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Background The patient–clinician interaction is a site at which defensive practice could occur, when clinicians provide tests, procedures and treatments mainly to reduce perceived legal risks, rather than to advance patient care. Defensive practice is a driver of low‐value care and exposes patients to the risks of unnecessary interventions. To date, patient perspectives on defensive practice and its impacts on them are largely missing from the literature. This exploratory study conducted in Australia aimed to examine the views and experiences of healthcare consumer representatives in this under‐examined area. Methods Semi‐structured interviews were conducted with healthcare consumer representatives involved in healthcare consumer advocacy organisations in Australia. Data were transcribed and analysed thematically. Results Nine healthcare consumer representatives participated. Most had over 20 years of involvement and advocacy in healthcare, including personal experiences as a patient or carer and/or formal service roles on committees or complaint bodies for healthcare organisations. Participants uniformly viewed defensive practice as having a negative impact on the clinician–patient relationship. Themes identified the importance of fostering patient–clinician partnership, effective communication and informed decision‐making. The themes support a shift from the concept of defensive practice to preventive practice in partnership, which focuses on the shared interests of patients and clinicians in achieving safe and high‐value care. Conclusion This Australian study offers healthcare consumers' perspectives on the impacts of defensive practice on patients. The findings highlight the features of clinician–patient partnership that will help to improve communication and decision‐making, and prevent the defensive provision of low‐value care. Patient or Public Contribution Healthcare consumer representatives were involved as participants in this study.

Research, policy and practice in the field of interprofessional collaboration have focused on how medical, nursing, allied health and social care practitioners work together to positively impact patient care. This paper extends conceptual thinking about interprofessional practice by focusing on lawyers as part of the interprofessional mix. This attention is prompted by medical���legal partnerships (MLPs), a service model by which lawyers join health care settings to assist patients with unmet, and often health-harming, legal needs. MLPs are present in around 450 hospitals and other health care sites across the United States and the model has spread to other countries, including Australia, the United Kingdom and Canada. However, enthusiasm for the MLP model is not yet matched by good evidence on how, when and for whom the model works. Interprofessional scholars contend that imprecise terminology and poor conceptualization of interprofessional arrangements hinder high-quality research and evaluation. In response to their critiques, this paper formulates a stepwise conceptual framework to guide the design, implementation and study of interprofessional arrangements that connect health, social care and legal practitioners. This framework draws on findings from national surveys of MLP initiatives in several countries and adapts several key conceptual frameworks that have been developed from systematic reviews of interprofessional working in primary health care. These conceptual frameworks are valuable because they promote clarity about different modes of interprofessional working and characterize the factors at macro (policy, funding), meso (organizational) and micro (practitioner, patient) levels that help or hinder professionals from different disciplines in working together. The paper considers factors at these three levels that require particular attention when lawyers join health care settings and proposes questions for future research in this emerging area.

Background Shortages of skills needed to deliver optimal health care in rural and remote locations raises questions about using extended scopes of practice or advanced practice models in a range of health professions. The nurse practitioner (NP) model was introduced to address health service gaps; however, its sustainability has been questioned, while other extended scope of practice roles have not progressed in Australia. This study aimed to explore the experiences and perceptions of NPs and their colleagues about barriers to and enablers of extended scope of practice and consider the relevance of the findings to other health professions. Methods Semi-structured, in-depth interviews were conducted with primary, nurse practitioner informants, who were also invited to nominate up to two colleagues, as secondary informants. Data analysis was guided by a multi-level, socio-institutional lens of macro-, meso- and micro-perspectives. Results Fifteen primary informants and five colleagues were interviewed from various rural and remote locations. There was a fairly even distribution of informants across primary, aged, chronic and emergency or critical care roles. Key barriers and enablers at each level of analysis were identified. At the macro-level were legal, regulatory, and economic barriers and enablers, as well as job availability. The meso-level concerned local health service and community factors, such as attitudes and support from managers and patients. The micro-level relates to day-to-day practice. Role clarity was of considerable importance, along with embedded professional hierarchies and traditional role expectations influencing interactions with individual colleagues. Given a lack of understanding of NP scope of practice, NPs often had to expend effort promoting and advocating for their roles. Conclusions For communities to benefit from extended scope of practice models of health service delivery, energy needs to be directed towards addressing legislative and regulatory barriers. To be successful, extended scope of practice roles must be promoted with managers and decision-makers, who may have limited understanding of the clinical importance. Support is also important from other members of the interprofessional health care team. Electronic supplementary material The online version of this article (10.1186/s12912-019-0337-z) contains supplementary material, which is available to authorized users.

This study systematically maps empirical research on physicians' views and experiences of hedging-type defensive medicine, which involves providing services (eg, tests, referrals) to reduce perceived legal risks. Such practices drive over-treatment and low value healthcare. Data sources were empirical, English-language publications in health, legal and multi-disciplinary databases. The extraction frame-work covered: where and when the research was conducted; what methods of data collection were used; who the study participants were; and what were the study aims, main findings in relation to hedging-type defensive practices, and proposed solutions. 79 papers met inclusion criteria. Defensive medicine has mainly been studied in the United States and European countries using quantitative surveys. Surgery and obstetrics have been key fields of investiga-tion. Hedging-type practices were commonly reported, including: ordering unnecessary tests, treatments and referrals; suggesting invasive procedures against professional judgment; ordering hospitalisation or delaying discharge; and excessive documentation in medical records. Defensive practice was often framed around the threat of negligence lawsuits, but studies recognised other legal risks, including patient complaints and regulatory investigations. Potential solutions to defensive medicine were identified at macro (law, policy), meso (organisation, profession) and micro (physician) levels. Areas for future research include qualitative studies to investigate the behavioural drivers of defensive medicine and intervention research to determine policies and practices that work to support clinicians in de-implementing defensive, low-value care. (c) 2021 Elsevier B.V. All rights reserved.

Objectives Doctors’ fear of legal liability and defensive practices are commonly cited as drivers of low value care. Defensive practices involve ordering tests and procedures, making referrals, and prescribing drugs to reduce perceived legal risks, rather than to advance patient care. Survey data report that defensive medicine is prevalent in countries across the world and significantly contributes to health care costs. This project aimed to understand psychosocial drivers and features of defensive practice. Methods Qualitative research with three groups of participants with medico-legal expertise purposively recruited from: (1) medical defence organisations/indemnity insurers, (2) medical colleges and societies and (3) peak healthcare consumer organisations, in Australia. Around 10 participants will be interviewed in each group (n=30–35 in total) using a semi-structured interview schedule grounded in the Theoretical Domains Framework of behavior change. The interview elicits participant’s views on e.g. drivers of defensive practice and low value care; barriers to and enablers of high value care; medical practices that are highly defensive (ie, driven mostly by legal fear); and potential interventions to address these problems. Interviews are audio-recorded, transcribed, and analysed thematically using Framework Analysis. Results Note that recruitment and interviews are ongoing at the time of abstract submission but will be completed in time for the conference. So far we have conducted 5 interviews of around 60 minutes each. Initial findings reveal that participants perceive defensive practice as a persistent problem, with drivers of low value care identified at the patient, clinician and policy level. According to the participants, strategies to reduce defensive practice should address factors such as: clinicians’ lack of knowledge of legal risks and responsibilities; challenges around doctor-patient communication and shared decision-making; and intolerance of uncertainty. Several participants emphasised the need for clinical leadership in this area and the importance of senior, respected clinicians setting examples and sending messages about avoiding defensive practice. Conclusions Defensive practice is driven by a complex constellation of factors. Our results so far suggest that interventions to address this problem should focus on promoting clinicians’ knowledge of legal duties and risks, enhancing their communication skills and changing their behaviour with the help of role models and peer support.

Background In 2014, Alberta’s health service providers implemented a province-wide Advance Care Planning (ACP) and Goals of Care Designation policy. Despite significant efforts, barriers to full implementation remain including lack of public comprehension across health, legal and other public systems. A World Cafe consultation revealed multi jurisdictional recommendations to ‘normalize ACP.’ Methods Through the ACP Collaborative Research Innovation Opportunities program, we formed a collaboration with lawyers, Legal Education Society of Alberta, Canadian Bar Association, Law Society of Alberta, palliative care physicians, patient advocates, academics, provincial health care providers and other stakeholders. A community of practice propagated spontaneously. Surveys and focus groups identified barriers, knowledge and resource gaps, and novel solutions, including joint health-legal education. Results Traditional approaches to ACP have been siloed. We expand on the innovative medico-legal framework to include other stakeholders including community agencies, faith groups, health advocacy agencies, national ACP projects, and the financial planning and insurance industries. Ongoing collaborative activities include community engagement, education, policy and practice innovation, which bundles activities relating to health care planning with those relating to personal and financial planning. Our business case addresses the identified gaps and adopts public recommendations through activities to coordinate, integrate and/or support development/implementation of a community volunteer program, an electronic registry for ACP and Goals of Care documentation, and a legal toolkit. Conclusion In practice, ACP spans medical, legal, social and personal domains. Multi-disciplinary and multi-sector approaches are posited to improve knowledge and uptake of ACP while improving the quality of life of Albertans.

Objectives Clinicians’ fear of legal liability and defensive practice are commonly cited as drivers of low value care. Defensive practice involves ordering tests and procedures, making referrals, and prescribing drugs mainly to reduce perceived legal risks, rather than to advance patient care. Literature on defensive practice dates back to the 1980s but has never been systematically analysed. We conducted the first-ever mapping review of published empirical studies on defensive practice. Methods We searched SCOPUS, Academic Search Complete (EBSCO), HeinOnline and Ovid MEDLINE with no restrictions. Two authors independently screened and extracted data using EPPI Reviewer software. We extracted data on: year of publication; country of study; study setting (eg, general practice clinic, emergency department); population studied (eg, GPs, surgeons); method of data collection (eg, survey, interview, record audits); and disciplinary affiliation of investigators (eg, medicine, law, economics). We also extracted key findings on the types of defensive practice reported, drivers of this behaviour, and proposed solutions. Results A total of 67 studies met our inclusion criteria. Most empirical studies on defensive practice have been done in the United States (28 out of 67), by medical researchers using quantitative surveys of clinicians, especially general practitioners, obstetricians and psychiatrists. Research activity on defensive practice intensified markedly from 2011 to present, with an increase in studies outside the US. This timing coincides with the expansion of international campaigns, such as Choosing Wisely, that promote appropriate care. Ordering unnecessary tests was the most commonly reported defensive practice. In addition to fear of legal liability, the culture of medicine and patient expectations were identified as drivers of low value care that can lead to overdiagnosis and overtreatment. Proposed solutions included ameliorating clinicians’ ‘existential anxiety’ about medico-legal risk and reducing ‘blame culture’ through system-level changes. Conclusions Available empirical data on defensive practice is limited by the predominant focus on the American medico-legal context. Caution is needed in applying these data to other countries with differing healthcare and legal systems. More qualitative research is needed to explore the behavioural drivers of defensive practice and potential solutions to legal fears that contribute to overdiagnosis and overtreatment. Our Australian research is a step toward filling this gap.

© 2019, Journal of Bioethical Inquiry Pty Ltd. People with dementia have commonly been excluded from research. The adverse impacts of this exclusion are now being recognized and research literature, position statements, and ethics guidelines increasingly call for inclusion of people with dementia in research. However, few published studies investigate the views of potential participants on taking part in research should they experience dementia-related cognitive impairment. This cross-sectional survey examined the views of people aged sixty and older (n=174) attending hospital outpatient clinics about clinical research participation if they had dementia and impaired decision-making ability. Over 90 percent of respondents were agreeable to participating in a wide range of research activities, such as cognitive testing, physical measurements, imaging procedures, and blood draws. For drug studies, however, agreement dropped to 60 percent. Altruism was a strong motivator for research participation. In regard to who should be involved in decisions about their participation in research during periods of incapacity, respondents mostly preferred the person they appoint as their substitute decision-maker for healthcare matters (88%) or a doctor or health professional on the research team (78%). Over three-quarters (79%) expressed interest in making an advance research directive. The study findings are discussed in relation to law reforms in Australia that aim to strengthen respect and inclusion for people with impaired decision-making capacity, especially by providing frameworks for advance planning for research participation.

© 2018 The Author(s). Background: Advance personal planning is the process by which people consider, document and communicate their preferences for personal, financial and health matters in case they lose the ability to make decisions or express their wishes in the future. Discussion: Advance personal planning is most often undertaken by individuals who are seriously ill, often in the context of a medical crisis and/or at the time of admission to hospital. However, the clinical utility and legal validity of the planning process may be compromised in these circumstances. Patients may lack sufficient capacity to meaningfully engage in advance personal planning; there may be insufficient time to adequately reflect on and discuss wishes with key others; and there may also be limited opportunity for inter-professional input and collaboration in the process. Here, we propose an agenda for research to advance the science of advance personal planning by promoting a 'whole community' approach. Adoption of advance personal planning at a community level may be achieved using a variety of strategies including public media campaigns, intervening with professionals across a range of health care and legal settings, and mobilising support from influential groups and local government. One potentially promising method for encouraging earlier adoption of advance personal planning among a broader population involves a community action approach, whereby multiple evidence-based strategies are integrated across multiple access points. Community action involves calling on community members, professionals, community and/or government organisations to work collaboratively to design and systematically implement intervention strategies with the aim of bringing about desired behaviour change. An example of a community action trial to improving uptake and quality of advance personal planning is described. Conclusion: While promising, there is a need for rigorous evidence to demonstrate whether a community action approach is effective in establishing whole community adoption of advance personal planning.

Advance care planning (ACP) is the process of thinking about, discussing and documenting one’s preferences for future health care. ACP has important benefits: people who have a written directive are more likely to receive care that accords with their preferences, have fewer hospitalizations, and die in their preferred location. This article focuses on the important role that legal professionals have in advising and assisting clients with ACP. Studies report that people who have a written advance care plan are more likely to have received assistance in preparing the document from a lawyer than from a doctor. Yet virtually no research engages with the legal profession to understand lawyers’ attitudes, beliefs, and practices in this important area. This article starts to fill this gap by reporting the findings of a survey of lawyers in the province of Alberta. The results reveal lawyers’ practices in relation to ACP, their perceptions of their professional role and factors that support or hinder lawyers in working with clients on ACP, and their preferences for resources to assist them in helping their clients. To the authors’ knowledge, this is the first survey of lawyers on their practices in relation to ACP.

Many factors affect whether and how practitioners from different professions work together to deliver healthcare services. In a recent review, Mulvale, Embrett, and Razavi (2016) identified 18 fact...

The provision of unnecessary healthcare is a serious problem in Australia and involves two key legal issues. First, doctors’ fear of litigation drives defensive practices – ordering tests and procedures, making referrals, and prescribing drugs to reduce perceived legal risks, rather than to advance patient care. Second, suboptimal communication and decision making processes undermine a patient’s right to make informed healthcare choices. This article critically analyses these problems and proposes solutions. An extensive body of medico-legal literature is synthesised to highlight gaps between legal requirements and what happens in practice. Negligence case law is discussed to clarify legal principles and show that courts discourage defensive practice. Finally, the article presents practical strategies to enhance communication and shared decision making in the clinical encounter.

Interprofessional collaboration in healthcare describes a model of practice where multiple health professionals work together in a team-based approach to patient care. A growing body of literature demonstrates that interprofessional collaboration advances healthcare quality and safety, improves patient outcomes and experiences of care, and promotes job satisfaction among health professionals. Governments and health organisations across Canada are working to advance interprofessional healthcare delivery. This paper examines the importance of law in supporting a shift to interprofessional collaboration in Canadian healthcare and discusses two key aspects of the legal context in which health practitioners work. First, the paper discusses trends in the legal regulation of health professions in Canada, including law reform initiatives aimed at promoting collaborative practice and expanding scopes of practice to break down the historically siloed approach to healthcare delivery. Second, the papers examines civil liability rules that courts apply when allegations of negligence are made against health care providers working in team-based situations. New legislative models that provide for expanded and overlapping scopes of practice, and which introduce new professional roles into the health workforce, may raise legal concerns regarding responsibility for patient care and outcomes. The paper illustrates how legal innovations, such as new models of health profession regulation, and legal adaptability, through judicial understanding of the modern context of health service delivery, are important to the advancement of interprofessional collaboration in Canadian healthcare.

Objectives: The A/H1N1 mass vaccination program in Canada garnered considerable attention from the media, including extensive newspaper coverage. Media reports have been shown to influence the public’s health care decisions, including vaccination choices. We analyzed Canadian newspapers’ portrayal of the A/H1N1 vaccine including mention of risks and benefits of the vaccine and whether the article supported, questioned or was neutral about the vaccine. Methods: We compiled a data set of Canadian newspaper articles (N=234) and conducted a frequency content analysis to examine discussion and/or mention of evidence concerning vaccination, risks of the A/H1N1 virus and the vaccine, and tone of article in regards to the vaccination program in Canada. Results: Reasons for getting vaccinated appeared in 71.8% of the articles, whereas only 18.4% provided reasons against getting vaccinated. Discussion of evidence to support claims for or against getting vaccinated appeared in only 27.8% and 6.8% of the articles, respectively. Risks associated with contracting the A/H1N1 virus were discussed in 49.6% of the articles and risks of the A/H1N1 vaccine were discussed in 12.4% of the articles. Conclusion: Newspaper coverage in Canada was largely supportive of the A/H1N1 mass vaccination program. However, serious risks associated with contracting the A/H1N1 virus were also frequently discussed in the print media. The news articles rarely presented direct evidence to support statements that the vaccine was safe, effective and properly tested. Known risks (such as potential allergic reactions and flu-like side effects) of the vaccine were rarely reported. The relationship between media portrayals and vaccine uptake warrants further research. Key words: Newspapers; influenza vaccines; Canada

Nutritional genomics has reached the public through applications of the Human Genome Project offered direct to consumers (DTC). The ability to pursue nutrigenetic testing without the involvement of a health care professional has received considerable attention from academic and policy commentators. To better understand the knowledge and attitudes of Canadian health care professionals regarding nutritional genomics and nutrigenetic testing, qualitative research in the form of focus group discussions was undertaken. Four key themes emerged: (1) concerns over DTC testing; (2) lack of health care professional competency; (3) genetic scepticism and inevitability; (4) expectation of regulation. Together, they indicate that health care professionals have little knowledge about nutritional genomics and hold contradictory attitudes towards genomics in general, and to nutritional genomics in particular. Respondents argue in favour of a delivery model where health care professionals act as intermediaries. They are also aware of their lack of competency to provide such services. To ensure greater public protection, respondents cite the importance of more stringent regulatory oversight of DTC genetic testing. Whether such an approach is necessary to address the various ethical and social issues raised by nutrigenetic testing remains an open debate.

A wide variety of genetic tests are now being marketed and sold in direct-to-consumer (DTC) commercial transactions. However, risk information revealed through many DTC testing services, especially those based on emerging genome wide-association studies, has limited predictive value for consumers. Some commentators contend that tests are being marketed prematurely, while others support rapid translation of genetic research findings to the marketplace. The potential harms and benefits of DTC access to genetic testing are not yet well understood, but some large-scale studies have recently been launched to examine how consumers understand and use genetic risk information. Greater consumer access to genetic tests creates a need for continuing education for health care professionals so they can respond to patients' inquiries about the benefits, risks and limitations of DTC services. Governmental bodies in many jurisdictions are considering options for regulating practices of DTC genetic testing companies, particularly to govern quality of commercial genetic tests and ensure fair and truthful advertising. Intersectoral initiatives involving government regulators, professional bodies and industry are important to facilitate development of standards to govern this rapidly developing area of personalized genomic commerce.

Nutrigenomics, the conjunction of molecular nutrition with human genomics, is among the first publicly available applications of the human genome project. Nutrigenomics raises ethical, legal and social issues particularly with respect to how the public may access nutrigenetic tests and associated nutritional and lifestyle advice. Current regulatory controversy focuses on potential harms associated with direct-to-consumer (DTC) marketing of nutrigenetic tests and especially the need to protect consumers from unreliable tests, false claims and unproven dietary supplements. Nutrigenomics does, however, offer the potential of important health benefits for some individuals. The regulation of nutrigenomic services is slowly evolving, but there is little indication of increased professional capacity to support service delivery. Primary care physicians have minimal training in nutrition and genetics, and medical geneticists are in high demand and short supply. Dietetic practitioners are experts in nutrition science and interest in nutrigenomics is growing among members of this professional group. However, as with physicians, dietetics practitioners would require considerable training to bring nutrigenomics into their practice capacity. A downside of regulatory restrictions on direct consumer access to nutrigenomics companies is that responsible businesses may be hindered in meeting emergent public demand while health care professional groups have not yet developed capacity to provide nutrigenomics services.

The authority to quarantine individuals was tested by the 2003 global outbreak of SARS. Quarantine was used during that lime as a public health intervention tool to attempt to control the disease in Toronto. The outbreak put the public health preparedness of the Ontario legal system to the test. This article examines the legal issues related to the use of quarantine as a tool to control infectious disease outbreaks using the Ontario SARS epidemic as a case study. The author first analyzes the laws authorizing public health officials to use quarantine and then identifies the legislative gaps that SARS exposed in these laws. The article then looks at the current legislative reform efforts to create a more prepared legal environment in the event of another public health crisis such as SARS. In addition, the impact of quarantine on an individual and his or her family, including social and economic impacts, as well as its effect on the health care system is discussed. Finally, the legal limits on the use of quarantine are further examined. The author concludes that, because it is likely that a novel infectious agent such as SARS will surface in the future, the public health authorities must be vigilant by ensuring public health legal preparedness.