Completion of Limitation of Medical Treatment forms by junior doctors for patients with dementia: clinical, medicolegal and education perspectivesJaclyn Yoong A B , Aleece MacPhail C , Gael Trytel D , Prashanti Yalini Rajendram D , Margaret Winbolt E and Joseph E. Ibrahim C D F
A Monash Health, Department of Supportive and Palliative Care, 246 Clayton Road, Clayton, Vic. 3168, Australia. Email: firstname.lastname@example.org
B Department of Palliative Care, Northern Health, 185 Cooper Street, Epping, Vic., 3076 Australia.
C Queen Elizabeth Centre, Ballarat Health Services, 102 Ascot Street Sth, Ballarat, Vic. 3350, Australia. Email: email@example.com
D Victorian Institute for Forensic Medicine, Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, Vic. 3006, Australia. Email: firstname.lastname@example.org; email@example.com
E Australian Centre for Evidence Based Aged Care, Health Sciences Building 2, La Trobe University, Vic. 3086, Australia. Email: Margaret.Winbolt@latrobe.edu.au
F Corresponding author. Email: firstname.lastname@example.org
Australian Health Review - https://doi.org/10.1071/AH16116
Submitted: 25 May 2016 Accepted: 23 August 2016 Published online: 14 October 2016
Objective Limitation of Medical Treatment (LMT) forms are an essential element of end-of-life care. Decision making around LMT is complex and often involves patients with dementia. Despite the complexity, junior doctors frequently play a central role in completing LMT forms. The present study sought perspectives from a range of stakeholders (hospital clinicians, medical education personnel, legal and advocacy staff) about junior doctors’ roles in completing LMT forms in general and for patients with dementia.
Methods Qualitative data were gathered in semi-structured interviews (SSI) and theoretical concepts were explored in roundtable discussion (RD). Participants were recruited through purposive and convenience sampling drawing on healthcare and legal personnel employed in the public hospital and aged care systems, selected from major metropolitan hospitals, healthcare and legal professional bodies and advocacy organisations in Victoria, Australia. The contents of the SSIs and RD were subject to thematic analysis using a framework approach. Data were indexed according to the topics established in the study aim; categories were systematically scrutinised, from which key themes were distilled.
Results Stakeholders reported that completing LMT forms was difficult for junior doctors because of a lack of medical and legal knowledge, as well as clinical inexperience and inadequate training. Healthcare organisations (HCOs) either lacked policies about the role of junior doctors or had practices that were discordant with policy. In this process, there were substantial gaps pertaining to patients with dementia. Recommendations made by the study participants included the provision of supervised clinical exposure and additional training for junior doctors, strengthening HCO policies and explicit consideration of the needs of patients with dementia.
Conclusions LMT forms should be designed for clarity and consistency across HCOs. Enhancing patient care requires appropriate and sensitive completion of LMT. Relevant HCO policy and clinical practice changes are discussed herein, and recommendations are made for junior doctors in this arena, specifically in the context of patients with dementia.
What is known about the topic? Junior doctors continue to play a central role in LMT orders, a highly complex decision-making task that they are poorly prepared to complete. LMT decision making in Australia’s aging population and for people with dementia is especially challenging.
What does this paper add? A broad range of stakeholders, including hospital clinicians, medical education personnel and legal and advocacy staff, identified ongoing substantial gaps in education and training of junior doctors (despite what is already known in the literature). Furthermore, LMT decision making for patients with dementia is not explicitly considered in policy of practice.
What are the implications for practitioners? Current policy and practice are not at the desired level to deliver appropriate end-of-life care with regard to LMT orders, especially for patients with dementia. Greater involvement of executives and senior clinicians is required to improve both practice at the bed side and the training and support of junior doctors, as well as creating more robust policy.
References Findlay GP, Shotton H, Kelly K, Mason M. Time to intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest. A report by the National Confidential Enquiry into Patient Outcome and Death. National Confidential Enquiry into Patient Outcome and Death (NCEPOD). London: NCEPOD; 2012.
 Spiller J, Kiehlmann P, Davison H, Murphy D, Wilkie R. NHS Scotland DNACPR and CYPADM integrated policies: development of quality measures. BMJ Support Palliat Care 2012; 2 A11–12.
| NHS Scotland DNACPR and CYPADM integrated policies: development of quality measures.CrossRef |
 Weissman D. Policy proposal: do not resuscitate orders: a call for reform. Virtual Mentor 2003; 5 Available at: http://journalofethics.ama-assn.org/2003/01/pfor2-0301.html [verified 12 September 2016].
| 23267686PubMed |
 Ache KA, Wallace LS, Shannon RP. Evaluation of limitation-of-medical-treatment forms used in emergency medicine residency programs in the United States. J Emerg Med 2011; 41 713–17.
| Evaluation of limitation-of-medical-treatment forms used in emergency medicine residency programs in the United States.CrossRef | 20434288PubMed |
 Fritz Z, Fuld J. Ethical issues surrounding do not attempt resuscitation orders: decisions, discussions and deleterious effects. J Med Ethics 2010; 36 593–7.
| Ethical issues surrounding do not attempt resuscitation orders: decisions, discussions and deleterious effects.CrossRef | 20675736PubMed |
 Resuscitation Council (UK). Do not attempt CPR. R (David Tracey) v (1) Cambridge University Hospitals NHS Foundation Trust (2) Secretary of State for Health. 2014. Available at: https://www.resus.org.uk/dnacpr/tracey-v-cuh-and-secretary-of-state-for-health/ [verified 18 September 2015].
 Derse AR. Limitation of treatment at the end-of-life: Withholding and withdrawal. Clin Geriatr Med 2005; 21 223–38, xi.
| Limitation of treatment at the end-of-life: Withholding and withdrawal.CrossRef | 15639048PubMed |
 Gorman TE, Ahern S, Wiseman J, Skrobik Y. Residents’ end-of-life decision making with adult hospitalized patients: a review of the literature. Acad Med 2005; 80 622–33.
| Residents’ end-of-life decision making with adult hospitalized patients: a review of the literature.CrossRef | 15980078PubMed |
 Foley D, Cunningham C. Not for resuscitation: more harm than good? Ir Med J 2011; 104 279–80.
| 1:STN:280:DC%2BC38%2Fkt1CntA%3D%3D&md5=93e373c6b6188db03e6a3bdeebea68baCAS | 22132598PubMed |
 McNeill D, Mohapatra B, Li JY, Spriggs D, Ahamed S, Gaddi Y, Hakendorf P, Ben-Tovim DI, Thompson CH. Quality of resuscitation orders in general medical patients. QJM 2012; 105 63–8.
| Quality of resuscitation orders in general medical patients.CrossRef | 1:STN:280:DC%2BC38%2FlvFahsg%3D%3D&md5=1d4da70361c425cbf751a0aa98d6d2dbCAS | 21865308PubMed |
 Brims FJ, Kilminster S, Thomas LM. Resuscitation decisions among hospital physicians and intensivists. Clin Med 2009; 9 16–20.
| Resuscitation decisions among hospital physicians and intensivists.CrossRef |
 Thomas RL, Zubair MY, Hayes B, et al Goals of care: a clinical framework for limitation of medical treatment. Med J Aust 2014; 201 452–5.
| Goals of care: a clinical framework for limitation of medical treatment.CrossRef | 25332031PubMed |
 Australian Bureau of Statistics. Dementia and Alzheimer’s disease now Australia’s second leading cause of death. [Media Release] 2015. Available at: http://www.abs.gov.au/ausstats/abs@.nsf/mf/3303.0 [verified 17 September 2015].
 Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA 2000; 284 47–52.
| Survival in end-stage dementia following acute illness.CrossRef | 1:STN:280:DC%2BD3czjt1WrsQ%3D%3D&md5=2d327c09e23d1e8609c54c841d221e09CAS | 10872012PubMed |
 Milne A. The ‘D’ word: reflections on the relationship between stigma, discrimination and dementia. J Ment Health 2010; 19 227–33.
| The ‘D’ word: reflections on the relationship between stigma, discrimination and dementia.CrossRef | 20441486PubMed |
 Volicer L. End-of-life care for people with dementia in residential care settings. Tampa: Alzheimer’s Association; 2005.
 Mezey MD, Mitty EL, Bottrell MM, Ramsey GC, Fisher T. Advance directives: older adults with dementia. Clin Geriatr Med 2000; 16 255–68.
| Advance directives: older adults with dementia.CrossRef | 1:STN:280:DC%2BD3c3kslWitA%3D%3D&md5=c1777a6623905de1cc488281d462d0c2CAS | 10783428PubMed |
 Sidhu N, Dunkley M, Egan M. ‘Not-for-resuscitation’ orders in Australian public hospitals: policies, standardised order forms and patient information leaflets. Med J Aust 2007; 186 72–5.
| 17223767PubMed |
 Salins NS, Jansen W. Clinical audit on documentation of anticipatory ‘not for resuscitation’ orders in a tertiary Australian teaching hospital. Indian J Palliat Care 2011; 17 42–6.
| Clinical audit on documentation of anticipatory ‘not for resuscitation’ orders in a tertiary Australian teaching hospital.CrossRef | 21633620PubMed |
 Lamas D, Rosenbaum L. Freedom from the tyranny of choice: teaching the end-of-life conversation. N Engl J Med 2012; 366 1655–7.
| Freedom from the tyranny of choice: teaching the end-of-life conversation.CrossRef | 1:CAS:528:DC%2BC38XmsFyms74%3D&md5=6f07c496c5bba386d2bb56689560d254CAS | 22551124PubMed |
 Siddiqui MF, Holley JL. Residents’ practices and perceptions about do not resuscitate orders and pronouncing death: an opportunity for clinical training. Am J Hosp Palliat Care 2011; 28 94–7.
| Residents’ practices and perceptions about do not resuscitate orders and pronouncing death: an opportunity for clinical training.CrossRef | 20801916PubMed |
 Davey B. Do-not-resuscitate decisions: too many, too few, too late? Mortality 2001; 6 247–64.
| Do-not-resuscitate decisions: too many, too few, too late?CrossRef |
 Morgan R, Westmoreland C. Survey of junior hospital doctors’ attitudes to cardiopulmonary resuscitation. Postgrad Med J 2002; 78 413–15.
| Survey of junior hospital doctors’ attitudes to cardiopulmonary resuscitation.CrossRef | 1:STN:280:DC%2BD38vgt1Ogug%3D%3D&md5=c89ec10bb65e14be540da4f7779cd20aCAS | 12151657PubMed |
 Mockford C, Fritz Z, George R, Court R, Grove A, Clarke B, Field R, Perkins GD. Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation. Resuscitation 2015; 88 99–113.
| Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation.CrossRef | 25433293PubMed |
 Cohn S, Fritz ZB, Frankau JM, Laroche CM, Fuld JP. Do not attempt cardiopulmonary resuscitation orders in acute medical settings: a qualitative study. QJM 2013; 106 165–77.
| Do not attempt cardiopulmonary resuscitation orders in acute medical settings: a qualitative study.CrossRef | 1:STN:280:DC%2BC3s7ms1Kgsw%3D%3D&md5=c1dd0208abddfb1d0dc1cf26098e5cdeCAS | 23185026PubMed |
 Hayes B. Clinical model for ethical cardiopulmonary resuscitation decision-making. Intern Med J 2013; 77–83.
| Clinical model for ethical cardiopulmonary resuscitation decision-making.CrossRef | 22646807PubMed |
 Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. BMJ 2000; 320 114–16.
| Qualitative research in health care. Analysing qualitative data.CrossRef | 1:STN:280:DC%2BD3c%2FptVOgug%3D%3D&md5=c5dd626ff76d3c361410d754936e5a59CAS | 10625273PubMed |
 Creswell JW. Qualitative inquiry and research design. Choosing among five approaches. 3rd edn. Thousand Oaks, CA: Sage; 2012.
 Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG, editors. Analyzing qualitative data. Oxon: Routledge; 1994. pp.173–194.
 Lemiengre J, de Casterlé BD, Van Craen K, Schotsmans P, Gastmans C. Institutional ethics policies on medical end-of-life decisions: a literature review. Health Policy 2007; 83 131–43.
| Institutional ethics policies on medical end-of-life decisions: a literature review.CrossRef | 17433489PubMed |
 Levinson M, Mills A, Hutchinson AM, Heriot G, Stephenson G, Gellie A. Comparison of not for resuscitation (NFR) forms across five Victorian health services. Intern Med J 2014; 44 671–5.
| Comparison of not for resuscitation (NFR) forms across five Victorian health services.CrossRef | 1:STN:280:DC%2BC2cnmvVWntw%3D%3D&md5=c4e50e308bb618d765615220d6dfcf8cCAS | 24766152PubMed |
 Schroder C, Heyland D, Jiang X, Rocker G, Dodek P. Educating medical residents in end-of-life care: insights from a multicenter survey. J Palliat Med 2009; 12 459–70.
| Educating medical residents in end-of-life care: insights from a multicenter survey.CrossRef | 19416043PubMed |
 Alzheimer’s Australia. End of life care for people with dementia: survey report. Executive summary. 2014. Available at: https://fightdementia.org.au/sites/default/files/EOI_ExecSummary_Web_Version.pdf [verified 18 September 2015].
 Poppe M, Burleigh S, Banerjee S. Qualitative evaluation of advanced care planning in early dementia (ACP-ED). PLoS One 2013; 8 e60412
| Qualitative evaluation of advanced care planning in early dementia (ACP-ED).CrossRef | 1:CAS:528:DC%2BC3sXmsFGns78%3D&md5=f3c834811c58e2881303d26538a0b72bCAS | 23630571PubMed |
 van der Steen JT, van Soest-Poortvliet MC, Hallie-Heierman M, Onwuteaka-Philipsen BD, Deliens L, de Boer ME, Van den Block L, van Uden N, Hertogh CM, de Vet HC. Factors associated with initiation of advance care planning in dementia: a systematic review. J Alzheimers Dis 2014; 40 743–57.
| Factors associated with initiation of advance care planning in dementia: a systematic review.CrossRef | 24531163PubMed |
 Hirschman KB, Kapo JM, Karlawish JH. Identifying the factors that facilitate or hinder advance planning by persons with dementia. Alzheimer Dis Assoc Disord 2008; 22 293–8.
| Identifying the factors that facilitate or hinder advance planning by persons with dementia.CrossRef | 18580595PubMed |
 Sampson EL, Thuné-Boyle I, Kukkastenvehmas R, Jone L, Tookman A, King M, Blanchard MR. Palliative care in advanced dementia; a mixed methods approach for the development of a complex intervention. BMC Palliat Care 2008; 7 8
| Palliative care in advanced dementia; a mixed methods approach for the development of a complex intervention.CrossRef | 18620567PubMed |
 Dickinson C, Bamford C, Exley C, Emmett C, Hughes J, Robinson L. Planning for tomorrow whilst living for today: the views of people with dementia and their families on advance care planning. Int Psychogeriatr 2013; 25 2011–21.
| Planning for tomorrow whilst living for today: the views of people with dementia and their families on advance care planning.CrossRef | 24053783PubMed |
 Ibrahim JE, MacPhail A, Winbolt M, Grano P. Limitation of care orders in patients with a diagnosis of dementia. Resuscitation 2016; 98 118–24.
| Limitation of care orders in patients with a diagnosis of dementia.CrossRef | 25818706PubMed |
 Kottewar SA, Bearelly D, Bearelly S, Johnson JE, Fleming DA. Residents’ end-of-life training experience: a literature review of interventions. J Palliat Med 2014; 17 725–32.
| Residents’ end-of-life training experience: a literature review of interventions.CrossRef | 24828688PubMed |
 Morrison C, Forbes K. Junior doctors’ learning and development in foundation year 1 posts in palliative medicine. Palliat Med 2012; 26 851–7.
| Junior doctors’ learning and development in foundation year 1 posts in palliative medicine.CrossRef | 21831917PubMed |
 Smith L, O’Sullivan P, Lo B, et al An educational intervention to improve resident comfort with communication at the end of life. J Palliat Med 2013; 16 54–9.
| 23030260PubMed |
 Volandes AE, Paasche-Orlow MK, Mitchell SL, El-Jawahri A, Davis AD, Barry MJ, Hartshorn KL, Jackson VA, Gillick MR, Walker-Corkery ES, Chang Y, López L, Kemeny M, Bulone L, Mann E, Misra S, Peachey M, Abbo ED, Eichler AF, Epstein AS, Noy A, Levin TT, Temel JS. Randomised controlled trial of a video decision support tool for cardiopulmonary resuscitation decision making in advanced cancer. J Clin Oncol 2013; 31 380–6.
| Randomised controlled trial of a video decision support tool for cardiopulmonary resuscitation decision making in advanced cancer.CrossRef | 23233708PubMed |
 Australian Commission on Safety and Quality in Health Care. Accreditation and the NSQHS Standards. 2015 Available at: http://www.safetyandquality.gov.au/our-work/accreditation-and-the-nsqhs-standards/ [verified 18 September 2015].