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Objectives: The assessment and management of a patient who refuses medical treatment requires clinical skill, and consideration of the relevant law and the patient's decision-making capacity. Psychiatrists are often asked to advise in these situations. We aimed to develop an algorithm describing the relevant legal pathways to assist clinicians, especially psychiatrists, working in New South Wales (NSW), Australia.Methods: We reviewed the academic literature on treatment refusal, relevant legislation, judicial rulings and NSW Health policy directives and guidelines. We consulted with clinicians and representatives of relevant tribunals.Results: We developed an algorithm for managing patients who refuse medical treatment in NSW. The algorithm emphases the evaluation of decision-making capacity and tracks separate pathways depending upon a person's status under the Mental Health Act 2007 (NSW).Conclusions: The algorithm provides a clear decision tree for clinicians responding to a patient refusing medical treatment in NSW. [ABSTRACT FROM AUTHOR]

Background: To effectively care for people who are terminally ill, including those without decision-making capacity, palliative care physicians must know and understand the legal standing of Advance Care Planning in their jurisdiction of practice. This includes the use of advance directives/living wills and substitute decision-makers who can legally consent to or refuse treatment if there is no valid advance directive. Aim: This study aimed to investigate the knowledge, attitudes and practices of medical specialists most often involved in end-of-life care in relation to the law on withholding/withdrawing life-sustaining treatment from adults without decision-making capacity. Design/participants: A pre-piloted survey was posted to specialists in palliative, emergency, geriatric, renal and respiratory medicine; intensive care; and medical oncology in three Australian States. Surveys were analysed using SPSS 20 and SAS 9.3. Results: The overall response rate was 32% (867/2702) – 52% from palliative care specialists. Palliative care specialists and geriatricians had significantly more positive attitudes towards the law ( χ 42 2 = 94 . 352 ; p < 0.001) and higher levels of knowledge about the withholding/withdrawing life-sustaining treatment law ( χ 7 2 = 30 . 033 ; p < 0.001) than did the other specialists, while still having critical gaps in their knowledge. Conclusion: A high level of knowledge of the law is essential to ensure that patients’ wishes and decisions, expressed through Advance Care Planning, are respected to the maximum extent possible within the law, thereby according with the principles and philosophy of palliative care. It is also essential to protect health professionals from legal action resulting from unauthorised provision or cessation of treatment. [ABSTRACT FROM AUTHOR]

Objective: In some Australian states clinicians and mental health tribunal members are already required to assess a person's decision-making capacity before involuntary treatment can be applied. Professionals in other jurisdictions will likely soon be required to do the same as mental health law reform in most Australian jurisdictions makes the assessment of decision-making capacity a central component of the process of providing unconsented psychiatric treatment. We provide a guide to the legal issues around the capacity to refuse psychiatric treatment to assist with this task. Method: We review the legislation in the four Australian states most advanced in the mental health law reform process and use examples from clinical practice and the common law to describe how decision-making capacity should be assessed by these statutory standards. Results: Clinicians and tribunal members will primarily be required to judge whether a person with mental illness can understand the information relevant to the treatment decision and whether he or she can use or weigh that information to come to a decision. A person with a mental illness is presumed to have capacity, but that presumption can be rebutted. Capacity is specific to the decision at hand and cannot be determined by the nature of the decision made. Conclusions: The information provided should assist clinicians and tribunal members to make determinations of decision- making capacity around treatment refusal in the context of mental illness. [ABSTRACT FROM AUTHOR]

Aim: To review the experience of a dedicated paediatric multidisciplinary lipid clinic in the management of familial hypercholesterolaemia (FH) by studying the demographics, clinical presentations as well as statin therapy and outcomes., Methods: Retrospective database review of all patients under 18 years old seen in the lipid clinic at an Australian tertiary paediatric hospital between April 1999 and August 2017. Outcome measures collected included patient demographics, family history, lipid profile, age at treatment commencement, treatment outcomes and complications., Results: One hundred and eight patients (53 males) were seen in the lipid clinic. Eighty-five had low-density lipoprotein cholesterol (LDL-C) levels at or above the 75th percentile for sex prior to treatment. Of these, 75 had a first-degree relative with hypercholesterolaemia and/or early cardiac death. Four patients had clinical manifestations. Thirty-two patients (14 males) were started on statin therapy for likely FH. LDL-C levels reduced by 2.4 mmol/L (1.4 to 2.7) in boys and 1.9 mmol/L (0.8 to 2.8) in girls at 12 month follow-up. Five patients reported side effects requiring adjustment in therapy. Main reasons for not starting statin therapy in eligible patients were parental refusal and/or lost to follow up (77%)., Conclusion: A dedicated multidisciplinary lipid clinic is helpful for streamlining and monitoring management of paediatric FH. Clinical manifestations of FH are rare in children and may represent more severe form of FH or other lipid disorder. Statin therapy is efficacious and well tolerated but current recommended targets of treatment are difficult to attain. Greater awareness and coordinated services are required to overcome poor family engagement., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

The duty of care concept is a common law legal principle which underpins all healthcare interactions. However, evidence within the Australian context suggests misuse of this common law principle as a justification for non-consensual coercive treatment. Misuse seems to occur particularly where patients have impaired decision-making capacity and/or refuse treatment. In this article, we discuss the emerging evidence of misuse, which arguably reflects healthcare practitioner confusion between the doctrines of 'duty of care' and 'necessity', and posit that cognisance of lawful substitute consent processes are lacking. We then discuss the concept of duty of care as an obligation, as opposed to a power, before presenting the elements of a valid consent and legislation relating to substitute consent, which allow health practitioners to proceed with treatment. We conclude this article with a discussion of the circumstances where treatment may be given without consent. [ABSTRACT FROM AUTHOR]

The law recognises that children can exert an increasing level of autonomy and decision-making about their healthcare as they mature, and that intelligence and maturity levels will vary from one child to the next. Therefore, the parameters for when older children can consent to healthcare can be a complex area for clinicians to navigate. Refusal of treatment provides additional challenges for clinicians because the law is less clear about when older children can be involved in refusing treatment which is in their best interests. This article outlines relevant legislation concerning child consent to treatment across Australian jurisdictions and examines refusal of treatment by children using the 2018 case of Mercy Hospitals Victoria v D1 & Anor., (© 2020 Australasian College for Emergency Medicine.)

Background: Homeless individuals suffer a greater burden of health problems than the general population. This study aimed to describe the epidemiology of physical trauma among homeless patients presenting to an urban major trauma center and to ascertain any differences in the nature, injury severity and outcomes among homeless compared to domiciled patients., Methods: A retrospective matched cohort study that included adults who met inclusion criteria for The Alfred Hospital Trauma Registry between 01 July 2010 and 31 March 2017 was conducted. Primary homelessness was identified using the International Statistical Classification of Diseases, 10th Revision Coding Z59.0 and/or 'No fixed abode' address data. Homeless and domiciled patients were matched at a 1:2 ratio on age, sex, month and year of injury. The primary outcome variable was the Injury Severity Score (ISS). Secondary outcomes were hospital length of stay (LOS), mortality, emergency department (ED) disposition, hospital disposition, discharge processes and trauma registry recidivism., Results: Of 25,920 cases in the trauma registry, 147 (0.6%) were identified as homeless, comprising 131 unique homeless individuals who were matched with 262 domiciled patients. The median (Inter-Quartile Range) ISS among homeless patients was 5(2-10), compared to 9(4-17) for domiciled patients (p < 0.001). Homeless patients had significantly lower odds of sustaining an injury with ISS>12 (OR 0.5, 95% CI: 0.3-0.8, p = 0.001). Homeless patients were treated more often than domiciled patients for assault (32.1% vs 9.5%), intentional self-harm (10.7% vs 2.7%), and penetrating injury (16.0% vs 6.5%). Homeless patients had higher rates of psychiatry admissions (9.2% vs 0.8%), positive blood alcohol concentration (30.5% vs 13.7%), and higher odds of discharging against medical advice (DAMA)(OR 2.0, 95% CI: 1.1-3.6 p = 0.02). There were no differences in LOS (p = 0.51), mortality (p = 0.19), ED disposition (p = 0.64) or trauma registry recidivism (p = 0.09)., Conclusion: Among injured patients who presented at an urban trauma center, homelessness was associated with higher odds of assault, intentional self-harm, penetrating injury, psychiatry admissions, DAMA but lower ISS than domiciled patients. Variable definitions of homelessness and lack of standardized documentation in the medical record should be addressed to ensure these vulnerable patients are identified and linked with peripheral services., Competing Interests: Declaration of Competing Interest Authors Jean-Philippe Miller, Gerard O'Reilly and Jessica Mackelprang have no conflicts of interest to report. Biswadev Mitra is a member of the International Editorial Board for Injury., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The right to refuse medical treatment can be contentious in maternity care. Professional guidance for midwives and obstetricians emphasises informed consent and respect for patient autonomy, but there is little guidance available to clinicians about the appropriate clinical responses when women decline recommended care., Objectives: We propose a comprehensive, woman-centred, systems-level framework for documentation and communication with the goal of supporting women, clinicians and health services in situations of maternal refusal. We term this the Personalised Alternative Care and Treatment framework., Discussion: The Personalised Alternative Care and Treatment framework addresses Australian policy, practice, education and professional issues to underpin woman-centred care in the context of maternal refusal. It embeds Respectful Maternity Care in system-level maternity care policy; highlights the woman's role as decision maker about her maternity care; documents information exchanged with women; creates a 'living' plan that respects the woman's birth intentions and can be reviewed as circumstances change; enables communication between clinicians; permits flexible initiation pathways; provides for professional education for clinicians, and incorporates a mediation role to act as a failsafe., Conclusion: The Personalised Alternative Care and Treatment framework has the potential to meet the needs of women, clinicians and health services when pregnant women decline recommended maternity care., (Copyright © 2018. Published by Elsevier Ltd.)

Rising public expectations and health care costs along with demographic ageing raise questions about whether individuals should consider the drain on community resources when deciding whether to have expensive, life-extending medical interventions towards the end of their lifespan. All respondents (n = 208) in this novel, policy-capturing study were prepared to nominate an age along their life trajectory where they would likely decline a life-extending medical intervention indicating a "sense of limits" or "reasonableness" associated with the concept of a natural lifespan. The results showed that individuals altered end-of-life decisions in circumstances of higher opportunity cost and competing need but their propensity to do so was affected by their age, gender, and their expectations of medical progress. Other within-person factors (type of scarcity, treatment side effects, and health at diagnosis) affected the age one would decline a medical intervention in the face of a life threatening illness. Between-person predictors of this age included subjective life expectancy and attitude to health spending. The results suggest possibilities for building on this sense of reasonableness in public discussions of the opportunity cost of current health care resource allocation and by having physicians consider appropriate ways of presenting cost of treatment in end-of life contexts., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: To investigate whether responses to a previously validated four-item medication adherence questionnaire were associated with adverse cardiovascular events., Design: Survey conducted among a cohort of participants in the Second Australian National Blood Pressure Study., Setting: Australian general practice., Participants: 4039 older people with hypertension., Main Outcome Measures: All major cardiovascular events or death; first specific cardiovascular event., Results: Subjects who adhered to their medication regimen (compared with non-adherent subjects) were significantly less likely to experience a first cardiovascular event or a first non-fatal cardiovascular event (hazard ratio [HR] for both, 0.81; 95% CI, 0.67-0.98; P = 0.03); a fatal other cardiovascular event (HR, 0.68; 95% CI, 0.48-0.99; P = 0.04); or a first occurrence of heart failure (HR, 0.58; 95% CI, 0.37-0.90; P = 0.02). Those who answered yes to "Did you ever forget to take your medication?" were significantly more likely to experience a cardiovascular event or death (HR, 1.28; 95% CI, 1.04-1.57; P = 0.02); a first cardiovascular event or death (HR, 1.31; 95% CI, 1.07-1.60; P = 0.01); a first cardiovascular event (HR, 1.34; 95% CI, 1.09-1.65; P = 0.01); or a first non-fatal cardiovascular event (HR, 1.35; 95% CI, 1.09-1.66; P = 0.01). Those who answered yes to "Sometimes, if you felt worse when you took your medicine, did you stop taking it?" were significantly more likely to experience a first occurrence of heart failure (HR, 2.06; 95% CI, 1.16-3.64; P = 0.01)., Conclusions: Subjects who adhered to their medication regimen were less likely to experience major cardiovascular events or death. The question relating to forgetting to take medication identified non-adherent subjects likely to experience a cardiovascular event or death. Clinicians could use this question to identify patients with hypertension who are likely to benefit from medication adherence strategies.

The purpose of this paper is to present data about the level and background characteristics of physicians' training in palliative care in Australia (AU), Belgium (BE), Denmark (DK), Italy (IT), The Netherlands (NL), Sweden (SE) and Switzerland (CH) (n = 16,486). The response rate to an anonymous questionnaire differed between countries (39%-68%). In most countries approximately half of all responding physicians had any formal training in palliative care (median: 3-10 days). Exceptions were NL (78%) and IT (35%). The most common type of training was a postgraduate course. Physicians in nursing home medicine (only in NL), geriatrics, oncology (not in NL), and general practice had the most training. In all seven countries, physicians with such training discussed options for palliative care and options to forgo life-sustaining treatment more often with their patients than did physicians without. Irrespective of earlier palliative care training, 87%-98% of the physicians wanted extended training.

Objectives: To describe the tolerability of mefloquine in Australian soldiers for malaria prophylaxis, including a comparison with doxycycline., Design: Open-label, prospective study and cross-sectional questionnaire and interview., Setting and Participants: Two contingents of Australian soldiers, each deployed to East Timor for peacekeeping duties over a 6-month period (April 2001-October 2001 and October 2001-May 2002)., Outcome Measures: Withdrawals during the study; adverse events relating to mefloquine prophylaxis; willingness to use mefloquine again on deployment., Results: Of 1157 soldiers starting on mefloquine, 75 (6.5%) withdrew because of adverse responses to the drug. There were three serious adverse events of a neuropsychiatric nature, possibly relating to mefloquine. Fifty-seven per cent of soldiers using mefloquine prophylaxis reported at least one adverse event, compared with 56% using doxycycline. The most commonly reported adverse effects of both drugs were sleep disturbance, headache, tiredness and nausea. Of the 968 soldiers still taking mefloquine at the end of their deployments, 94% indicated they would use mefloquine again. Of 388 soldiers taking doxycycline prophylaxis who were deployed with the first mefloquine study contingent, 89% indicated they would use doxycycline again., Conclusions: Mefloquine was generally well tolerated by Australian soldiers and should continue to be used for those intolerant of doxycycline.

Objective: To identify key relationships between the decision to take a break from antiretroviral treatments and potential clinical and social antecedents., Methods: An analysis of a self-completed survey of various clinical and social aspects of the lives of people living with HIV/AIDS (PLWHA) distributed nationally in Australia was carried out., Results: The questionnaire was completed by a sample of 894 PLWHA. From this sample, three groups of interest were identified: a 'no break' group that had been using antiretrovirals continuously (n=378), a 'lifestyle break' group that had taken a break for purely lifestyle reasons on their last occasion (n=76), and a 'clinical break' group that had taken a break for purely clinical reasons on their last occasion (n=99). Clinical breaks were found to be longer than lifestyle breaks and involved more consultation with doctors. Differences were also found between the two break types in effects on the respondents' health and well-being. The clinical break group was further found to experience a higher level of health difficulties on a range of variables, while the lifestyle break group was younger, had a longer experience of HIV and its consequences, and engaged in greater participation in activities associated with both pleasure and risk., Conclusions: The analyses offer a pattern of health and social factors that places the HIV-positive individual, as a social actor, squarely within the experience of treatment interruptions. Understanding the social motivations and correlates of treatment interruption offers new challenges in maximizing the efficacy of health maintenance and support for PLWHA.

Background: Diabetes, heart disease and other vascular diseases are a great problem in Aboriginal communities and there are many reasons for this. As a health professional it is easy to feel overwhelmed by both the magnitude of the problem and the feeling that it is just too hard when patients don't seem to take charge of their own health., Objective: This article aims to outline the increased vascular disease and vascular risk factors in the Aboriginal community and explore some of the historical, socio-economic, cultural and genetic reasons for this. The barriers to health care and self management are discussed and some positive developments in the area of Aboriginal vascular health are noted., Discussion: To improve health outcomes we need to focus on two parts of the same problem. First, we need to tackle the vascular diseases at their roots--the vascular risk factors. Second, we need to look at ways to promote self management so that our patients can identify personal barriers to self care and be partners in their health care. There is evidence that better organised systems of care, such as recall systems and improved screening systems, are very beneficial. The most successful interventions are culturally appropriate and developed and implemented with Aboriginal community control.

We examine the ethical principles underpinning advance directives (ADs) and the legal duties of doctors in determining their validity. A physician attending an incompetent patient with an acute life-threatening illness, and an AD refusing treatment, should ensure that the AD is legally valid before making the treatment decision. Treatment against a patient's wishes, as expressed in a valid AD, compromises patient autonomy and may constitute battery. Conversely, withholding treatment in accordance with an AD that is not legally valid risks substantial harm to the patient and may constitute breach of the duty of care and negligence. Legally valid directives should be respected. If an AD is not legally valid, the patient should be treated in his or her best interests. If uncertain, the physician should treat according to the patient's best interests while seeking legal advice.

Background: Despite the proven benefits of hypertension control, fewer than 50% of those treated for hypertension have their blood pressure adequately controlled. The major reason for this is poor compliance with treatment., Objective: This article examines the extent of the problem, methods of detection and effective strategies in managing the problem of poor compliance with medical care with particular reference to hypertension. New ideas in the field are also discussed., Discussion: Self-report is probably the best method of detection of poor compliance. Strategies of managing the problem are discussed.

This study aimed to estimate the prevalence of dental anxiety and examine its associations among a representative sample of Australians aged 18 and over. A random sub-sample of participants in a national dental telephone interview survey completed a follow-up postal questionnaire (response rate 85.2 per cent) which included Corah's Dental Anxiety Scale (DAS). The prevalence of dental anxiety (defined by a DAS score of 13 or more) in the sample was 14.9 per cent, with overall severity represented by the mean score of 9.04 (sd, 3.45). The prevalence and severity of dental anxiety were greater among women than men, and in the 35-44 age group. High-anxiety individuals reported more deferring of dental care, and more frequently reported an episodic dental visiting pattern. Although there were no differences in dental anxiety by self-reported dental status, individuals who reported impact from their oral conditions had higher dental anxiety. These associations with social impacts and deferment of care indicate that dental anxiety may be an important dental public health problem in Australia.

Five approaches to postal faecal occult blood test (FOBT) were compared in a population sample of 966 subjects collected from three general practitioner patient lists in Southern Sydney. The highest compliance rate (59.8%) was achieved by a method using a general practitioner letter, with no dietary restrictions with FOBT. This was also the least expensive method. Compliance rates can be affected by incorrect address information and screenees not considering themselves to be current patients. An explanation from the family doctor addressed personally to the patient with an enclosed FOBT kit can achieve high compliance rates.

This article summarises and comments on a number of legal developments (legislation and judicial precedents) in Australia and England in recent years concerned with definitions of death, and withdrawal of life-preserving treatment. The general thrust of these developments and other proposed legislation is four-fold: (i) to respond to technological advances in clinical medicine; (ii) to strengthen patient rights of autonomy and self-determination in the right to refuse treatment; (iii) to reflect a shift in dominant community attitudes and social morality, and to approximate more closely to common clinical practices, which take account of 'quality-of-life' considerations as well as 'sanctity of life' in decision-making for patients unable to express a view because of youth or impaired mental capacity; (iv) to give a greater certainty and legal guidance to clinicians, and to give legal protection to clinicians who follow certain decision-making procedures.