Challenges in maintaining treatment services for people who use drugs during the COVID-19 pandemic.

The impact of COVID-19 across health services, including treatment services for people who use drugs, is emerging but likely to have a high impact. Treatment services for people who use drugs provide essential treatment services including opiate agonist treatment and needle syringe programmes alongside other important treatment programmes across all substance types including withdrawal and counselling services. Drug and alcohol hospital consultation-liaison clinicians support emergency departments and other services provided in hospital settings in efficiently managing patients who use drugs and present with other health problems.COVID-19 will impact on staff availability for work due to illness. Patients may require home isolation and quarantine periods. Ensuring ongoing supply of opiate treatment during these periods will require significant changes to how treatment is provided. The use of monthly depot buprenorphine as well as moving from a framework of supervised dosing will be required for patients on sublingual buprenorphine and methadone. Ensuring ready access to take-home naloxone for patients is crucial to reduce overdose risks. Delivery of methadone and buprenorphine to the homes of people with confirmed COVID-19 infections is likely to need to occur to support home isolation.People who use drugs are likely to be more vulnerable during the COVID-19 epidemic, due to poorer health literacy and stigma and discrimination towards this group. People who use drugs may prioritise drug use above other health concerns. Adequate supply of clean injecting equipment is important to prevent outbreaks of blood-borne viruses. Opiate users may misinterpret SARS-CoV2 symptoms as opiate withdrawal and manage this by using opioids. Ensuring people who use drugs have access to drug treatment as well as access to screening and testing for SARS-CoV2 where this is indicated is important.

Study protocol to investigate the efficacy of normalisation of Advance Care Planning (ACP) for people with chronic diseases in acute and community settings: a quasi-experimental design.

BACKGROUND: Advanced care planning (ACP) is a process that involves thinking about what medical care one would like should individuals be seriously ill and cannot communicate decisions about treatment for themselves. The literature indicates that ACP leads to increased satisfaction from both patients and healthcare professionals. Despite the well-known benefits of ACP, it is still underutilised in Australia. METHODS: The aim of this study is to investigate the effects of normalising ACP in acute and community settings with the use of specially trained normalisation agents. This is a quasi-experimental study, involving 16 sites (8 intervention and 8 control) in two health districts in Australia. A minimum of total 288 participants will be recruited (144 intervention, 144 control). We will train four registered nurses as normalisation agents in the intervention sites, who will promote and facilitate ACP discussions with adult patients with chronic conditions in hospital and community settings. An audit of the prevalence of ACP and Advanced Care Directives (ACDs) will be conducted before and after the 6-month intervention period at the 16 sites to assess the effects of the ACP service delivered by these agents. We will also collect interview and survey data from patients and families who participate, and healthcare professionals who are involved in this service to capture their experiences with ACP. DISCUSSION: This study will potentially contribute to better patient outcomes with their health care services. Completion of ACDs will allow patients to express their wishes for care and receive the care that they wish for, as well as ease their family from the burden of making difficult decisions. The study will contribute to development of a new best practice model to normalise ACP that is sustainable and transferable in the processes of: 1) initiation of conversation; 2) discussion of important issues; 3) documentation of the wishes; 4) storage of the documented wishes; and 5) access and execution of the documented wishes. The study will generate new evidence on the challenges, strategies and benefits of normalising ACP into practice in acute and community settings. TRIAL REGISTRATION: This project has been approved by the Hunter New England Human Research Ethics Committee (Approval No. 17/12/13/4.16). It has also been retrospectively registered on 3 October 2018 with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ). This study will operate in accordance with the National Health and Medical Research Council's National Statement on Ethical Conduct in Human Research (2007) and the CPMP/ICH Note for Guidance on Good Clinical Practice.

Cultural and religious beliefs and values, and their impact on preferences for end-of-life care among four ethnic groups of community-dwelling older persons.

AIMS AND OBJECTIVES: To explore specific cultural and religious beliefs and values concerning death and dying, truth telling, and advance care planning, and the preferences for end-of-life care among older persons from culturally and linguistically diverse backgrounds. BACKGROUND: Whilst literature indicates that culture impacts on end-of-life decision-making significantly, there is limited evidence on the topic. DESIGN: A cross-sectional survey. METHODS: A total of 171 community older persons who make regular visits to 17 day care centres expressed in a questionnaire their; (1) beliefs about death and dying, truth telling, and advance care planning, and (2) preferences for end-of-life care. RESULTS: More than 92% of respondents believed that dying is a normal part of life, and more than 70% felt comfortable talking about death. Whilst respondents accepted dying as a normal part of life, 64% of Eastern Europeans and 53% of Asia/Pacific groups believed that death should be avoided at all costs. People from the Asia/Pacific group reported the most consensual view against all of the life-prolonging measures. CONCLUSION: Cultural and religious beliefs and values may have an impact on preferences for treatment at end-of-life. The study offers nurses empirical data to help shape conversations about end-of-life care, and thus to enhance their commitment to help people 'die well'. RELEVANCE TO CLINICAL PRACTICE: Information acquisition to extend understanding of each individual before proceeding with documentation of advance care planning is essential and should include retrieval of individuals' cultural and religious beliefs and values, and preferences for care. An institutional system and/or protocol that promote conversations about these among nurses and other healthcare professionals are warranted.

Development of a video-based education and process change intervention to improve advance cardiopulmonary resuscitation decision-making.

BACKGROUND: Advance cardiopulmonary resuscitation (CPR) decision-making and escalation of care discussions are variable in routine clinical practice. We aimed to explore physician barriers to advance CPR decision-making in an inpatient hospital setting and develop a pragmatic intervention to support clinicians to undertake and document routine advance care planning discussions. METHODS: Two focus groups, which involved eight consultants and ten junior doctors, were conducted following a review of the current literature. A subsequent iterative consensus process developed two intervention elements: (i) an updated 'Goals of Patient Care' (GOPC) form and process; (ii) an education video and resources for teaching advance CPR decision-making and communication. A multidisciplinary group of health professionals and policy-makers with experience in systems development, education and research provided critical feedback. RESULTS: Three key themes emerged from the focus groups and the literature, which identified a structure for the intervention: (i) knowing what to say; (ii) knowing how to say it; (iii) wanting to say it. The themes informed the development of a video to provide education about advance CPR decision-making framework, improving communication and contextualising relevant clinical issues. Critical feedback assisted in refining the video and further guided development and evolution of a medical GOPC approach to discussing and recording medical treatment and advance care plans. CONCLUSION: Through an iterative process of consultation and review, video-based education and an expanded GOPC form and approach were developed to address physician and systemic barriers to advance CPR decision-making and documentation. Implementation and evaluation across hospital settings is required to examine utility and determine effect on quality of care.

'Planning ahead' among community-dwelling older people from culturally and linguistically diverse background: a cross-sectional survey.

AIMS AND OBJECTIVES: To explore preparedness of end-of-life care planning among community-dwelling older persons of culturally and linguistically diverse background. BACKGROUND: To improve end-of-life care through advance care planning, the key concept 'Planning ahead' has been promoted in Australia. However, since the introduction of the model in 2008, it is not known whether 'Planning Ahead' practice by older people from culturally and linguistically diverse backgrounds has improved. DESIGN: A cross-sectional survey. METHODS: A total of 453 community older adults (65+) who attended 17 day care centres in a region were invited to participate in the study. A total of 229 people completed the survey with a response rate of 50·5%. The questions relevant to this study include: (1) awareness of enduring guardian, advance care directive and advance care planning, (2) the preference for substitute decision-makers and (3) the challenges experienced with advance care planning. RESULTS: Awareness of advance care planning was low, and completion of advance care directive was very low. 37·5% of Anglo Celtic group had an enduring guardian, compared with 15·5, 24·1 and 13·3% from Mediterranean, Eastern European and Asia/Pacific group, respectively. Children were the most preferred substitute decision-makers more for Asia/Pacific group than Anglo Celtic, Mediterranean and Eastern Europeans. The various difficulties experienced included being time-consuming, difficult to understand terms and forms, and do not know how to do it. CONCLUSION: Regardless of cultural and ethnic backgrounds, a low level of 'Planning ahead' practices was apparent because of a lack of understanding of the concept, the forms and the processes involved. The gap identified between the existing legal/ethical frameworks and the preferences of older people as substitute decision-makers adds new knowledge for further discussion. RELEVANCE TO CLINICAL PRACTICE: Nursing professionals are provided with an opportunity to improve their practice to meet the needs of older persons and their families in planning ahead for future treatment options.

Dying in two acute hospitals: would usual care meet Australian national clinical standards?

The Australian Commission for Quality and Safety in Health Care (ACQSHC) has articulated 10 clinical standards with the aim of improving the consistency of quality healthcare delivery. Currently, the majority of Australians die in acute hospitals. But despite this, no agreed standard of care exists to define the minimum standard of care that people should accept in the final hours to days of life. As a result, there is limited capacity to conduct audits that focus on the gap between current care and recommended care. There is, however, accumulating evidence in the end of life literature to define which aspects of care are likely to be considered most important to those people facing imminent death. These themes offer standards against which to conduct audits. This is very apt given the national recommendation that healthcare should be delivered in the context of considering people's wishes while always treating people with dignity and respect.

A pilot audit of the process of end-of-life decision-making in the intensive care unit.

BACKGROUND: Withdrawal of potentially life-prolonging treatments is a common procedure in most intensive care units. Until recently, quality improvement activities have been hampered by the absence of a clear sense of "best practice" in this complex area. OBJECTIVE: This pilot audit addresses the feasibility of developing an end-of-life (EOL) decision-making audit and quality improvement tool and applying it in the intensive care setting. METHODS: Between November 2005 and April 2006, treatment was withdrawn from 47 patients in our ICU. Their charts were audited, and a structured interview was conducted with the intensivist who documented the decision. We defined treatment withdrawal as the cessation of mechanical ventilation and all other forms of life support in the anticipation of the patient's death. RESULTS: 55% of ICU deaths were the result of treatment withdrawal. Overwhelmingly, treatment failure or futility was the reason cited for withdrawal. There were no cases of conflict between the medical team and the patient's family. The level of confidence among intensivists about EOL decision-making was high. Consultation with ICU colleagues was rated as the most helpful factor in decisionmaking. Intensivists wished for earlier and more active support from the admitting medical officers in decisionmaking. Strong support for advance planning and for audit of EOL decision-making was highlighted. CONCLUSIONS: A current ICU quality improvement review lists EOL management as a possible audit item (Curtis et al. Crit Care Med 2006; 34: 211). Our study demonstrated the feasibility of developing a quality improvement tool for EOL decision-making and applying it in the intensive care setting. As evidence about the process of EOL decisionmaking accumulates, that process should become a component of quality assurance audit in intensive care.

Acute clinical ethics consultation: the practicalities.

In Australia there has been only limited experience with ethics consultation, and there are no reports of practical details. In 1999, the Institutional Clinical Ethics Committee at John Hunter Hospital, Newcastle, initiated an Acute Clinical Ethics Service (ACES) to formalise a perceived need within the hospital for ethics consultation. This need had previously been met by ad-hoc councils of "wise men". The ACES approach uses a team of people with different perspectives to provide an ethics consultation in a timely manner. Our initial experience of ACES has shown that a formal process of ethics consultation may be preferable to informal approaches in many circumstances; even when genuine consensus is not possible, an ethics consultation nevertheless provides an opportunity to share different points of view and helps to avoid practices that may be unacceptable. The specific implications of acute ethics consultations are not yet fully elucidated.