R Fullam

Teaching general practitioners and doctors-in-training to discuss advance care planning: evaluation of a brief multimodality education programme

Objective To develop and evaluate an interactive advance care planning (ACP) educational programme for general practitioners and doctors-in-training. Design Development of training materials was overseen by a committee; informed by literature and previous teaching experience. The evaluation assessed participant confidence, knowledge and attitude toward ACP before and after training. Setting Training provided to metropolitan and rural settings in Victoria, Australia. Participants 148 doctors participated in training. The majority were aged at least 40 years with more than 10 years work experience; 63% had not trained in Australia. Intervention The programme included prereading, a DVD, interactive patient e-simulation workshop and a training manual. All educational materials followed an evidence-based stepwise approach to ACP: Introducing the topic, exploring concepts, introducing solutions and summarising the conversation. Main outcome measures The primary outcome was the change in doctors’ self-reported confidence to undertake ACP conversations. Secondary measures included pretest/post-test scores in patient ACP e-simulation, change in ACP knowledge and attitude, and satisfaction with programme materials. Results 69 participants completed the preworkshop and postworkshop evaluation. Following education, there was a significant change in self-reported confidence in six of eight items (p=0.008 –0.08). There was a significant improvement (p<0.001) in median scores on the e-simulation (pre 7/80, post 60/80). There were no significant differences observed in ACP knowledge following training, and most participants were supportive of patient autonomy and ACP pretraining. Educational materials were rated highly. Conclusions A short multimodal interactive education programme improves doctors’ confidence with ACP and performance on an ACP patient e-simulation.

Quality of advance care planning policy and practice in residential aged care facilities in Australia

Objectives To assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes towards ACP. Design Surveys of participating organisations concerning ACP-related policies and procedures, review of existing ACP-related documentation, and pre-intervention survey of RACF staff covering their role, experiences and attitudes towards ACP-related procedures. Setting 19 selected RACFs in Victoria. Participants 12 aged care organisations (representing 19 RACFs) who provided existing ACP-related documentation for review, 12 RACFs who completed an organisational survey and 45 staff (from 19 RACFs) who completed a pre-intervention survey of knowledge, attitudes and behaviour. Results Findings suggested that some ACP-related practices were already occurring in RACFs; however, these activities were inconsistent and variable in quality. Six of the 12 responding RACFs had written policies and procedures for ACP; however, none of the ACP-related documents submitted covered all information required to meet ACP best practice. Surveyed staff had limited experience of ACP, and discrepancies between self reported comfort, and levels of knowledge and confidence to undertake ACP-related activities, indicated a need for training and ongoing organisational support. Conclusions Surveyed organisations â policies and procedures related to ACP were limited and the quality of existing documentation was poor. RACF staff had relatively limited experience in developing advance care plans with facility residents, although attitudes were positive. A systematic approach to the implementation of ACP in residential aged care settings is required to ensure best practice is implemented and sustained.

Development and evaluation of an aged care specific Advance Care Plan

Objectives To report on the quality of advance care planning (ACP) documents in use in residential aged care facilities (RACF) in areas of Victoria Australia prior to a systematic intervention; to report on the development and performance of an aged care specific Advance Care Plan template used during the intervention. Design An audit of the quality of pre-existing documentation used to record resident treatment preferences and end-of-life wishes at participating RACFs; development and pilot of an aged care specific Advance Care Plan template; an audit of the completeness and quality of Advance Care Plans completed on the new template during a systematic ACP intervention. Participants and setting 19 selected RACFs (managed by 12 aged care organisations) in metropolitan and regional areas of Victoria. Results Documentation in use at facilities prior to the ACP intervention most commonly recorded preferences regarding hospital transfer, life prolonging treatment and personal/cultural/religious wishes. However, 7 of 12 document sets failed to adequately and clearly specify the residents preferences as regards life prolonging medical treatment. The newly developed aged care specific Advance Care Plan template was met with approval by participating RACFs. Of 203 Advance Care Plans completed on the template throughout the project period, 49% included the appointment of a Medical Enduring Power of Attorney. Requests concerning medical treatment were specified in almost all completed documents (97%), with 73% nominating the option of refusal of life-prolonging treatment. Over 90% of plans included information concerning residents’ values and beliefs, and future health situations that the resident would find to be unacceptable were specified in 78% of completed plans. Conclusions Standardised procedures and documentation are needed to improve the quality of processes, documents and outcomes of ACP in the residential aged care sector.

Does the Youth Level of Service/Case Management Inventory Generalize Across Ethnicity?

Few studies have explored the cross-cultural utility of youth violence risk instruments. Moreover both the discrimination and calibration performance indicators of such instruments are rarely investigated. This study aimed to address both gaps in the literature by exploring the predictive validity of the YLS/CMI instrument for an Australian multi-ethnic cohort of young offenders in custody. The YLS/CMI total score was able to discriminate between re-offenders and non-reoffenders for the overall sample; however, a breakdown across ethnicity showed only strong effects for Australian English Speaking Background youth. Despite an inability to distinguish re-offenders from non-reoffenders for both Culturally and Linguistically Diverse and Indigenous youth, the instrument was able to accurately predict recidivism for high-risk youth for all ethnic groups. Findings highlight the importance of adopting both calibration and discrimination indicators when assessing predictive validity.

Australian Psychiatrists' Support for Psychiatric Advance Directives: Responses to a Hypothetical Vignette

This study examines whether Australian psychiatrists would support requests in a psychiatric advance directive (PAD) and the reasons underlying their decisions in response to a hypothetical vignette. An online survey was completed by 143 psychiatrists. Fewer than 3 out of 10 psychiatrists supported the patient to create a PAD which requested cessation of pharmacotherapy (27%) or remaining out of hospital and not being subject to an involuntary treatment order (24%) should their depression condition deteriorate. A thematic analysis showed that patient autonomy was the strongest theme among those who supported the patient to create a PAD, whereas the clinical profile of and risk to the patient and the professional or ethical imperative of the psychiatrist were strongest among those who were unsure about supporting the patient or who did not support the patient. These findings provide a challenge about how to fulfil obligations under the United Nations Convention on the Rights of Persons with Disabilities (2006).

An analysis of high-risk offending pathways for young females in custody

Abstract Adolescent females who have engaged in severe and/or chronic offending are an understudied population internationally. The literature on female offending pathways has indeed advanced, and there is a better understanding of how female offending behaviours manifest and how correctional agencies should be responding. However, much of the existing research has focused on the risk factors and retrospective biographical narratives of adult female offenders. The present study focused on thematically exploring the self-reported life experiences and offending pathways of 36 detained adolescent females. Findings identified multiple themes including disconnection from education, early care-giver disruption/family separation, personal and family mental health problems, poly-substance abuse, anti-social peers, victimisation and anger problems. The study identifies that early family disruption is an important factor that may contribute to later offending behaviour and other negative life events. Prevention efforts should begin with the family when it comes to high-risk young females.

Making health choices; Part 1. Advance Care planning in aged care project. Setting the scene

Introduction The (2009) Australian National Health & Hospital Reform Commission Report highlighted the need for advance care planning (ACP) for older persons in residential aged care facilities (RACFs). Using knowledge gained from a previous RACF Project Implementation in 2004-5, Respecting Patient Choices has developed a sustainability based model for the effective training of residential aged care service staff to deliver ACP to their residents. This presentation will provide a unique insight into the complexities of ACP implementation within Australian residential aged care. Project methods 19 individual RACFs, representing 12 Aged Care organisations were selected from regional and metropolitan areas of Victoria. Three full-day workshops were delivered over a 6 month period, with RACFs expected to complete sustainability oriented tasks in between each workshop in order to meet the project deliverables. As part of the project an aged care specific ACP document was developed by an expert working party. Pre-implementation over-view A number of contextual factors have impacted the present project including; Australian geography, RACF funding issues, and provision of medical support to RACF residents. Results from a pre-implementation policy and practice survey demonstrated a wide variation of the quality of existing ACP knowledge and practices. An audit of pre-existing ACP documents revealed that all documents were missing key elements of a best practice ACP document. 11 of the 12 organisations in the project have adopted the specially developed document.