Advance directives, autonomy and the refusal of life-sustaining medical treatment

As Australian society 1s agemg, individuals are increasingly concerned about managing their future, including making decisions about the medical treatment they may wish to receive or refuse if they lose decision-making capacity. To date, there has been relatively little research into the extent to which legal regulation allows competent adults to make advance refusals of life-sustaining medical treatment that will bind health professionals and others when a decision needs to be made at a future time. This thesis aims to fill this gap in the research by presenting the results of research into the legal regulation of advance directives that refuse life-sustaining medical treatment. In the five papers that comprise this thesis, the law that governs this area is examined, and the ethical principle of autonomy is used to critically evaluate that law. The principal finding of this research is that the current scheme of regulation is ineffective to adequately promote the right of a competent adult to make binding advance directives about refusal of medical treatment. The research concludes that legislation should be enacted to enable individuals to complete an advance directive, only imposing restrictions to the extent that this is necessary to promote individual autonomy. The thesis first examines the principle of autonomy upon which the common law (and some statutory law) is expressed to be based, to determine whether that principle is an appropriate one to underpin regulation. 1 The finding of the research is that autonomy can be justified as an organising principle on a number of grounds: it is consistent with the values of a liberal democracy; over recent decades, it is a principle that has been even more prominent within the discipline of medical ethics; and it is the principle which underpins the legal regulation of a related topic, namely the contemporaneous refusal of medical treatment. Next, the thesis reviews the common law to determine whether it effectively achieves the goal of promoting autonomy by allowing a competent adult to make an advance directive refusing treatment that will operate if he or she later loses decision-making capacity. 2 This research finds that conunon law doctrine, as espoused by the judiciary, prioritises individual choice by recognising valid advance directives that refuse treatment as binding. However, the research also concludes that the common law, as applied by the judiciary in some cases, may not be effective to promote individual autonomy, as there have been a number of circumstances where advance directives that refuse treatment have not been followed. The thesis then examines the statutory regimes in Australia that regulate advance directives, with a focus on the regulation of advance refusals of life-sustaining medical treatment.3 This review commences with an examination ofparliamentary debates to establish why legislation was thought to be necessary. It then provides a detailed review of all of the statutory regimes, the extent to which the legislation regulates the form of advance directives, and the circumstances in which they can be completed, will operate and can be ignored by medical professionals. The research finds that legislation was enacted mainly to clarify the common law and bring a level of certainty to the field. Legislative regimes were thought to provide medical professionals with the assurance that compliance with an advance directive that refuses life-sustaining medical treatment will not expose them to legal sanction. However, the research also finds that the legislation places so many restrictions on when an advance directive refusing treatment can be made, or will operate, that they have not been successful in promoting individual autonomy.

Distribution feeder voltage support and power factor control by distributed multiple inverters

The potential of distributed reactive power control to improve the voltage profile of radial distribution feeders has been reported in literature by few authors. However, the multiple inverters injecting or absorbing reactive power across a distribution feeder may introduce control interactions and/or voltage instability. Such controller interactions can be alleviated if the inverters are allowed to operate on voltage droop. First, the paper demonstrates that a linear shallow droop line can maintain the steady state voltage profile close to reference, up to a certain level of loading. Then, impacts of the shallow droop line control on line losses and line power factors are examined. Finally, a piecewise linear droop line which can achieve reduced line losses and close to unity power factor at the feeder source is proposed.

New Evidence for Structured Telephone Support in the Management of Patients with Heart Failure [Letter to Editor]

Letter to the Editor of New England Journal of Medicine on behalf of the Cochrane Systematic Review team.

Support for energy-oriented design in the Australian context

There is a need for decision support tools that integrate energy simulation into early design in the context of Australian practice. Despite the proliferation of simulation programs in the last decade, there are no ready-to-use applications that cater specifically for the Australian climate and regulations. Furthermore, the majority of existing tools focus on achieving interaction with the design domain through model-based interoperability, and largely overlook the issue of process integration. This paper proposes an energy-oriented design environment that both accommodates the Australian context and provides interactive and iterative information exchanges that facilitate feedback between domains. It then presents the structure for DEEPA, an openly customisable system that couples parametric modelling and energy simulation software as a means of developing a decision support tool to allow designers to rapidly and flexibly assess the performance of early design alternatives. Finally, it discusses the benefits of developing a dynamic and concurrent performance evaluation process that parallels the characteristics and relationships of the design process.

Closing the loop of design and analysis : Parametric modelling tools for early decision support

There is a growing need for parametric design software that communicates building performance feedback in early architectural exploration to support decision-making. This paper examines how the circuit of design and analysis process can be closed to provide active and concurrent feedback between architecture and services engineering domains. It presents the structure for an openly customisable design system that couples parametric modelling and energy analysis software to allow designers to assess the performance of early design iterations quickly. Finally, it discusses how user interactions with the system foster information exchanges that facilitate the sharing of design intelligence across disciplines.

Affiliation, autonomy and assessment for learning

Assessment for Learning (AfL) is an international assessment area of interest, yet, during 20 years of AfL research, the desired outcome of increased learner autonomy remains elusive. This article analyses AfL practices in classrooms as students negotiated identities as autonomous learners within a classroom community of practice. A sociocultural theoretical framework in formed the analysis of three case studies conducted in Queensland middle school classrooms. Key findings include the importance of the teacher–student relationship, viewing AfL as patterns of participation that develop expertise, and learner autonomy as a negotiated learner identity within each classroom context.

Telemonitoring or Structured Telephone Support Programmes for Patients with Chronic Heart Failure: Systematic Review and Meta-Analysis

Objective: To determine whether remote monitoring (structured telephone support or telemonitoring) without regular clinic or home visits improves outcomes for patients with chronic heart failure. Data sources: 15 electronic databases, hand searches of previous studies, and contact with authors and experts. Data extraction: Two investigators independently screened the results. Review methods: Published randomised controlled trials comparing remote monitoring programmes with usual care in patients with chronic heart failure managed within the community. Results: 14 randomised controlled trials (4264 patients) of remote monitoring met the inclusion criteria: four evaluated telemonitoring, nine evaluated structured telephone support, and one evaluated both. Remote monitoring programmes reduced the rates of admission to hospital for chronic heart failure by 21% (95% confidence interval 11% to 31%) and all cause mortality by 20% (8% to 31%); of the six trials evaluating health related quality of life three reported significant benefits with remote monitoring, and of the four studies examining healthcare costs with structured telephone support three reported reduced cost and one no effect. Conclusion: Programmes for chronic heart failure that include remote monitoring have a positive effect on clinical outcomes in community dwelling patients with chronic heart failure.

The Use of Social Technology to Support Organisational Knowledge

In the current economy, knowledge has been recognized to be a valuable organisational asset, a crucial factor that aids organisations to succeed in highly competitive environments. Many organisations have begun projects and special initiatives aimed at fostering better knowledge sharing amongst their employees. Not surprisingly, information technology (IT) has been a central element of many of these projects and initiatives, as the potential of emerging information technologies such as Web 2.0 for enabling the process of managing organisational knowledge is recognised. This technology could be used as a collaborative system for knowledge management (KM) within enterprises. Enterprise 2.0 is the application of Web 2.0 in an organisational context. Enterprise 2.0 technologies are web-based social software that facilitate collaboration, communication and information flow in a bidirectional manner: an essential aspect of organisational knowledge management. This chapter explains how Enterprise 2.0 technologies (Web 2.0 technologies within organisations) can support knowledge management. The chapter also explores how such technologies support the codifying (technology-centred) and social network (people-centred) approaches of KM, towards bridging the current gap between these two approaches.

Predicting employee intentions to support organizational change : an examination of identification processes during a re-brand

This study examined if organizational identification can account for the mechanisms by which two-change management practices (communication and participation) influence employees’ intentions to support change. The context was a sample of 82 hotel employees in the early stages of a re-brand. Identification with the new hotel fully mediated the relationship between communication and adaptive and proactive intentions to support change, as well as between participation and proactive intentions.

Employee perceived workplace stress : examining core self-evaluations, political skill, coping strategies and support

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Keeping friends safe : a prospective study examining early adolescent's confidence and support networks

There is a continued need to consider ways to prevent early adolescent engagement in a variety of harmful risk-taking behaviours for example, violence, road-related risks and alcohol use. The current prospective study examined adolescents’ reports of intervening to try and stop friends’ engagement in such behaviours among 207 early adolescents (mean age = 13.51 years, 50.1% females). Findings showed that intervening behaviour after three months was predicted by the confidence to intervene which in turn was predicted by student and teacher support although not parental support. The findings suggest that the benefits of positive relationship experiences might extend to the safety of early adolescent friendship groups particularly through the development of confidence to try and stop friends’ risky and dangerous behaviours. Findings from the study support the important role of the school in creating a culture of positive adolescent behaviour whereby young people take social responsibility.

Developing financial decision support for highway infrastructure sustainability

The development of highway infrastructure typically requires major capital input over a long period. This often causes serious financial constraints for investors. The push for sustainability has added new dimensions to the complexity in the evaluation of highway projects, particularly on the cost front. This makes the determination of long-term viability even more a precarious exercise. Life-cycle costing analysis (LCCA) is generally recognised as a valuable tool for the assessment of financial decisions on construction works. However to date, existing LCCA models are deficient in dealing with sustainability factors, particularly for infrastructure projects due to their inherent focus on the economic issues alone. This research probed into the major challenges of implementing sustainability in highway infrastructure development in terms of financial concerns and obligations. Using results of research through literature review, questionnaire survey of industry stakeholders and semi-structured interview of senior practitioners involved in highway infrastructure development, the research identified the relative importance of cost components relating to sustainability measures and on such basis, developed ways of improving existing LCCA models to incorporate sustainability commitments into long-term financial management. On such a platform, a decision support model incorporated Fuzzy Analytical Hierarchy Process and LCCA for the evaluation of the specific cost components most concerned by infrastructure stakeholders. Two real highway infrastructure projects in Australia were then used for testing, application and validation, before the decision support model was finalised. Improved industry understanding and tools such as the developed model will lead to positive sustainability deliverables while ensuring financial viability over the lifecycle of highway infrastructure projects.

Understanding evaluation of learning support in mathematics and statistics

With rapid and continuing growth of learning support initiatives in mathematics and statistics found in many parts of the world, and with the likelihood that this trend will continue, there is a need to ensure that robust and coherent measures are in place to evaluate the effectiveness of these initiatives. The nature of learning support brings challenges for measurement and analysis of its effects. After briefly reviewing the purpose, rationale for, and extent of current provision, this article provides a framework for those working in learning support to think about how their efforts can be evaluated. It provides references and specific examples of how workers in this field are collecting, analysing and reporting their findings. The framework is used to structure evaluation in terms of usage of facilities, resources and services provided, and also in terms of improvements in performance of the students and staff who engage with them. Very recent developments have started to address the effects of learning support on the development of deeper approaches to learning, the affective domain and the development of communities of practice of both learners and teachers. This article intends to be a stimulus to those who work in mathematics and statistics support to gather even richer, more valuable, forms of data. It provides a 'toolkit' for those interested in evaluation of learning support and closes by referring to an on-line resource being developed to archive the growing body of evidence. © 2011 Taylor & Francis.