Participant Selection for Inpatient Physical Rehabilitation.

Intensive, inpatient physical rehabilitation in a dedicated unit can have a hugely positive influence on a person's life after a major injury or illness. This resource, however, is scarce and not every participant will benefit. Appropriate and fair participant selection for inpatient rehabilitation is therefore vital. This article considers challenges in these selection decisions, including the potential for inconsistency, bias and controversy, and the limits of evidence-based selection criteria. To provide best care in this setting, this article suggests that a clear process of decision-making is also important, alongside the use of objective selection criteria. One possible framework for this selection process is New Zealand's Health and Disability Commissioner Code of Patients' Rights, which is informative for clinicians and health authorities in rehabilitation selection in all jurisdictions, and which supports appropriate and fair participant selection.

Should older people ever be discharged from hospital at night?

The discharge of older people from hospital at night is a topical and emotive issue that has recently gained media attention in New Zealand and the United Kingdom, including calls to prevent it occurring. With growing pressures on hospital capacity and ageing populations, normative aspects of hospital discharge are increasingly relevant. This paper therefore addresses the question: Should older people (say, over eighty years old) ever be discharged home from hospital during the night? Or given safety concerns, should regulation against the night-time discharge of older people be put in place? Employing a principlist lens to bioethics, this paper considers key principles or values involved, including discharge safety concerns, personal preference and consent, the risk of remaining in hospital, and broader considerations around discharge policy. These points act as a possible framework for further research and discussion of normative aspects of hospital discharge. Overall, this paper argues that while discharge safety concerns must be properly acknowledged and addressed, it can still sometimes be appropriate for an older person to leave hospital at night. The option of night-time discharge should therefore remain open to people of all ages.

Perceived versus objective sleep quality in long-stay hospitalised older adults-a mixed methods study.

BACKGROUND: Hospital inpatients experience substantial sleep problems that have been linked with worse health outcomes, poor quality of life and the post-hospital syndrome. However, little is known about assessing sleep issues in older hospitalised patients. OBJECTIVE: To conduct an in-depth investigation on hospitalised older adults' sleep challenges and methods of sleep assessment. DESIGN: Cross-sectional observational study. SETTING: Public hospital inpatient unit. SUBJECTS: Long-stay hospitalised older adults. METHODS: Data were collected using validated sleep questionnaires, actigraphy devices and qualitative interviews. Quantitative data were analysed with descriptive statistics, multiple logistic regression and Cohen's Kappa. Qualitative data were analysed with qualitative content analysis; findings compared to the quantitative assessments. RESULTS: We collected data on 33 older long-stay hospital inpatients, who were mean (SD) 80.2(7.4) years old, 57.6% female and were hospitalised following stroke, medical illness and orthopaedic fracture. Mean (SD) total sleep time and actigraphic sleep efficiency were 480.6(73.6) minutes and 81.5(11.2)%, respectively. About, 57.6% were poor sleepers (Pittsburgh Sleep Quality Index [PSQI]) and 30.8% had indicators of clinical depression/low quality of life (WHO-5 well-being index). Three main themes were identified: "sleep assessment"; "factors that affect sleep"; "expectations of sleep". Bad sleepers were more likely to feel a lack of control over their sleep, while good sleepers spoke about the ability to adjust and accept their circumstances. CONCLUSIONS: We found high levels of sleep problems and identified substantial discrepancies between the validated sleep questionnaire and qualitative response data. Our findings indicate that standard assessment tools, such as PSQI, may not be suitable to assess sleep in hospitalised older adults and call for further investigations to build more appropriate methods. Further exploring psychological factors and expectations could potentially lead to novel interventions to improve sleep in this setting.

Classifying discharge scenarios to improve understanding and care.

Hospital discharge planning is valuable in improving care and avoiding discharge delays. This is highly relevant to older people. Although usual discharge planning is now well understood and applicable to most patients, a range of different discharge scenarios exist that involve different considerations. These less common scenarios appear less well understood and can be challenging for clinical staff. To improve understanding and care, this Commentary suggests a basic classification of six discharge planning scenarios. These are: usual discharge planning, premature discharge, rehabilitation selection, safety concerns, reluctant discharge and delayed discharge. Clinical and system responses to each scenario are briefly discussed. This classification could potentially be useful in clinical education and quality improvement.

'Not safe for discharge'? Words, values, and person-centred care.

The phrase 'not safe for discharge home' is often heard in relation to an older person in hospital, commonly due to functional limitations or risk of falls. But it remains unclear how such a standard of safety should be set in this context, or who should set it. In addition, labelling someone 'unsafe' to return to their own home has significant practical and ethical implications. After briefly exploring these issues, this Commentary suggests that a holistic approach and shared decision-making is required in this setting. Instead of simply declaring someone safe or unsafe for discharge home, specific 'safety concerns' (or 'hazards') should be identified and addressed as able. Ongoing specific concerns can then be discussed in conjunction with a patient's values and perceived benefits of returning home, in comparison with potential pros and cons of other discharge options. Overall, this paper suggests that paying attention to our words and values can enhance discharge planning and person-centred care.

Decisional Competence and Fitness to Stand Trial in New Zealand.

New Zealand courts are increasingly finding people unfit to stand trial. It is therefore important that the topic is carefully explored. For instance, should an assessment of fitness to stand trial include an assessment of a person's ability to make autonomous decisions about how to conduct their defence? This ability is referred to as "decisional competence". A pivotal case on this issue is Solicitor-General v Dougherty [2012] NZCA 405. In this case, the Court of Appeal decided that an assessment of decisional competence should not be part of an assessment of fitness to stand trial, but in doing so, appeared to misunderstand the concept. This article aims to discuss a correct understanding of decisional competence, in particular by contrasting it with the notion of "acting in one's best interests". This will aid further discussion on this important and relevant issue.

Best Interests and Non-consensual Research.

The issue of clinical research on adults who are unable to provide consent (non-consensual research - NCR) is a challenging area of law, which has gained prominence in New Zealand and elsewhere. In New Zealand, the legality of such research depends on a best interests test. It has been claimed, however, that a best interests test cannot be satisfied in NCR, and that a new legal standard is required to allow valuable research to appropriately proceed. This article argues that a best interests test can be satisfied in NCR and should be reconsidered as a suitable benefit-harm standard. Furthermore, there is a possibility of maintaining a best interests test as well as adopting a new, more specific standard and other recommendations for reform. These two components could be seen as consistent, or even synergistic, and this dual approach should be considered in current discussion.

Decision-Making Capacity and Unusual Beliefs: Two Contentious Cases : Australasian Association of Bioethics and Health Law John McPhee (Law) Student Essay Prize 2016.

Decision-making capacity is a vital concept in law, ethics, and clinical practice. Two legal cases where capacity literally had life and death significance are NHS Trust v Ms T [2004] and Kings College Hospital v C [2015]. These cases share another feature: unusual beliefs. This essay will critically assess the concept of capacity, particularly in relation to the unusual beliefs in these cases. Firstly, the interface between capacity and unusual beliefs will be examined. This will show that the "using and weighing of information" is the pivotal element in assessment. Next, this essay will explore the relationship between capacity assessment and a decision's "rationality." Then, in light of these findings, the essay will appraise the judgments in NHS v T and Kings v C, and consider these judgments' implications. More broadly, this essay asks: Does capacity assessment examine only the decision-making process (as the law states), or is it also influenced by a decision's rationality? If influenced by rationality, capacity assessment has the potential to become "a search and disable policy aimed at those who are differently orientated in the human life-world" (Gillett 2012, 233). In contentious cases like these, this potential deserves attention.

Smokefree outdoor areas without the smoke-police: the New Zealand local authority experience.

AIM: To investigate (i) the extent, nature and effectiveness of smokefree outdoor area (SFOA) policies in New Zealand, (ii) incentives and motivations for, and barriers to creating these SFOA. METHODS: Literature and media searches were conducted for relevant material to February 2009. Nine in-depth interviews were conducted in October 2008, with key informants from local government, health and related research areas. RESULTS: Twenty-three of 73 local authorities have 'educative' (non-enforceable) SFOA policies for at least one playground. There has been an increasing trend of SFOA policy adoption since the first 'educative' policy in 2005. Motivations for policy adoption include child well-being, community leadership, and environmental and fire concerns. Barriers have included arguments about 'freedoms', over-regulation, park attendance, enforcement, media comment, and some local authority lack of focus on health. There appears to be increasing support nationally for at least SFOA for children's areas, including 66% support from smokers for smokefree playgrounds. There is some evidence of SFOA policy effectiveness, but considerable need for further evaluation of the policies. CONCLUSIONS: Councils have moved to create SFOA, in the absence of substantial central government efforts. It is likely that the adoption of SFOA will continue, and there is potential for an expansion of the policies to wider settings.