tools (nurse call systems and communication aids), (d) access personally held written health information, (e) collaborate effectively with carers, spouses, and parents, and (f) increase the communicative competence of hospital staff. Currently there are no reports that trial or validate any of these strategies specifically in hospital settings. Observational and evaluative research is needed to investigate the ecological validity of strategies proposed to improve communication.

A trial of e-simulation of sudden patient deterioration (FIRST2ACT WEB) on student learning

BACKGROUND: High-fidelity simulation pedagogy is of increasing importance in health professional education; however, face-to-face simulation programs are resource intensive and impractical to implement across large numbers of students. OBJECTIVES: To investigate undergraduate nursing students' theoretical and applied learning in response to the e-simulation program-FIRST2ACT WEBTM, and explore predictors of virtual clinical performance. DESIGN AND SETTING: Multi-center trial of FIRST2ACT WEBTM accessible to students in five Australian universities and colleges, across 8 campuses. PARTICIPANTS: A population of 489 final-year nursing students in programs of study leading to license to practice. METHODS: Participants proceeded through three phases: (i) pre-simulation-briefing and assessment of clinical knowledge and experience; (ii) e-simulation-three interactive e-simulation clinical scenarios which included video recordings of patients with deteriorating conditions, interactive clinical tasks, pop up responses to tasks, and timed performance; and (iii) post-simulation feedback and evaluation. Descriptive statistics were followed by bivariate analysis to detect any associations, which were further tested using standard regression analysis. RESULTS: Of 409 students who commenced the program (83% response rate), 367 undergraduate nursing students completed the web-based program in its entirety, yielding a completion rate of 89.7%; 38.1% of students achieved passing clinical performance across three scenarios, and the proportion achieving passing clinical knowledge increased from 78.15% pre-simulation to 91.6% post-simulation. Knowledge was the main independent predictor of clinical performance in responding to a virtual deteriorating patient R(2)=0.090, F(7, 352)=4.962, p<0.001. DISCUSSION: The use of web-based technology allows simulation activities to be accessible to a large number of participants and completion rates indicate that 'Net Generation' nursing students were highly engaged with this mode of learning. CONCLUSION: The web-based e-simulation program FIRST2ACTTM effectively enhanced knowledge, virtual clinical performance, and self-assessed knowledge, skills, confidence, and competence in final-year nursing students.

ED-HOME: improving educator confidence and patient education in the emergency department

BACKGROUND: Barriers to effective patient communication in the emergency department (ED) are well recognised; time, resources and staff and consumer expectations. This project aimed to improve the quality of health education provided in the ED by increasing nurses' confidence as educators.

METHOD: By providing a staff information package including the introduction of a new structured education tool; ED-HOME, and by assessing the confidence and self-efficacy of the nurses in the process, we hoped to determine if an improvement in practice and confidence was achieved. A quantitative, pre and post-test questionnaire comparison study was undertaken before and after a four week implementation period. The project examined the attitudes and practices of registered emergency nurses and was conducted in one metropolitan emergency department.

RESULTS: Results indicated that nurse confidence and self-efficacy improved by using the new structured ED-HOME format and both staff satisfaction and education competence increased. Participants positively responded to the new tool and recommended future use in the ED.

CONCLUSION: This project demonstrates that if emergency nurses feel more confident with their educating practices and by using a structured format, patients will benefit from better quality patient education provided in the ED.

Challenges of measuring and linking patient outcomes to nursing interventions in acute care settings

Measuring and linking patient outcomes to nursing intervention is an important task that has professional, financial and political ramifications. The importance and complexity of measuring patient outcomes accurately should not be overlooked, as there are a number of emergent factors that influence this process. These include the turbulent context of practise, variations in care due to the large number of health professionals, individual patient characteristics impacting on outcomes, determining appropriate nursing outcome measures, nursing's lack of autonomy within the system and difficulties experienced while trying to link patient outcomes to nursing interventions. So that the results reflect reality, it is important for researchers in the field to take note and consider these factors when measuring patient outcomes. The present article aimed to examine and discuss a number of these factors as they relate to the evaluation of patient care.

Direct patient contacts of dietetic students during their final clinical placement

Direct student-patient contacts, during the professional clinical placement of a Master of Nutrition and Dietetics course, were collected and analysed for the first time using a computerised method. In the final eight-week hospital placement, 26 dietetic students submitted data on direct patient contacts which included: dietetic activities (e.g. assessing, counselling and reviewing); the primary nutritional condition of the patient (e.g. type 2 diabetes and liver disease); and the time spent in contact with patients. The most common dietetic activities were reviews, followed by collection of dietary information and counselling. The most common nutritional condition encountered by students was an inadequate nutrient intake, followed by patients receiving enteral nutrition. Contact time with patients increased over the placement, with proportionately more time spent by students seeing patients independently than when being observed by supervising dietitians. The data collected provided valuable informa tion on the amount of time spent by students in direct patient contacts, the range of dietetic activities undertaken and the amount of time student activities were directly observed. This information will be useful in the development of benchmarks for clinical skill development, hospital and university staff planning and the assessment of the impact of any changes to the format of student placement experience in the clinical setting.

Assessing financial competence

Some people have cognitive impairments that may reduce their capacity to manage their own financial affairs. The legal decision to limit a person's right to manage his or her own finances depends, in part, on an assessment of financial competence. Currently, tribunals and courts may receive information from a variety of different sources (e.g., family members, general practitioner, psychologist, social worker etc.) and have to reconcile this information in order to make guardianship decisions. The first aim of this article is to critique contemporary methods, procedures and practices for assessing financial competence. The second aim is to suggest a standard assessment framework that could be employed by tribunals and courts to help them evaluate the status of a person's financial competence.

Correction of the copper transport defect of Menkes patient fibroblasts by expression of two forms of the sheep Wilson ATPase

The Wilson disease (WD) protein (ATP7B) is a copper-transporting P-type ATPase that is responsible for the efflux of hepatic copper into the bile, a process that is essential for copper homeostasis in mammals. Compared with other mammals, sheep have a variant copper phenotype and do not efficiently excrete copper via the bile, often resulting in excessive copper accumulation in the liver. To investigate the function of sheep ATP7B and its potential role in the copper-accumulation phenotype, cDNAs encoding the two forms of ovine ATP7B were transfected into immortalised fibroblast cell lines derived from a Menkes disease patient and a normal control. Both forms of ATP7B were able to correct the copper-retention phenotype of the Menkes cell line, demonstrating each to be functional copper-transporting molecules and suggesting that the accumulation of copper in the sheep liver is not due to a defect in the copper transport function of either form of sATP7B.

Pharmaceuticals and the consumer movement: the ambivalences of 'patient power'

Consumer and patient advocacy groups (PAGs) are important participants in the politics of pharmaceuticals. Yet very little is known about the precise nature and extent of their influence. It is argued in this article that PAGs fulfil a mixed role within the health system at national and transnational levels, and that they are at times fully incorporated into economic and political power structures. Their frequent dependence on pharma industry funding is of particular concern. PAGs provide a means of direct industry interaction with the final customer, thereby partially bypassing and putting additional pressure on doctors and regulators. The article presents the case for research to establish a better empirical base for discussions about the role of PAGs within contemporary neo-liberal governance structures.