The assessment of competency and coercion in the End of Life Choice Act 2019.

The eligibility criteria of the End of Life Choice Act 2019 specify the person must be competent to make an informed decision about assisted dying. The patient must initiate the conversation about assisted dying, and then it is incumbent on health professionals to perform a skilled exploration of the person's suffering and rationale. The legal standards for competence must be met. Common mental health and cognitive disorders that may impact on decision-making must be recognised. The context and the authenticity and consistency in choice are important elements. Education and training of involved health practitioners is required to ensure the assessment process is robust. A comprehensive approach is necessary to determine the autonomy of the decision and for the protection of the rights of the individual.

Australasian contributions to the "shell shock" literature of World War I.

OBJECTIVE: Australasians contributed to the medical literature on shell shock during and after World War I. CONCLUSIONS: AW Campbell, Elliot Smith, Carmalt Jones and AG Butler made significant contributions, and several 'frontline doctors' recorded astute observations.

Comparison of cognitive and UHDRS measures in monitoring disease progression in Huntington's disease: a 12-month longitudinal study.

Progressive cognitive decline is a feature of Huntington's disease (HD), an inherited neurodegenerative movement disorder. Comprehensive neuropsychological testing is the 'gold standard' to establish cognitive status but is often impractical in time-constrained clinics. The study evaluated the utility of brief cognitive tests (MMSE and MoCA), UHDRS measures and a comprehensive neuropsychological tests battery in monitoring short-term disease progression in HD. Twenty-two manifest HD patients and 22 matched controls were assessed at baseline and 12-month. A linear mixed-effect model showed that although the HD group had minimal change in overall global cognition after 12 months, they did show a significant decline relative to the control group. The controls exhibited a practice effect in most of the cognitive domain scores over time. Cognitive decline at 12-month in HD was found in the executive function domain but the effect of this on global cognitive score was masked by the improvement in their language domain score. The varying practice effects by cognitive domain with repeated testing indicates the importance of comparing HD patients to control group in research trials and that cognitive progression over 12 months in HD should not be judged by changes in global cognitive score. The three brief cognitive tests effectively described cognition of HD patients on cross-sectional analysis. The UHDRS cognitive component, which focuses on testing executive function and had low variance over time, is a more reliable brief substitute for comprehensive neuropsychological testing than MMSE and MoCA in monitoring cognitive changes in HD patients after 12 months.

Assisted dying in liberalised jurisdictions and the role of psychiatry: a clinician's view.

OBJECTIVE: Assisted dying is a contentious and topical issue. Mental disorder is a relevant influence on requests of hastened death. The psychiatry of dying is not a prominent component in the assessment of euthanasia and physician-assisted suicide (PAS) in jurisdictions with liberalised assisted dying laws. The literature on the assessment processes, with particular reference to mental status, involved in euthanasia requests is considered. METHODS: An experienced palliative medicine specialist and psychiatrist selectively reviewed the recent literature published about the mental health issues involved in euthanasia and PAS. RESULTS: Assessments of competency, sustained wish to die prematurely, depressive disorder, demoralisation and 'unbearable suffering' in the terminally ill are clinically uncertain and difficult tasks. There is a growing psychiatric and psychological literature on the mental status of the terminally ill. As yet psychiatry does not have the expertise to 'select' those whose wish for hastened death is rational, humane and 'healthy'. Rarely in those societies with liberalised assisted dying laws are psychiatrists involved in the decision-making for individuals requesting early death. This role is fulfilled by non-specialists. CONCLUSIONS: There remain significant concerns about the accuracy of psychiatric assessment in the terminally ill. Mental processes are more relevant influences on a hastened wish to die than are the physical symptoms of terminal malignant disease. Psychiatric review of persons requesting euthanasia is relevant. It is not obligatory or emphasised in those legislations allowing assisted dying. Psychiatry needs to play a greater role in the assessment processes of euthanasia and PAS.

Christchurch earthquakes: how did former refugees cope?

AIM: This study investigated how former refugees now living in Christchurch (Canterbury Province, New Zealand) communities coped after the 4 September 2010 and subsequent earthquakes. METHOD: A systematic sample of one in three former refugees from five ethnic groupings (Afghanistan, Kurdistan, Ethiopia, Somalia and Bhutan) was selected from a list of 317 refugees provided by the Canterbury Refugee Council and invited to participate in the study. Seventy-two out of 105 potential participants completed a 26 item questionnaire regarding the impact of the quakes, their concerns and anxieties, coping strategies and social supports. The methodology was complicated by ongoing aftershocks, particularly that of 22 February 2011. RESULTS: Three-quarters of participants reported that they had coped well, spirituality and religious practice being an important support for many, despite less then 20% receiving support from mainstream agencies. Most participants (72%) had not experienced a traumatic event or natural disaster before. Older participants and married couples with children were more likely to worry about the earthquakes and their impact than single individuals. There was a significant difference in the level of anxiety between males and females. Those who completed the questionnaire after the 22 February 2011 quake were more worried overall than those interviewed before this. CONCLUSION: Overall, the former refugees reported they had coped well despite most of them not experiencing an earthquake before and few receiving support from statutory relief agencies. More engagement from local services is needed in order to build trust and cooperation between the refugee and local communities.

The pharmacokinetics and pharmacogenetics of the antiemetic cyclizine in palliative care patients.

CONTEXT: Cyclizine, an antihistaminic antiemetic, is commonly used in palliative care. Its pharmacokinetics have been poorly studied, and its metabolic pathway is unknown but may involve the genetically controlled cytochrome P450 2D6 (CYP2D6). If this is the case, the metabolic ratio of cyclizine to norcyclizine and efficacy/adverse effects may vary between patients according to their CYP2D6 genotype. OBJECTIVES: To deduce the pharmacokinetics and antiemetic/sedative effects of cyclizine and relate these and its metabolic ratio to the CYP2D6 genotype in palliative care patients. METHODS: Palliative care patients initiated on continuous cyclizine subcutaneous (SC) infusions had blood samples taken and efficacy/toxicity scores measured during the approach to steady state. Another group of patients at steady state receiving oral cyclizine had a single blood sample taken. Samples were analyzed to elucidate pharmacokinetic parameters and CYP2D6 genetics. RESULTS: SC dosing group: The median (interquartile range) cyclizine half-life, volume of distribution, and clearance were 13 (7-48) hours, 23 (12-30)L/kg, and 15 (11-26)mL/min/kg, respectively. Nausea and sedation scores were 3.0 (1.2-5.7) and 5.0 (2.6-8.1), respectively, overall and did not vary with genotype (P=0.76 and 0.11, respectively). The median overall metabolic ratio at steady state was 4.9 (3.8-9.2) and did vary with CYP2D6 genotype (P=0.02). Oral dosing group: The median metabolic ratio was 2.1 (1.5-2.9) and did not vary with CYP2D6 genotype (P=0.37). CONCLUSION: Palliative care patients have similar cyclizine pharmacokinetics to those reported in other patient groups. Cyclizine metabolism to norcyclizine may include CYP2D6 as the metabolic ratio varied with CYP2D6 genotype in the SC group.

Psychiatry on the Burma-Thai Railway (1942-1943): Dr Rowley Richards and colleagues.

OBJECTIVE: The aim of this paper was to review the literature written by doctor-prisoners of the Japanese working on the Burma-Thai Railway with particular emphasis on the psychological and psychiatric conditions they encountered. CONCLUSIONS: The enormous respect and gratitude expressed by survivors for their medical attendants is an indication that in addition to performing extraordinary surgical and medical care in appalling conditions and with very limited available resources, these doctors also very adequately attended the clinical problems of demoralization, depression and acute delirium.

"If there is a doctor aboard this flight. . .": issues and advice for the passenger-psychiatrist.

OBJECTIVE: On several occasions, the author has responded to requests for medical assistance while travelling by air. This paper examines the various issues when a passenger-psychiatrist is confronted with an in-flight medical emergency. CONCLUSIONS: A range of medical problems can present during air travel. A review of the available literature on a doctor's obligations when confronted with an in-flight medical emergency is provided. Guidelines for the passenger psychiatrist,who at some stage is likely to encounter such a circumstance, are offered.

Cochrane's problem: psychoanalysis and anejaculation.

OBJECTIVE: The stimulus inciting Archie Cochrane's interest in scientific medicine was his own ill health and the inability of psychoanalysis to cure his problem of sexual dysfunction. The aetiology and modern management of anejaculation will be considered. CONCLUSIONS: The treatment undertaken by Cochrane failed because his condition was organic. Evidence-based medicine was founded upon Cochrane's critical evaluation of his own psychoanalytic psychotherapy.

Mrs Hitler and her doctor.

OBJECTIVE: The doctor who attended the mother of Adolf Hitler in her terminal illness has been blamed as a cause of the Holocaust. The medical details recorded of this professional relationship are presented and discussed. CONCLUSIONS: Dr Bloch's medical care of Mrs Hitler was consistent with the prevailing medical practice of the management of fungating breast carcinoma. Indeed, the general practitioner's care and attention of the family appear to have been astute and supportive. There is nothing to suggest that Dr Bloch's medical care was other than competent. Doctors who have the (mis)fortune to professionally attend major figures of history may be unfairly viewed, despite their appropriate and adequate care.