Health Opinion

Exploring the Impact of the Medical Planning and Decision Act on Nursing Practice

         A legislation is a law that has been enacted by the governing body, in Australia it is the parliament that makes laws. The role of the Judge is to interpret the law in a broader context and in specific circumstances (Strahl et al., 2021). The purpose of legislation is to regulate, outlaw, provide, to sanction, grant, declare or restrict behaviours (Grant, 2021). For example, under law, informed consent is a person’s decision that is given voluntarily, to agree to health care treatment. This follows the provision of accurate and relevant information about health interventions and the alternate options available (Teven et al., 2017).  Informed consent means that the individual must have adequate knowledge and understanding of the benefits and the material risks of the proposed intervention relevant to the person receiving the medical intervention. Broadly, any treatment that is given without the individual consenting is tantamount to battery, and maybe grounds for criminal investigation (Heinrichs, 2019).  Good clinical practice ensures that informed consent is validly and appropriately obtained. Informed consent also forms part of the professional code of conduct for nurses. In a broader context consent is about the patient’s autonomy, it puts the patient at the centre of all decision-making process (Zahle, 2017).

Legislation

         The aim of this paper is to explore the impact of the Medical Planning and Decision Act of 2018, and the Aged Care Act of 1997 on nursing care of the elderly people. The medical planning and decision act are part of the broader shift towards empowering people to make their own treatment decisions. The act establishes a single framework for individuals that have the capacity to decide for themselves. It tries to ensure that patient receive treatment that is consistent with their own preferences and values. Under the act, individuals can make legally binding advance health care directives about the treatment consents and interventions they do not want. They can make instructions, such as only pursue treatment that lesson pain and allows them to die with dignity. Individuals can appoint a medical decision-maker and support person (Medical Treatment Planning and Decisions Act, 2016). This is different from the regular advanced health care directive that only gives instructions on what nurses must do if the heart stops. They do not give a directive of what must happen when the individual suffers a medical emergency, and as result it takes away their right to die with dignity, as is the case with falls. The previous laws surrounding ACDs did not give guidance on what sort of treatment to have, or at what point during care should a conversation be had with client to consider comfort care (Carr & Luth, 2017).  End of life care is complicated with Individuals who do not have family but also lack the capacity to make an informed decision.  Under the law, if the individual cannot decide for themselves, a next of kin in form of a family member can make decision on their behalf. Complexity, in this case, is when the individual does not have any immediate family members to make medical decisions on there behalf. State appointed public advocates can only do so much in the way of advocating for the patients’ rights (Hack et al., 2017).

           Secondly, the Aged Care Act of 1997.  The Aged Care act of 1997 governs laws surrounding government-funded aged care and community care services (Federal Register of Legislation , 2021). It sets out rules for things such as funding, regulations, approval of providers, quality of care and the rights of the people receiving care. The commonwealth Community Support Program (CHSP) is part of the Aged Care Act, CHSP is designed to provide funding and support for older people living at home and want to maintain their independence. Service providers work with clients to maintain their independence, support can include help with daily tasks, home modification, transport, social support, and nursing care. CHSP providers receive funding from the government in form of grant agreements, they then provide subsidised services. Clients, in this case, contribute a fee towards a range of services. Clients are expected to contribute to the services they can afford. The CHSP is regulated by the Aged Care Quality and Safety Commission (Commonwealth Home Support Programme , 2021).  

      The commission is a national end to end regulator of aged care services, it has the responsibility of approving providers and receiving compulsory reports on the services provided. The commission indirectly accredits, assesses, and monitors aged care services that are subsidised by the government. The commission also conducts home care investigations and determine compliance requirements and is responsible for imposing sanctions if the standards of care are not met. The commission was created to make sure that the standards and quality of care are maintained in the health systems and to protect the rights of the consumers.  Imposing sanctions means increased scrutiny on the practices of staff and reduced funding which further increases the levels of stress in the organisation. Reduced funding inevitably impacts the levels of services the organisation can offer (Commonwealth Home Support Programme Key Changes, 2019). Assessment teams consisting of registered quality assessors undertake performance assessment through assessments, site, review, and quality audits. Assessment teams conduct performance assessment by collecting evidence of the quality of care, including observations, interviews, and document review.  They collect statistics on falls, wounds, and the general quality and improvement cycle of the organisation. The accreditation team will also look at the quality of the food provided.  Awarding accreditation to an organisation assures the community that the facility meets the safety and quality standards. The accreditation process aims to make sure that the standards of care are maintained across the health care system.  (The NSQHS Standards, 2021). 

Impact on Food and housing Security

         The Aged Care Act affects food security in two main ways; firstly, the funding structure is long and complicated, different aged care sectors have a different funding structure. Secondly, how much funding an organisation receives is dependant on the education and competence of staff within the organisation. The quality of care the client receives depends on the competency of the care coordinator and how well the coordinator can source funding. It also relies on the training of the personal care workers and how well they can document the patient’s condition and the general care needs. Because community care does not require clinical staff to be with the client all the time, day to day care is done by personal care workers, the risk here is that small changes in the client’s condition can be missed.

           Secondly, Home community care services are very expensive and hard to co-ordinate, for individuals that have financial trustees it is even harder to work out the financial payment method. 24hour home community care is even more expensive for individuals that do not have private health insurance, in this case the choice of services they are able to have at home is also limited. The basic medical care will be provided but the extra home and community care services are limited.  If the client cannot afford a small contribution to the care, in most cases the individual’s equity is sold. The money raised is used as bond prior to nursing home admission. Aged care homes are funded through the Aged care funding Instrument (ACFI) (Health, 2019).  ACFI, is a needs-based instrument, funding is based on the assessed needs of the client on a day to day basis. Community care, on the other hand, is done through the CHSP program, the CHSP program is available across Australia and funds a large variety of organisation to deliver services. Clients under this scheme must contribute up to 10% towards their care (Community Care Program |2019).  The contribution fees vary between providers and the level of services the clients receive are dependent on how wealthy they are. To get funding, assessors will normally come and review client to determine what level of support they are eligible to receive. More wealthy clients will be able to afford 24hour care at home. However, for clients from low social economic status, that need more care and community care is not suitable, aged care then becomes the only option.

 Implication on Nursing Practice

           The medical planning and decision act help nurses have a decision-making framework when caring for the elderly. It helps the clinicians figure out what sort of interventions can be pursued should a critical event happen.  This act goals beyond the narrow provision of whether to resuscitate or not to resuscitate. In this case the role of the care coordinator is to help the patient and the family make informed treatment preferences, appropriate prognosis, and the available options. Under this law the individual can specify specific instances for hospital transfer and the sort of treatment the hospital can explore.  It means that when creating a care plan, the care coordinator must work with the patient on what type of care they want and the care expectations.  For nurses the ethical value of patient autonomy and the families must be respected but must also be weighed against the use of expensive management.   It is important to explain to the patient and the families that advanced technologies do not hold a promise of full recovery and in most cases, the recovery can be so humiliating and burdensome for the patient.

Ethical Issues

          legislations that are made to protect the interest of the vulnerable are generally good, if they are implemented properly. If they are not implemented properly it can be a source of major psychological stress between carers and clinical staff. Provisional laws are generally created for maximum utility, meaning for the greater good of the wider community and do not account for specific differences within the community.  They do not account for the social, cultural, and religious differences in the community. For example, advanced care planning laws have the best of intentions and that is to safeguard the interest of the elderly. But ACDs are made at a point in time, they are meant to be reviewed yearly or when there is a change in the client’s condition.  Advanced care directives do not account for cases where the individual suffers a medical event that lives them unable to make decision for themselves, and do not have family to communicate what the client would have wanted should they deteriorated further (Hack et al., 2017).  Families playing the role of the surrogate tend to be emotionally attached to the client and hence their moral interest often lean towards active treatment. It is also hard to tell in most cases if the interest in the patient from the family is purely what is in best interest of the client.  While, an advanced care directive gives the patient the right to refuse medical interventions. For nurses however, it is often hard to workout at what point should care be considered futile. This is partly out of fear of litigation from the family, and the healthcare workers own moral leanings. Another reason is that while the client may have come to terms with the fact that they are dying, in majority of cases the families are not, and will want to do anything possible to prolong the process.  

Cultural Issues

          Finally, the law forces nurses to consider all aspects of care planning, especially when caring for culturally diverse communities, as is the case with Aboriginal people. When providing patient-centred care for Aboriginal clients, the coordinator needs to find out if the individual has a person who they would like to be involved in the discussion about their health. As they may have a decision-maker and spokesperson (Palliative Care and End-of-Life Care , 2019) . Things to consider when creating an end of life care plan includes who the client wants to call during the dying process and what music they would like to be played. In culturally religious groups like Muslims, only certain people trained in the Islamic way of performing last orifices can do that, in some cases nurses are not even allowed to touch the body. And in Many of these cultures, autopsies are also forbidden. In some African cultures, they do not burry the body for at least three days after death. In most cases, the body is taken home placed in the middle of the living room and people will morn for a week before the actual burial. Having an open dialogue with families and the client enables the care coordinator to know exactly what the patients want and ensures that their end of life pathways is respected.

Conclusion

       This paper has looked at the ethical, cultural, and professional impact of the aged care act of 1997 and the medical planning and decision act of 2016. This paper also looked at the implications of the medical planning act on nursing practice, particular focus was on the impact it has hard on the care of culturally diverse communities.

References

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