Adherence to a national consensus statement on informed consent: medical students' experience of obtaining informed consent from patients for sensitive examinations.

AIM: To determine whether the guidance from the New Zealand medical programmes' national consensus statement on obtaining informed consent from patients for sensitive examinations are being met, and to explore medical students' experience of obtaining consent. METHOD: A self-reported, online, anonymous questionnaire was developed. Data were collected in the period just after graduation from final year medical students at The University of Auckland in 2019. RESULTS: The response rate was 35% (93/265). Most students reported that they were "not always compliant" with the national consensus statement for obtaining informed consent for almost all sensitive examinations. The main exception was for the female pelvic examination (not in labour) under anaesthesia, where most students reported being "always compliant". We identified factors related to students, supervisors, institution, and the learning context as reasons for lack of compliance. CONCLUSION: Adherence to the national consensus statement on obtaining informed consent for sensitive examinations is unsatisfactory. The medical programme needs to review the reasons for lapses in implementing the policy in practice, to ensure a safe learning environment for patients and our students.

Conceptual framework for assisted dying for individuals with dementia: Views of experts not opposed in principle.

Dementia is one of the prominent conditions for which an aging population has been seeking end-of-life solutions such as assisted dying. Individuals with dementia, however, are often unable to meet the eligibility criteria of being mentally competent and are thus discriminated against in relation to assisted dying laws. Provided that the assisted death directive is being made in sound mind, it is still of concern whether these advance directives can be appropriately framed and safeguarded to protect the wish of these vulnerable individuals while preventing harm. Therefore, to establish consensus views of experts on primary issues of, and concerns about, assisted dying for individuals with dementia as well as exploring tentative conceptual framework to safeguard practice and application, a three-round Delphi study was conducted. A core group of 12 experts from five countries was recruited comprising expertise in domains relevant to assisted dying and dementia. A semantic-thematic approach was applied to analyze the 119 generated statements. Evaluation of these research statements resulted in full consensus of 84 (70%) items. Our primary findings highlight seven core domains: applicability of assisted dying for dementia; ethical, practical, and pathological issues regarding the application of assisted dying; and ethical, legal, and professional recommendations for the ways forward. Despite the issues surrounding the provision of assisted death for individuals with dementia, our findings lead us to cautiously conclude that devising "adequate" safeguards is achievable. The result of this research may benefit future research and practice.

Happiness at the End of Life: A Qualitative Study.

BACKGROUND: Happiness is a core ingredient of health and well-being, yet relatively little is known about what happiness means for individuals near the end of life, and whether perceptions of happiness change as individuals approach the end of their lives. AIM: The aim of this study was to explore, through interviews, how individuals experiencing hospice care understood and conceptualized happiness. DESIGN: Qualitative interviews with hospice patients were analyzed thematically. SETTING/PARTICIPANTS: Adult patients (n = 20) in a New Zealand hospice who were receiving palliative care and who could give their informed consent were invited by hospice nurse coordinators to an interview. RESULTS: Four themes emerged from analysis of the transcribed interviews. Participants defined happiness most frequently and in most depth in relation to connection with others. They identified being in the present moment, particularly in relation to nature, and that happiness had become less associated with money, status, or possessions. They had an attitude of determination to focus on what mattered now. CONCLUSION: Patients receiving palliative care were generally happy with their lives, appreciated the simpler aspects of life away from the material. There was a common exhortation to young people to avoid focusing too much on acquisition and the internet and to prioritize instead social connection and engagement with the natural world.

A Netnographic Approach: Views on Assisted Dying for Individuals With Dementia.

Alongside increasing rates of dementia diagnoses worldwide, efforts to seek alternative end-of-life options also increase. While the concept of assisted dying remains controversial, the discussion around its provision for people with dementia raises even more sensitivity. In this study, we explored how the practice of assisted dying for people with dementia is conceptualized and understood using the shared narratives of online contributors. An observational netnography over 20 months was carried out within five open Facebook communities. Thematic analysis was conducted on 1,007 online comments about assisted dying and dementia. Results reflected four central themes and five subthemes: understanding dementia; understanding assisted dying laws; caregivers' feelings; and moral/personal dilemmas. Findings reveal that the majority of communities' contributors fear developing dementia. They support the provision of advance euthanasia directives-written by competent patients-to prevent unnecessary suffering, and protect patients' wishes and freedom of choice when decision-making competency is lost.

Do à la carte menus serve infertility patients? The ethics and regulation of in vitro fertility add-ons.

Add-on treatments are the new black. They are provided (most frequently, sold) to patients undergoing in vitro fertilization on the premise that they will improve the chances of having a baby. However, the regulation of add-ons is consistently minimal, meaning that they are introduced into routine practice before they have been shown to improve the live birth rate. Debate on the adequacy of this light-touch approach rages. Defenders argue that demands for a rigorous approval process are paternalistic, as this would delay access to promising treatments. Critics respond that promising treatments may turn out to have adverse effects on patients and their offspring, contradicting the clinician's responsibility to do no harm. Some add-ons, including earlier versions of preimplantation genetic testing for aneuploidy, might even reduce the live birth rate, raising the prospect of desperate patients paying more to worsen their chances. Informed consent represents a solution in principle, but in practice there is a clear tension between impartial information and direct-to-consumer advertising. Because the effects of a treatment cannot be known until it has been robustly evaluated, we argue that strong evidence should be required before add-ons are introduced to the clinic. In the meantime, there is an imperative to identify methods for communicating the associated risks and uncertainties of add-ons to prospective patients.

Describing the Attributional Nature of Academic Dishonesty.

There is strong evidence that dishonesty occurs amongst medical students, and other allied health students and growing evidence that it occurs amongst medical academics. We believe that accidental dishonesty (or not knowing about the rules of regulations governing academic integrity) is a common attribution describing engagement in dishonesty; however, we believe that dishonest action is more often influenced and determined according to circumstance. In this paper, we aim to work through the literature that frames dishonest action with a focus on medical education, research and publication. We argue that the implications for medical education are far reaching and the root causes of many instances of dishonesty need to be more fully understood so that comprehensive, case-by-case ameliorative strategies can be developed.

Nurses' views on legalising assisted dying in New Zealand: A cross-sectional study.

AIMS: This study investigated New Zealand nurses' views on legalising assisted dying across a range of clinical conditions, nurses' willingness to engage in legal assisted dying, potential deterrents and enablers to such engagement, and nurses' perceptions of the proper role of their professional bodies in relation to legalising assisted dying. BACKGROUND: A Bill for legalising assisted dying is currently before the New Zealand parliament. Of the 16 jurisdictions where assisted dying has been specifically legislated, only the Canadian federal statute provides nurses with explicit legal protection for their performance of assisted dying-related tasks. An absence of policy development and planning for safe nursing practice prior to legalisation of assisted dying results in a gap in professional support and guidance. DESIGN: Exploratory cross-sectional survey. RESPONDENTS: A self-selected sample of 475 New Zealand nurses responded to an anonymous online survey disseminated through the newsletters and websites of relevant medical and nursing professional bodies. A sub-sample of nurses who expressed support for or ambivalence about legalisation (n = 356): rated their level of support for legalising assisted dying in New Zealand across a range of medical conditions, and their willingness to participate in a range of assisted dying tasks; identified barriers and facilitators to potential participation; and assessed the responsibility of the professional bodies to provide practice supports. METHOD: Mixed-method approach using descriptive analysis of quantitative data; qualitative data were analysed thematically. RESULTS: Nurses supported legalisation at a rate (67%) significantly greater than that of doctors (37%) and for a diverse range of medical conditions. Most supporting nurses were willing to engage in the full range of relevant assisted dying roles. They identified several practical and ethical supports as essential to safe engagement, in particular practice guidelines, specific training, legal protections, clinical supervision and mentoring, and independent review of assisted dying service provision. They saw the facilitation of these supports as primarily the responsibility of their professional bodies. IMPLICATIONS FOR POLICY: Nursing bodies should proactively facilitate workforce awareness and development of assisted dying policy and practice supports in anticipation of legalisation. This can be done through information campaigns and by adapting assisted dying policy, practice materials and systems already developed internationally. Nursing bodies need to engage in formulating legislation to ensure inclusion of explicit protections for participating nurses and to delegate relevant responsibilities to regulatory bodies.

My Father's Dying.

The monarch butterflies so abundant around the small pond are slowly disappearing. Tomatoes from the vine that curled its way up the drainage spout are now lined up on the kitchen windowsill to capture the sun's rays. Summer draws to an end as my father's life also draws to a close.As part of my narrative, I have included, in italics, entries from my journal from this time.

Medical students, sensitive examinations and patient consent: a qualitative review.

AIM: We set out to explore the question, what ethical challenges do medical students identify when asked to perform or observe a sensitive examination, given a historical background relevant to this context. METHOD: Thematic analysis of 21 Ethics Reports from 9 female and 12 male students. RESULTS: Overall 14 students undertook a sensitive examination without the patient's consent; three did not carry out a sensitive examination because of a lack of consent; and two students (or their senior colleagues) gained the patient's written consent for the student to undertake the examination. One patient refused the student's request for consent to perform a digital rectal examination; and in the final case, verbal consent was given by the patient for the student to observe a bimanual examination only. Three interrelated core themes arose from thematic analysis of the research question: systemic constraints on getting consent; internal conflicts of interest; and, power and hierarchy. CONCLUSIONS: A number of senior medical students at our institution disclosed observing or performing sensitive examinations on patients without the patients' knowledge or consent.

Deathbed Confession: When a Dying Patient Confesses to Murder: Clinical, Ethical, and Legal Implications.

During an initial palliative care assessment, a dying man discloses that he had killed several people whilst a young man. The junior doctor, to whom he revealed his story, consulted with senior palliative care colleagues. It was agreed that legal advice would be sought on the issue of breaching the man's confidentiality. Two legal opinions conflicted with each other. A decision was made by the clinical team not to inform the police. In this article the junior doctor, the palliative medicine specialist, a medical ethicist, and a lawyer consider the case from their various perspectives.

New Zealand transplant patients and organ transplantation in China: some ethical considerations.

In this viewpoint article we consider the situation of organ procurement from China, and address some of the ethical aspects arising for health professionals when New Zealand transplant patients contemplate traveling to China for an organ. We also consider some of the challenges facing health professionals involved in providing care to such patients.

Ethics Education in New Zealand Medical Schools.

This article describes the well-developed and long-standing medical ethics teaching programs in both of New Zealand's medical schools at the University of Otago and the University of Auckland. The programs reflect the awareness that has been increasing as to the important role that ethics education plays in contributing to the "professionalism" and "professional development" in medical curricula.

Should capacity assessments be performed routinely prior to discussing advance care planning with older people?

ABSTRACTBackground:People with dementia receive worse end of life care compared to those with cancer. Barriers to undertaking advanced care planning (ACP) in people with dementia include the uncertainty about their capacity to engage in such discussions. The primary aim of this study was to compare the Advance Care Planning-Capacity Assessment Vignette tool (ACP-CAV) with a semi-structured interview adapted from the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). The secondary aim was to identify demographic and cognitive functioning variables that may predict whether a person has capacity to discuss ACP. METHODS: 32 older people (mean age = 84.1) with a Mini-Mental State Examination of 24 or above were recruited from two retirement villages in Auckland. Participants also completed Trail Making Test Part A & Part B and Geriatric Depression Scale (GDS-15) before undertaking the two capacity assessments that were video recorded to enable further analysis by four independent old age psychiatrists. RESULTS: Using the MacCAT-T as the gold standard, over half (53.1%) of the participants were considered as lacking in capacity to engage in ACP. Participants struggled with the "Understanding ACP" domain the most. Capacity was not predictable by any of the demographic or cognitive functioning variables. When compared to the gold standard, ACP-CAV was accurate in assessing capacity in 68.8% of the cases. CONCLUSION: Clinicians should routinely explain ACP to older people and ensure they fully understand it prior to an ACP discussion. If there is any concern about their understanding, further exploration and documentation of their capacity using the capacity assessment framework would be necessary. However, capacity assessment is a complex iterative process that does not easily lend itself to screening methodology and requires a high level of clinical judgment.

Compassion from a palliative care perspective.

BACKGROUND: Compassion is a core virtue in medicine and lies at the heart of good medical care. It connects us to each other and reflects our need for relationships with others. AIM: Our aim is to explore how palliative care patients perceive, understand and experience compassion from health professionals, and to inform clinical practice. METHODS: Seven hospice managers in the North Island of New Zealand were contacted and invited to join the study. Twenty participants expressed a desire to participate and were involved in semi-structured face-to-face interviews. A set of questions guided the interviewers with interviews lasting between 15-60 minutes. RESULTS: In regards to the question, what is your understanding of compassion?, four central themes emerged: connection, presence and warmth, respect and caring. When asked, what advice can you give to trainee health professionals?, participants articulated four themes: connecting with patients and talking in a way they can understand, treating the person with respect, showing interest in them and being a positive presence for them. CONCLUSIONS: Compassion was seen as a connection between the carer and the patient. Compassion is having a positive presence and warmth; an attitude of respect and caring. The main advice given by research participants to enhance compassion is for doctors and nurses to connect, to talk in a way that can be understood, and show interest and respect to patients facing the end of their lives.

Humanities for medical students: essential to their cultural competence and patient-engaged practices of care.

This article was migrated. The article was marked as recommended. Over the past 50 years, advances in medical technology have revolutionised the medical landscape. The ways in which patients, their families, and health professionals connect and interact together in the medical endeavour have also changed. At the same time as advances in medical technology resulted in tremendous gains for society, criticism began emerging that the patient as a whole person had been overshadowed by the disease the person had. The interface of medicine and the humanities concerns itself with our relationships with others, the ways in which we confront challenges to our mortality, how we understand human behaviour, and the meanings we give to situations within the medical context. In this paper we outline the genesis of a medical humanities programme at the University of Auckland, and how the programme has advanced over the past twenty years. The programme promotes important social aspects of medicine such as cultural competence and person-centred engaged care. It also encourages students to improve their academic and reflective writing skills. We discuss how one course within the programme promotes student cultural awareness of - and responsiveness to - Maori people and Deaf people. Specific attention is paid to current leading pedagogy, as well as how the use of space and language contribute to student learning. We conclude that medical humanities remains an essential and valued element in medical curricula.

'Trust me, I'm a doctor': a qualitative study of the role of paternalism and older people in decision-making when they have lost their capacity.

OBJECTIVE: The objective of this study was to explore whether older people want their doctors to make treatment decisions on their behalf when they no longer have capacity to do so, and their reasons for these preferences. METHOD: A convenience sample of older people from two retirement villages were interviewed and asked to respond to a hypothetical vignette. Their responses were analysed using qualitative thematic methodology. RESULTS: Thirty-seven people (56.8% female; mean age = 83.9 years; mean Mini Mental State Examination = 26.5) participated; 73.0% indicated that they would want their doctor to make treatment decisions on their behalf. Three key themes emerged: 1) trust in the doctor-patient relationship; 2) doctor-derived factors: knowledge and expertise, professionalism, role and responsibility; 3) patient-derived factors: vulnerability, dependence and reliance, compromised autonomy. CONCLUSION: Our findings suggest that the paternalistic model within medical care can be an expectation of some older patients and if taking a paternalistic approach we should not underestimate the trust and power that is imparted to us.

New Zealand doctors' and nurses' views on legalising assisted dying in New Zealand.

BACKGROUND: Assisted dying (AD) has been legalised by statute or court decisions in at least 15 jurisdictions internationally. Nonetheless, only three medical professional bodies (and none in nursing) across those jurisdictions have proactively developed authorised policy, practice standards, guidelines or protocols, or other professional supports for health practitioners who may legally participate in AD services, and the majority internationally remain formally opposed to AD. There is a perceived likelihood that AD may be legalised in New Zealand soon. AIM: This study explored the views of doctors and nurses as to support for or opposition to legalising AD, including reasons for those views, what might deter generally willing doctors and nurses from providing AD services and what professional supports were perceived as essential or desirable to enable willing engagement in AD service provision. RESULTS: While only 37% of doctors supported legalising AD in New Zealand, 67% of nurses were supportive. Of those respondents who were willing in principle to provide AD services, large majorities identified a range of practical and ethical professional supports as essential to safe practitioner engagement. Those respondents overwhelmingly saw the provision of most of those supports as the responsibility of the medical and nursing professional bodies. CONCLUSION: There is a substantial cohort of doctors and nurses in New Zealand who support legalising AD, potentially sufficient for reasonable seeker access to AD services once legalised. However, many doctors in particular still oppose AD, and international research shows that the main barrier to access to legal AD is a lack of capacity and capability among health professionals, due in large part to several related factors, in particular: a lack of either accredited training and education for the AD provider tasks and roles; inadequate immunities within the legislation to protect participating professionals; and most importantly, a lack of practice standards and guidelines authorised by the relevant medical and nursing professional bodies. The challenge is for such protections to be available well in advance of legalisation, so that health practitioners are not at risk ethically or otherwise in early participation.

A critical exploration of a collaborative Kaupapa Maori consistent research project on physician-assisted dying.

AIM: This paper critically explores the research approach undertaken by Maori and tauiwi researchers working alongside kaumatua within the context of physician-assisted dying. We critically explore the collaborative process we undertook in framing the research context and discuss the rewards and challenges that emerged. METHOD: The research this critical discussion draws on undertook a qualitative Kaupapa Maori consistent research approach and drew on the principles of an Interface Research approach. The paper focuses on the collaborative approach taken between the 10 researchers involved in the study. RESULTS: Challenges identified within the collaborative Kaupapa Maori consistent research process included: determining appropriate authority and representation of researchers and participants; maintaining clear communication; time and logistical management. The key strengths that emerged from this research design were: establishing a culturally safe and robust research process; an ability to build and maintain relationships between researchers and participants; and the opportunity to develop academic research skills between researchers and participants. CONCLUSION: Collaborative Kaupapa Maori consistent research approaches to research can enable accountability, control and representation throughout the entire research process. Given the rich research results achieved and personal rewards gained from this study design, we would advocate for the application of such approaches within health research contexts.