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Advance care planning in the hospital & critical care unit
The evolving role of a ‘clinical ethicist’
  1. K Detering and
  2. W Silvester
  1. Respecting Patient Choices, Austin Health, Melbourne, Australia

Abstract

Background Austin health is a 600 bed tertiary hospital with a wide range of acute and sub acute services, including a number of specialist services. Many patients have extremely complex medical and ethical issues that are often raised during the care of these people. In order to address such concerns a ‘clinical ethicist’, who is an experienced doctor has been employed.

Aim To perform a retrospective audit of consecutive cases referred to the clinical ethicist.

Results 104 patients, mean age 66 (range 19–102), 64% male were seen.

  • Reason for referral - (≥1 reason per patient).

    • Unrealistic patient/family (34%).

    • Poor or unrealistic medical assessment of situation (53%).

    • Patient/family in need of advance care planning (44%).

  • Outcome of referral – treatment related (≥ 1 per patient).

    • Patient died or discharged (63%).

    • Decision to limit treatment (64%).

    • Advance care planning occurred (45%).

    • Treating doctors ignored recommendation of clinical ethicist (5%).

  • Outcome of referral – people related (≥1 per patient).

    • Staff Education (71%).

    • Improved staff morale (31%).

    • Support of medical decision making (41%).

    • Patient/family support (42%).

Patient deaths were, on average 70 days (range 1–619) from initial referral.

Conclusion Establishment of the clinical ethicist role has provided support and education to staff and patients. Although not specifically set up to focus on end-of-life decision making and care, the majority of patients seen have died. This role also has an important link in referring patients/families for advance care planning.

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