Background Access to voluntary assisted dying in Australia is affected by the availability of authorised and willing health practitioners. Nurse practitioners (NPs) play a vital role in helping patients and their families navigate voluntary assisted dying processes, but can be constrained by laws governing eligibility assessment, prescribing, and administration. Evidence about NPs’ experiences of, and willingness to participate in voluntary assisted dying in Australia, remains limited. Aim To explore NPs’ willingness to participate in voluntary assisted dying, and the factors that influence participation. Methods A convergent mixed methods study design using an online survey and semistructured interviews. Findings Forty-one NPs completed the survey, with a subsample of seven participating in an interview. Most participants had knowledge of and supported voluntary assisted dying. Three themes were identified from the interviews: (i) NP expertise and limitations, (ii) complex systems create access barriers, and (iii) human connection and relationships. Integrating the results confirmed that NPs are willing to participate in a range of voluntary assisted dying activities, particularly where those skills were part, or an extension of their current practice. Discussion NPs are open to engaging in voluntary assisted dying activities within their scope of practice. Their support reflects their professional ethical values and desire to minimise suffering at the end of life. Conclusion Voluntary assisted dying requires access to willing practitioners, and NPs are prepared to assist. With legislative amendment, greater NP participation could improve the sustainability of the workforce and enhance access.

AIM:To identify nurse practitioners' and registered nurses' willingness to participate in voluntary assisted dying, and the factors that influence these decisions. DESIGN:A cross-sectional design. METHODS:An online survey was disseminated to members of 16 professional nursing organisations and associations between April and August 2024. RESULTS:Responses from 396 participants were analysed. Most were registered nurses (n = 335, 84.6%), aged between 45 and 64 years (n = 217, 54.8%). Over half of the participants (n = 219, 55.3%) had some knowledge of voluntary assisted dying, and more than two-thirds (n = 274, 69.2%) strongly supported it. Respect for a person's rights (n = 345, 89.8%) and relieving suffering (n = 342, 89.1%) were the main reasons nurses participated. Most nurse practitioner participants would be prepared to assess a person's eligibility for voluntary assisted dying (n = 32, 82.1%) or prescribe a substance (n = 31, 79.5%), if permitted by law. Religion, age and years of experience were characteristics associated with reasons for participation. CONCLUSION:In Australia, some RNs and NPs are willing to participate in a range of VAD-related activities. However, in some jurisdictions, nurses' engagement is limited by legislative and policy settings. Reconsideration of nurses' roles may enhance access. IMPLICATIONS FOR THE PROFESSION:With appropriate support, nurses can make a valuable contribution to the sustainability of the voluntary assisted dying workforce.

Background Voluntary assisted dying (VAD) is legal in most of Australia. Despite growing societal acceptance, clinicians’ views remain mixed, particularly in critical care. Aim The aim of this study was to identify and describe factors influencing critical care nurses’ support for and willingness to participate in VAD. Methods convergent mixed-method study was undertaken involving (i) an online survey; (ii) individual interviews; and (iii) integration. Critical care nurses were recruited through multiple Australian nursing organisations. Results Forty-two critical care nurses completed the survey. Over half (57.1%, n = 21) provided end-of-life care at least monthly, 76.2% (n = 32) had at least some knowledge of VAD, and 92.9% (n = 39) were supportive of VAD. Almost all (97.6%, n = 40) were willing to participate in VAD by providing care, advice, or support to a person requesting VAD (97.6%, n = 40), even if family members did not agree (92.7%, n = 38), to care for a person after taking the VAD substance (92.7%, n = 38), and to be present at death (92.7%, n = 38). Willingness reflected respondents’ support for patient choice, autonomy, and alignment with professional obligations and personal values. Critical care nurses’ cultural beliefs, religion/spirituality, and workload concerns were less important. Eight critical care nurses were interviewed, providing greater detail about VAD in the intensive care unit (ICU) with three themes identified: (i) the complex context, describing tensions with the momentum of ICU care; (ii) if it’s the person’s wishes, upholding patient autonomy and choice; and (iii) VAD fit and function, reflecting scope of practice and legal concerns and the essential skills for participation. Nurse practitioners were universally regarded as possessing the skills and relational qualities necessary for VAD participation. Conclusions Critical care nurses showed strong support for VAD, and a willingness to provide VAD-related care, grounded in professional values and commitment to patient autonomy. Policy and practice frameworks formally recognising critical care nurses’ role in VAD in the ICU are essential.

Some dying individuals can develop skin injuries at the end-of-life (EOL) due to factors associated with the disease processes, aging or both. These EOL wounds, which include Kennedy terminal ulcers, Trombley-Brennan terminal tissue injuries, Skin Changes at Life’s End and end-stage skin failure, have distinguishing features. Yet, they can appear similar to pressure injuries (PIs), making assessment difficult. Compounding this was the lack of clinical assessment tool for EOL wounds. In 2022, we conducted a modified Delphi panel to develop a new EOL wound assessment tool for use in dying adults and established the face and content validity of the items. The new tool does not differentiate between a PI and EOL wound; rather, it aids clinicians’ assessment of EOL wound characteristics and suggests the development of a multidisciplinary management plan. The next step in the tool development is to determine its reliability. The aim of this study was to test the study protocol and interrater reliability of a new EOL wound assessment tool. This feasibility study was conducted in dying hospitalised adult patients admitted to medical and palliative care units at three hospitals across southeast Queensland, Australia. We gathered quantitative data according to the study protocol including participant screening, recruitment, consent, data collection and interrater reliability. Our four research assistants (RAs) and an independent blinded outcome assessor were trained in the study protocol and use of the new EOL wound assessment tool. Using a pragmatic approach, patients with a new reported PI were screened for study eligibility. For recruited participants, clinical data, skin blanching, and a deidentified wound photograph were first collected. Next, the RAs used the new tool to assess the patient and the skin to determine the presence of an EOL wound (Yes/No). An off-site independent blinded outcome assessor accessed the participant research data and, using the new tool, undertook the same assessment as the RA. Frequencies and percentages were computed for the feasibility outcomes. Cohen’s kappa statistic was calculated to determine the interrater reliability agreement. Over 20 months, 140 patients were screened, with 23 (16.4

Background Disclosure of information that identifies deceased organ donors and/or organ transplant recipients is prohibited in many countries, including Australia. Anecdotal evidence suggests that some donor family members and transplant recipients desire and independently establish contact using strategies such as social media.Objective To describe and synthesise the views of Australian donor family members, transplant recipients, and healthcare professionals regarding the disclosure of identifying information between donor family members and transplant recipients.Research design An exploratory descriptive qualitative study design was used.Participants and research context Semi-structured interviews were conducted with 23 donor family members, 25 transplant recipients, and 16 healthcare professionals. Interviews were audio recorded and transcribed verbatim. Data were extracted and synthesised using thematic analysis.Ethical considerations This study was approved by the Human Research Ethics Committee of Griffith University, Queensland. Participation was voluntary, and informed consent was obtained from all participants.Findings Three themes were revealed: (i) a desire for choice, (ii) perceptions of benefits, and (iii) perceptions of risks and risk mitigation. Some donor family members and transplant recipients would like the choice to pursue identifiable contact, and for this to be facilitated by donation agencies and transplant units. Many healthcare professionals also support the notion of choice.Conclusion Current Australian laws prohibit the disclosure of information identifying deceased organ donors and transplant recipients to each other. Any desire to amend existing laws would necessitate a thorough consultation process and the establishment of suitable systems and processes to support identity disclosure. Further research is needed to ascertain options for identifiable contact and to identify strategies to maximise benefit and minimise harm for donor family members and recipients.

Background: There is growing momentum worldwide for assisted dying. In Australia, voluntary assisted dying may occur in any setting, including an intensive care unit (ICU). As the subject of much debate worldwide, exploring ICU clinicians' perceptions of assisted dying is essential. Aim: The aim of this study was to explore clinicians' perceptions of and preparedness for voluntary assisted dying in the ICU. Method: An exploratory qualitative descriptive design using individual interviews was used. Medical, nursing, and allied health clinicians from three ICUs were recruited. Interviews were conducted between Nov 2022 and Jan 2023, with a hypothetical scenario about voluntary assisted dying used to prompt discussion. Interviews were recorded, professionally transcribed, and analysed using inductive content analysis. Findings: ICU registered nurses (n = 20), physicians (n = 2), and allied health clinicians (n = 4) participated with interviews lasting 18e45 min (mean: 28 min). Analysis revealed four themes: (i) purpose of ICU reflected that ICU care was not all about saving lives, yet recognising dying and changing priorities was challenging; (ii) dying in the ICU is complex due to difficulties in talking about dying, accepting death as the outcome and evaluating care efficacy; (iii) voluntary assisted dying is a lot of grey because of perceived clinical and ethicolegal challenges; and finally, (iv) respecting choice was about respecting patients' values, beliefs, and autonomy, as well as clinicians' beliefs and right to exercise autonomy through conscientious objection. Conclusion: Dying and death are inevitable, and views and perspectives about assisted dying will continue to evolve. Respecting patient choice is at the core of assisted dying, but respecting clinicians' perspectives and choice is equally important. With voluntary assisted dying now legal in all Australian states, ensuring ICU team and individual clinician preparedness through access to education, resources, and specialist support services is key to raising awareness and easing uncertainty about deaths through voluntary assisted dying. (c) 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. This is an open access

BACKGROUND:All health care is underpinned by legal frameworks, including those that regulate who is responsible for healthcare decisions at the end of life. How these frameworks support decision-making in emergency departments (EDs) and intensive care units (ICUs) is underexplored. OBJECTIVE:The objective of this study was to identify factors that help or hinder healthcare professionals' understanding and application of the law that applies to end-of-life decision-making in the EDs and ICUs in Queensland, Australia. METHODS:A descriptive qualitative study based on naturalistic inquiry was undertaken. Participants were healthcare professionals working in the ICUs or EDs of one South East Queensland Hospital and Health Service, responsible for the care of adult patients who had died. RESULTS:Thirteen medical practitioners, 19 registered nurses, and three social workers participated in semistructured interviews. Three themes and eight subthemes were identified in the data. First, the theme the complexity of communication is laid bare at the end of life described the challenges associated with talking about death and dying and the need to reframe conversations where death is inevitable. Next, the theme decision-making has layers highlighted family inclusion in decisions, navigating different perspectives to share decision-making and acknowledging that decision-making is emotionally burdensome. Finally, the theme how the law should apply is uncertain described the difficulties in deciding who should decide, knowing when Advance Health Directives can be relied on, and the need to reduce legal risk. CONCLUSION:Decision-making at the end of life is complex and challenging. Healthcare professionals charged with leading conversations find them challenging and are mindful of the burdens associated with such decisions. The need to work within the legal framework is acknowledged, but applying the law can be difficult.

Objective Voluntary assisted dying is a contested practice that some end-of-life care providers choose not to offer to patients. In some jurisdictions, this has restricted access. Queensland addressed this with a law designed to ensure that access to voluntary assisted dying was not hindered. The aim of this research was to explore how privately funded health services that provide end-of-life care, prepared for, and identified challenges related to, enabling access to voluntary assisted dying in Queensland. Methods An interpretivist exploratory study was undertaken. Health service representatives responsible for developing and implementing organisational voluntary assisted dying policy were invited to participate in semi-structured interviews. Data were analysed thematically. Results Fifteen participants participated in an interview. Analysis of the data generated four themes: navigating a spectrum of values and beliefs; knowing and understanding voluntary assisted dying; moderating voluntary assisted dying conversations; and finding space for voluntary assisted dying in end-of-life care. The preparedness of privately funded health services for voluntary assisted dying varied, yet all providers were committed to providing compassionate end-of-life care while meeting their new legal obligations. The need to support staff with a range of values and beliefs about voluntary assisted dying was highlighted. Conclusions Using law to balance the rights of individuals to access voluntary assisted dying and those of non-participating organisations obliges all health services to consider patient access, the views of staff, and broader organisational values concerning voluntary assisted dying. Future research will explore whether access to voluntary assisted dying is affected.

ABSTRACTBackgroundIn nearly all jurisdictions where it is permitted, Medical Assistance in Dying is situated in a healthcare system. Currently, limited evidence demonstrates how supply and demand factors influence access to Medical Assistance in Dying.ObjectiveThe aim of this study is to synthesise empirical research from jurisdictions where Medical Assistance in Dying is legal to identify how supply and demand factors influence access for eligible adults.MethodAn integrative review was conducted. CINAHL Complete, PubMed, ProQuest, PsycINFO and Embase databases were systematically searched for studies published between January 1998 and January 2024. Records were independently assessed against inclusion and exclusion criteria. Additional studies were identified by forward and backward citation searching. All studies were assessed for quality. Findings were analysed deductively using an established conceptual framework, and a secondary narrative synthesis was undertaken.ResultsFifty‐eight studies met the inclusion criteria. Most studies (n = 32) reported results related to the supply side, 16 reported on the demand side and 10 reported on both supply and demand dimensions of access. Studies about supply showed that health service policies may obstruct access to Medical Assistance in Dying. For healthcare professionals, the practice entails an additional workload and can create tensions with colleagues. Studies of the demand for Medical Assistance in Dying focused on supporting time‐critical decisions, adequate planning and caregiver support.ConclusionAccess to Medical Assistance in Dying requires the participation of health services and healthcare professionals but is hindered by policies that obstruct access and direct financial and indirect emotional labour costs. Innovative and inclusive models to promote high‐quality, compassionate care at the end of life and access to Medical Assistance in Dying should be considered.Patient or Public ContributionPatients, caregivers and service users were involved in many of the studies included in this review, and their experiences and perspectives contributed to the analysis and synthesis in this review.

Background: Assisted dying, also commonly known as euthanasia and physician-assisted suicide, is legal in many countries. Interest in assisted dying is growing due to evolving societal understandings of a good death and a desire for choice. Ethico-legal perspectives are well-known, but as societies become more heterogenous, a greater understanding of the perspectives of people from diverse racial, ethnic, and cultural backgrounds is needed. Aim: To explore perspectives of people from diverse racial, ethnic and cultural backgrounds about assisted dying. Design: Scoping review with narrative synthesis. The protocol was registered with Open Science Framework. Data sources: Medline, CINAHL Complete, PsycINFO and ProQuest Dissertations & Theses Global were searched from inception to May 2023. Citations were independently assessed against inclusion and exclusion criteria. Results: Of the 17 included studies, perspectives of assisted dying were presented according to religion, religiosity, spirituality, race, ethnicity and ancestry. Perspectives were diverse, presenting more as a spectrum, with multiple intersections and interconnections. Support and/or opposition for assisted dying differed according to cultural attributes, but even amongst those with similar cultural attributes, perspectives differed according to life experiences and notions of suffering. Conclusion: Perspectives on assisted dying are dynamic and evolving. Even where assisted dying is legalised, individual’s cultural attributes contribute to unique perspectives of assisted dying as an end-of-life option. Thus, understanding a person’s culture, beliefs, expectations and choices in illness, treatment goals and care is fundamental, extending beyond what may be already considered as part of clinician-patient care relationships and routine advance care planning.

The framing of patients making decisions about their medical treatment and care as traditional legal decisions, thresholds and formalities is a means to avoid legal liabilities through a rationalisation of decision-making, autonomy and choice. A credible account for the actual place of patients posits the sovereign power (founded in the works of Carl Schmitt and Giorgio Agamben) of the health care professional deciding the state of exception - a discrete legal space where the authority of health care professionals is both lawful and beyond the law. This reveals that dealing with broadly conceived consent issues with more law, more process and procedure but without addressing the inherent legality assumptions that empower health care professionals will always be flawed. This section piece concludes that the resolution of consent issues is about a culture of consent rather than a frame of legal process and limiting legal liability.

OBJECTIVE:To investigate ED and intensive care unit healthcare professionals' perspectives and knowledge of the law that underpins end-of-life decision-making in Queensland, Australia. METHODS:An online survey with questions about perspectives, perceived, and actual, knowledge of the law was distributed by the professional organisations of medical practitioners, nurses and social workers who work in Queensland EDs and intensive care units. RESULTS:The survey responses of 126 healthcare professionals were included in the final analysis. Most respondents agreed that the law was relevant to end-of-life decision-making, but that clinician and family consensus mattered more than following the law. Generally, doctors' legal knowledge was higher than nurses'; however, there were significant gaps in the knowledge of all respondents about the operation of advance health directives in Queensland. CONCLUSIONS:The legal framework that supports end-of-life decision-making for adults who lack decision-making capacity has been in place for more than two decades. Despite frequently being involved in making or enacting these decisions, gaps in the legal knowledge of healthcare professionals who work in EDs and intensive care units in Queensland are evident. Further research to better understand how to improve knowledge and application of the law is warranted.

Objective There is limited evidence about how legal frameworks that underpin end-of-life decisions are applied in practice. This study aimed to identify how end-of-life decisions are made and documented in emergency departments and intensive care units. The secondary aim was to explore the extent to which the legal processes featured in these decisions. Methods A retrospective chart audit of 85 adult patients who died in the emergency departments and intensive care units of a Queensland health service was undertaken. Quantitative data were analysed and reported using descriptive statistics. Qualitative textual data were analysed using inductive content analysis. Results Nearly all admissions were unplanned (97.6%), and most patients (74.1%) were admitted from home. Only one patient had an advance health directive, although all had an eligible substitute decision-maker. The qualitative analysis revealed two main concepts – ‘healthcare professionals choreograph the end of life’ and ‘patients and families are carried on an unplanned journey’. Conclusions There was limited documentation related to the application of the legal framework in these decisions. Healthcare professionals relied on their clinical judgment about what was in the best interest of the patient. It was common for there to be a substantial effort to achieve consensus in decision-making which coincidently complied with the law.

Background: Obtaining consent for surgery is a legal requirement and a professional practice standard, but little is known about how nurses and other healthcare professionals (HCPs) engage with this process. Aim: To describe operating room (OR) HCPs' perceptions of consent processes for adult patients undergoing planned surgery at one health service. Methods: A qualitative exploratory design and purposive maximum variation sampling relative to age, discipline, experience, and role, were used to ensure broad perspectives were gathered. Semi-structured interviews with 17 OR HCPs were conducted between April and May 2021. Findings: Thematic analysis identified three themes: the HCPs' role in verifying consent goes beyond the World Health Organization's Surgical Safety Checklist, effective communication is crucial for obtaining and verifying consent, and day-of-surgery delays and errors are multi-factorial. Discussion: Production pressures in surgery can compromise consent processes, undermine communication, and impact patient safety in the OR. Conclusion: HCPs verify more items than the World Health Organization Surgical Safety Checklist, suggesting the checklist may not go far enough when verifying consent in surgery. (c) 2023 Australian College of Nursing Ltd. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

INTRODUCTION:The disclosure of information that identifies deceased organ donors and/or organ transplant recipients by organ donation agencies and transplant centres is regulated in Australia by state and territory legislation, yet a significant number of donor family members and transplant recipients independently establish contact with each other. AIM:To describe and synthesize Australian laws and guidelines on the disclosure of identifying information. METHOD:Legislation and guidelines relevant to organ donation and transplantation were obtained following a search of government and DonateLife network websites. Information about the regulation of identity disclosure was extracted and synthesised using a process guided by Walt and Gilson's (1994) policy analysis framework. FINDINGS:Nineteen documents were examined. Six guidelines refer to and were consistent with current legislation. Four documents did not address identity disclosure. All jurisdictions prohibit healthcare professionals from disclosing identifying information. In three states, the prohibition extends to all members of the public including donor family members and transplant recipients. CONCLUSION:Restrictions on identity disclosure have implications for public promotion of donation and transplantation where sharing of stories and images of organ donors and transplant recipients is common. Further research is required to understand the perspective of donor family members, transplant recipients, and healthcare professionals impacted by the current laws.

The number of countries introducing voluntary assisted dying (VAD) laws is increasing. Actively taking steps to end a person's life is contentious so implementing these laws into healthcare services presents unique challenges. Theoretically underpinned by the Advocacy Coalition Framework, this study identified the beliefs of classes of stakeholders who engaged with the parliamentary process associated with the introduction of VAD laws in Queensland, Australia. Submissions about VAD made to a parliamentary inquiry were allocated to a class and qualitatively analysed to identify underlying beliefs. The data were then subjected to statistical analysis including nonmetric dimensional scaling and one-way analysis of similarity. Data visualisation techniques were used to generate a chord map and heatmap, to identify the belief types, as well as similarities and differences between beliefs and among classes. Fourteen different beliefs were identified in the 91 reviewed submissions. Six were deep core beliefs and eight were policy core beliefs. Beliefs could be associated with a positive or negative sentiment toward VAD. In this study, the class of Health Services expressed more negative sentiments to VAD than neutral or positive sentiments. The sentiments expressed by the class of Health Professionals were equally divided between positive, neutral and negative. These findings provide important insights for implementors as laws become operational. In particular, for organisations that provide health services, clear articulation of their stance in relevant policy and guidance documents is recommended.

Background: The enactment of laws that permit voluntary assisted dying reflects community views about end-of-life choices for those who are suffering and dying and includes a commitment to equitable ac-cess. Australian and New Zealand voluntary assisted dying frameworks are embedded in healthcare and authorise medical practitioners to assess whether a person meets prescribed eligibility criteria for access to voluntary assisted dying. Aim: In this article, we argue that including nurse practitioners as assessing practitioners in Australian and New Zealand voluntary assisted dying frameworks can promote equitable access. Method: We demonstrate that nurse practitioners have the required education and skillset to assess el-igibility, eligibility assessment is within their scope of practice, and recent evidence demonstrates that they may be more likely to participate in voluntary assisted dying than medical practitioners. Review-ing information relied on by lawmakers, we highlight the cursory consideration given to roles for nurse practitioners, and that their exclusion from assessing eligibility has not been justified. Conclusion: As new voluntary assisted dying laws are implemented in health services across Australia and New Zealand, research on the actual and potential contribution of nurse practitioners must be un-dertaken and reported. This will make it more likely that there is evidence to inform decisions about whether including nurse practitioners as assessing practitioners is feasible and necessary as laws are reviewed. (c) 2022 Australian College of Nursing Ltd. Published by Elsevier Ltd.