Category: New Zealand Associations and Organisaitons

Source: Association of Salaried Medical Specialists – Press Release/Statement:

Headline: End of Life Choices Act | What you need to know

The End of Life Choice Act came into effect on 7th November. We asked experts from the Medical Assurance Society (MAS) for medico-legal advice to share with our members. They have provided a good overview of the legislation, along with information which you as senior clinicians may need or want to know.
Overview of the EOLC Act
Homicide and aiding and abetting suicide are unlawful under the Crimes Act 1961.  Notwithstanding this, from 7 November 2021 the EOLC Act will provide a process that, if followed, will allow ‘eligible’ people to choose to die and be assisted to die by a medical practitioner.

Who is involved in the EOLC Act process?
What is involved in the EOLC Act process?
Who is eligible for a medically assisted death?
What is the test for competence?
Pressure
Conscientious objection
Assisted dying must not be initiated by a health practitioner
Obligations if you are not a conscientious objector
Medical Council position
Summary
Where can I find out more?

Who is involved in the EOLC Act process?

The patient — patients who meet the EOLC Act’s tests for competence and eligibility can have a medically assisted death.
The attending medical practitioner (AMP) — any doctor can choose to be an AMP. The AMP is the doctor at the centre of the EOLC Act process who holds the main relationship with the patient in respect of the process; undertakes the initial assessment of eligibility; and works with the patient to complete an assisted death.

Independent medical practitioners (IMP) — these are doctors who have been pre-approved to undertake the required second assessment of eligibility.

Psychiatrists — these are pre-approved psychiatrists who can be asked to resolve any disagreements about competence.

Replacement medical practitioners — these are pre-approved doctors who are happy to fulfil the role of AMP and to whom patients can be referred.

Support and Consultation for End of Life in New Zealand Group (SCENZ) — this is a group of experts appointed by the Director-General of Health. Their functions include to maintain lists of independent medical practitioners, psychiatrists and replacement medical practitioners; refer patients to replacement medical practitioners; prepare standards of care; and provide advice and practical assistance.

Registrar — this is a Ministry of Health employee tasked with collating information and checking that all the necessary forms have been properly completed before an assisted death can take place.

Review Committee — this is a committee of two health practitioners and a medical ethicist, whose functions include considering (after the fact) reports on each assisted death that occurs under the EOLC Act.

What is involved in the EOLC Act process?

A patient makes a request to their doctor for assistance with ending their life.
If the doctor is happy and able to be involved, they become the AMP and assume obligations to counsel and inform the patient. (If the doctor cannot or does not wish to be involved, they can refer the patient to SCENZ.  SCENZ will then refer the patient to a replacement medical practitioner.)
If the patient decides following counselling to proceed, the AMP gives a formal first opinion about the patient’s competence and eligibility.
If the AMP concludes the patient is eligible, SCENZ provides the name of an IMP to give a second competence and eligibility opinion. (Disagreements over competence can be resolved by SCENZ-recommended psychiatrist.)
If the first and second opinions find the patient to be eligible and competent, the AMP will help them choose the time, place and method for an assisted death.
The AMP is then responsible for prescribing the medication and overseeing its administration and the patient’s death. The patient must agree to receive the medication and must be competent at the time it is used.  They cannot rely on an advance directive or an enduring power of attorney for personal care and welfare.  A nurse practitioner may also prescribe and/or administer the medication under the AMP’s direction, although has no formal role in other parts of the process.
At various stages the AMP is required to complete forms and witness the patient’s agreement. These forms are checked by the Registrar, who must give final approval before the medicine is administered.
The whole process is expected to take approximately 2-4 weeks, but could be longer.
After an assisted death the AMP has reporting obligations.

The process will be fully publicly funded by the Ministry of Health, with co-payments prohibited.
Who is eligible for a medically assisted death?
To be eligible for a medically assisted death, a patient must:

be 18 years or older;
be a New Zealand citizen or permanent resident;
suffer from a terminal illness that is likely to end the patient’s life within 6 months;
be in an advanced state of irreversible decline in physical capability;
experience unbearable suffering that cannot be relieved in a manner that the patient considers tolerable; and
be competent to make an informed decision about assisted dying.

What is the test for competence?
Under the EOLC Act, a patient is competent to make an informed decision about assisted dying if they:

understand information about the nature of assisted dying that is relevant to the decision; and
retain that information to the extent necessary to make the decision; and
use or weigh that information as part of the process of making the decision; and
communicate the decision in some way.

Patients must remain competent at each stage of the process, not just when the first and second opinions are given.  If a patient loses competence before the medicine to effect an assisted death has been administered, the process must stop.
Pressure
AMPs are required to do their best to ensure patients express their wishes about exercising the option of receiving assisted dying, free from pressure from any other person.  If pressure is reasonably suspected, the AMP must stop the process; inform the patient they cannot continue; and inform the Registrar of the suspected pressure by submitting a form.
What do all doctors need to know?
Conscientious objection
A health practitioner is not under any obligation to assist any person who wishes to exercise the option of receiving assisted dying under this Act if the health practitioner has a conscientious objection to providing that assistance to the person.
However, if you do have a conscientious objection and a patient informs you that they wish to exercise the option of assisted dying, you must tell the patient:

of the fact of your conscientious objection; and
of the patient’s right to ask SCENZ for the name and contact details of a replacement medical practitioner.

Conscientious objection does not need to be all or nothing.  You can be prepared to accept the role of AMP in some cases but not others.
Assisted dying must not be initiated by a health practitioner
A health practitioner who provides any health service to a person must not, in the course of providing that service:

initiate any discussion with the person that, in substance, is about assisted dying under the EOLC Act; or
make any suggestion to the person that, in substance, is a suggestion that the person exercise the option of receiving assisted dying under the EOLC Act.

This has implications for advance care planning, as doctors will need to avoid raising the topic of assisted dying while being alert to patients making a request to exercise that option.
Obligations if you are not a conscientious objector
Not being a conscientious objector does not mean you must accept the role of AMP if one of your patients informs you of their wish to exercise the option of receiving assisted dying.  GP practices and hospices are not required to offer assisted dying as a service, however there is an expectation each DHB will have a policy to manage request made by patients.  Further, the EOLC Act does not exclude the professional obligations of practitioners as set by the Medical Council.  Doctors should only take steps under the EOLC Act if they have the competence to do so in accordance with their professional standards.  If you do not wish to take on the role of AMP, patients should be advised how they can access assisted dying care.  This could be by a clinical referral to a colleague, or by contacting SCENZ for the name of an replacement medical practitioner.
If you are an employee or contractor, you should check with your employer/principal as to whether the practice/DHB offers assisted dying as a service.  It is expected most assisted deaths will occur in the community, at home.  Hospital patients can make requests however, and there may be patients whose care needs to transfer to a hospital setting part-way through the EOLC Act process.
If you do wish to be the AMP for one of your patients, you should reach out to SCENZ for advice and assistance — including more information about how the service is funded and how to access that funding.  For doctors who become the AMP for a patient, s 11 of the EOLC Act sets out your initial set of obligations.  These include:

Give a prognosis and information about assisted dying.
Stay in touch with the patient.
Ensure the patient understands their end-of-life care options.
Ensure the patient knows they can change their mind.
Encourage the patient to discuss their wish with others (but tell them they are not obliged to).
Ensure the patient has had the opportunity to discuss their wish with whom they choose.
Do your best (including by conferring with others) to ensure the patient expresses their wish free from pressure.
Record the actions taken.

Medical Council position
The Medical Council has not adopted a specific standard for the EOLC Act process.  It has however published an analysis of which existing standards may be relevant.  It is recommended that doctors familiarise themselves with this guidance statement.
Summary
It is a good idea to think in advance about how you will respond if assisted dying is raised with you — how you will engage with the person; are you equipped to have a respectful and appropriate conversation; and how you will fulfill your obligations under the EOLC Act?
Identify in advance the approach your organisation has taken, and who you can refer to inside the organisation.  DHBs are likely starting to adopt policies to implement the EOLC Act now, and there may be opportunities to provide feedback on draft policies.  If you are the owner of a practice, consider trying to reach a consensus view with your partners about how you will approach the new law.
If you are not a conscientious objector, consider accessing the LearnOnline training offered by the Ministry of Health.
Where can I find out more?
The Ministry of Health website  includes a range of detailed information about the implementation of the EOLC Act, the delivery of assisted dying, and the way the service will be funded.  There are also resources for health practitioners, including guidance and training.
Dr Margaret Abercrombie, is Medicolegal Consultant at Medical Protection and Adam Holloway is a partner at Wotton Kearney.
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Source: Association of Salaried Medical Specialists – Press Release/Statement:

Headline: The moral injury of keeping patients waiting

Overseeing clinical work that involves most people missing out on timely care goes hard against the grain of medical training and ethics. Making the least bad decision about a patient’s treatment wears a person down and significantly pushes up burnout risk. Read our opinion piece.

Moral injury: knowing patient care could be better but being unable to make the necessary changes due to constraints that are beyond [a doctor’s] control.
It’s a definition senior hospital doctors are well-acquainted with.
Doctors care deeply for their patients. As part of becoming a doctor, they all must sign the Hippocratic Oath by which they agree to treat the ill to the best of their abilities and do no harm.
Our members – doctors and dentists working in public hospitals – tell us that this is increasingly hard to achieve.  Many are burnt-out, fed up working in stretched environments where there are more patients than they can see, where they are covering unfilled vacancies, care is routinely rationed, and short staffing is the norm not the exception.
We now hear reports that patients from Southland and Otago may be sent to neighbouring regions for their surgeries as Southern DHB tries to deal with the hundreds of patients lingering on waiting lists, facing unacceptably long delays. Those are all patients living with pain or illness which is treatable.
Covid lockdowns have created additional delays, but more to the point, they have amplified existing problems and frustrations.
Covid backlogs can’t explain away the endemic staffing shortages which mean there aren’t enough hospital beds or theatre capacity, not to mention the fact that elective surgeries continue to be pushed back because staff are swamped trying to deal with the growing number of patients presenting with urgent or acute needs.
A contributing factor in Southland, which doctors believe has never been properly accounted for, is what they describe as a ‘staggering’ rise in trauma-based accidents and hospitalisations due to the increase in adventure- based sports in the past ten years or so. Well before Covid came along elective surgeries were being routinely cancelled as surgeons tried to juggle very limited acute theatre space.
Last year the Government gave DHBs an extra $282 million to clear the Covid related backlog of deferred elective operations, but that’s a hard ask when you don’t have the staff and hospitals are already running at 100% capacity.
It’s a domino effect. Patients can’t get surgery if doctors can’t access theatre time. Doctors can’t access theatre time because of dire nursing shortages both in theatres and on the wards. Allied health staff such as anaesthetic technicians and physiotherapists are in desperately short supply with dozens of positions vacant.
We’ve been told that surgeons have been ready and waiting to get patients through the door but some weeks they have only been able to do one or two operations due to inadequate staffing levels.
It harks back to moral injury. Overseeing clinical work that involves most people missing out on timely care goes hard against the grain of medical training and ethics. Making the least bad decision about a patient’s treatment wears a person down and significantly pushes up burnout risk.
At the heart of all this is a longstanding failure to invest in the health workforce.
The fact that serious discussions were being had about downgrading Southland Hospital’s maternity service because the clinical director of the Obstetrics and Gynaecology Service could not get back into the country, serves to illustrate this further and shows a worryingly short-sighted grasp on deep-seated health need. We shouldn’t be shutting services down, but building them up
The service is perilously short of both doctors and midwives.
It is magical thinking if the Government and health managers believe we can continue to burn through health workers and more will pop up.
What is needed is proper workforce planning and the re-building of a health system that people want to work in. That means valuing and investing in the health care workers we do have by offering pay and conditions to encourage recruitment and retention.
It also means some honesty from health leaders about the real state of health need and the limits on our system’s ability to meet that need.
The longer the Government waits to act on critical understaffing in our hospitals the harder the fix will be.
The perfect storm we see in Southland is just a microcosm of cracks appearing across the whole of our health system. We all see it – some of us live it day to day. Now it’s time to step up and fix it. It’s time to remember that our public health system (and the people at its heart) belongs to us all. As taxpayers and health system users, it’s time to hold the planners and funders to account. Investing in the people who keep our health system running is in investment in all our health.
– As published in The Southland Times and on Stuff – 3 November 2021
 
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Source: Association of Salaried Medical Specialists – Press Release/Statement:

Headline: Annual Conference Programme now available

The 33rd ASMS Annual Conference is fast-approaching and we now have a confirmed programme.
Due to Covid restrictions the Conference is being held virtually and will run over just one day on Thursday 25 November.
Despite that we have organised an interesting line-up of speakers, including the Health Minister Andrew Little who will give an opening address.
You can see the full programme by clicking here.
Registrations are still open. You can register here .
Look forward to seeing you on your screens on Conference day.
 
 
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Source: Association of Salaried Medical Specialists – Press Release/Statement:

Headline: Senior doctors need more than hollow words as Australia comes knocking

The Association of Salaried Medical Specialists Toi Mata Hauora is calling on the Government to put words into action when it comes to valuing frontline health workers, with Australia poised to bring in thousands of extra clinical staff.
The Health Minister Andrew Little said this week that health workers should feel assured that the pressure they are under, is not unnoticed.
“When you’ve been offered a zero percent pay rise, which effectively amounts to a pay cut, and no prospect of better staffing and conditions, those words seem very hollow,” says ASMS Executive Director Sarah Dalton.
The senior doctor workforce is fatigued and demoralised as it juggles entrenched staffing shortages and overstretched services, alongside the immediate threat of Covid and resulting patient backlogs.
ASMS and DHBs are due to go into mediation next month over stalled collective contract negotiations for senior hospital doctors and dentists.
ASMS is asking for a very modest pay rise to simply reflect cost of living increases, but DHBs have continued to come back with a zero offer.
“Employer gratitude should not equal pay restraint, especially at a time when our doctors, who work tirelessly for the public health system, are being asked to step up, cover staffing gaps, work longer hours and make personal sacrifices to keep their patients and their families safe during Covid,” Sarah Dalton says.
Australia is reportedly set to allow 2,000 overseas doctors and nurses into the country to ease a healthcare staffing crisis there.
“With specialists earning up to 60% more in Australia, it’s a very promising option. We’ve had members writing to us saying they are being regularly targeted by Australian medical recruiters offering to double their current salaries”.
“Our doctors are keeping New Zealanders safe and holding our health system together. The Government needs to show senior medical and dental specialists the same commitment and give them a reason to stay,” says Sarah Dalton.
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Source: Association of Salaried Medical Specialists – Press Release/Statement:

Headline: Priority MIQ for essential health workers applauded

The Association of Salaried Medical Specialists Toi Mata Hauora is welcoming the Government’s announcement to guarantee 300 Managed Isolation and Quarantine (MIQ) spaces a month for much-needed health professionals.
Border closures have exacerbated problems in an already stretched health system. ASMS understood that 100 of the 250 requests made by DHBs in recent months to prioritise health staff had been rejected.
ASMS Executive Director Sarah Dalton says not being able to get desperately-needed health staff into the country has been a frustration.
“We were hearing how broken the MIQ system was for health professionals, and it was something we had repeatedly raised. We are thrilled the Government has listened and taken action.”
Even without Covid, hospitals and health services have been struggling with significant staffing shortages.
“Services are crying out for skilled staff. The number of vacancies is putting senior clinicians under immense pressure and is a major cause of burnout. It didn’t make sense to have people stranded overseas,” she says.
Earlier this month the head of Southland Hospital’s Obstetrics and Gynaecology service, Dr Jim Faherty, made headlines when he couldn’t get a spot in MIQ and his absence forced the hospital to consider downgrading its maternity unit.
Sarah Dalton says that illustrates just how fragile the staffing situation and system is.
“Endemic Covid will stretch resources further and highlights the need for proper workforce supply planning,” she says.
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Source: Association of Salaried Medical Specialists – Press Release/Statement:

Headline: Endemic Covid will expose lack of health workforce investment and cost lives

The Association of Salaried Medical Specialist Toi Mata Hauora says endemic Covid is set to expose the long-term lack of investment and planning in New Zealand’s health workforce, costing lives.
The Government has detailed how the health system will deal with the expected increase in Covid cases.
ASMS Executive Director Sarah Dalton says frontline ICU specialists do not share the Government’s confidence around ICU bed capacity and there are real fears about what lies ahead.
“We have been repeatedly told by our ICU specialists that there has been no meaningful investment or expansion in ICU capacity and in many parts of the country staffing levels are running at unsafe levels.”
“A number of our regional hospitals won’t be able to keep patients because their ICUs are so poorly equipped, meaning staff and patients will have to be juggled across different parts of the country”.
One ICU specialist recently said they only had two specialists left in their department and if one is sick the other must work continuously. That senior doctor had recently worked 84 hours in one week – 14 of those unpaid.
All parts of the health system are under pressure and as more resources are shifted to deal with Covid, backlogs will get bigger and there will be even longer delays in diagnosing and treating patients.
“That is an added stress for senior clinicians who will be forced to make the tough decisions around further rationing of patient care,” Sarah Dalton says.
“Planned care is already being delayed due to overwhelming acute demand, even in regions which haven’t seen Covid cases yet”.
Irrespective of the size and nature of any Covid surge the health system must make workforce planning and supply its number one focus.
“It’s all very well to acknowledge the pressure our doctors are under, but it’s time for the Government to show some commitment to keeping them safe and supported which includes fair pay and decent conditions of work,” she says.
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Source: Association of Salaried Medical Specialists – Press Release/Statement:

Headline: Mandatory vaccination welcome – booster planning next step

The Association of Salaried Medical Specialists Toi Mata Hauora says planning for Covid boosters must follow today’s decision on mandatory vaccination for health workers.
ASMS welcomes mandatory vaccination for health workers as a common-sense decision and senior doctors are actively promoting vaccination in their workplaces and communities.
Executive Director Sarah Dalton says there had been some disquiet among senior clinicians about having unvaccinated staff working in our hospitals and health services.
“It’s been an added stress in an already stressed environment. This will give everyone working in a healthcare or hospital setting reassurance around their own personal risk and safety”.
“We need our hospitals to be as safe as they can be for patients and the people who care for them”.
She says the focus now needs to shift to thinking about booster planning for frontline health workers.
“Some of our doctors are beginning to point to international research suggesting that boosters may be needed for those frontline staff who were part of the initial vaccine rollout”.
“It’s an issue we intend to bring up with the Ministry of Health this week”.
ASMS is also pleased that children’s health is being prioritised with mandatory vaccination being extended to teachers.
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Source: Association of Salaried Medical Specialists – Press Release/Statement:

Headline: Welcome end to residency uncertainty – now let’s sort MIQ

The Association of Salaried Medical Specialists Toi Mata Hauora says the Government’s move to fast-track residency visa applications is a positive step, but urgent consideration now needs to be given to prioritising medical staff into MIQ.
Thousands of people have been waiting to apply for residency visas since the processing of applications was paused around April last year.
Figures obtained by RNZ under the Official Information Act on 31 August, showed there were 675 doctors and just over 2,200 nurses waiting to apply for residence under the skilled migrant category.
ASMS Executive Director Sarah Dalton says today’s announcement follows months of lobbying and will end the uncertainty for hundreds of much-needed medical specialists, who can now plan to put down permanent roots in New Zealand.
“We were facing a situation where these overseas-trained doctors, who New Zealand relies so heavily on to staff our hospitals, were living in limbo and being forced to leave or reconsider their futures here”.
One provincial hospital was at risk of losing four desperately needed radiologists.
“With gaping staffing shortages across so many specialties in our hospitals, and services struggling to keep up with demand, we can ill afford to be losing valuable, highly skilled people out of the system,” Sarah Dalton says.
“It also highlights the fact that currently there is no national plan to tackle entrenched workforce shortages as far as we can see. This must be a number one priority for the new Health NZ and Māori Health Authority”.
Given Covid and the vulnerable state of the health workforce ASMS is calling for support from the Government in fast-tracking health workers into the country.
“We don’t understand why direct requests by DHBs to expedite MIQ for urgently needed health workers seem to be falling on deaf ears, especially when priority spaces are found for sports teams and other individuals,” Sarah Dalton says.
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Source: Association of Salaried Medical Specialists – Press Release/Statement:

Headline: Our new report – a roadmap to health equity by 2040

In July ASMS co-hosted a virtual conference with the Canterbury Charity Hospital Trust to look at stark health inequities in Aotearoa New Zealand and look at solutions. Out of that we have written a report – Creating Solutions Te Ara Whai Tika which sets out a policy roadmap to health equity by 2040.
The Creating Solutions Te Ara Whai Tika report finds that based on current trends, it will take a century for Māori to catch up with pakeha New Zealanders in terms of life expectancy.
It recommends a national goal of achieving health equity for all New Zealanders by 2040 and lays out a roadmap of policies to get there.
It follows presentations, discussions, and input from more than 200 health professionals who attended a virtual conference co-hosted by ASMS and the Canterbury Charity Hospital Trust, established by Dame Sue and Associate Professor Phil Bagshaw.
Not only is there a gap in life expectancy between Māori and pakeha males of about 7.6 years, the gap in life expectancy between the wealthiest and the poorest and middle-income New Zealanders is widening. The wealthiest 10% of New Zealanders can now expect to live a decade longer than the poorest 10%, who are disproportionately Māori and Pasifika.
Health equity means everyone has the opportunity and support to live the healthiest life they can.
ASMS Executive Director Sarah Dalton says unfortunately, that’s a very distant reality in Aotearoa New Zealand.
“It is shocking to think that we have some groups of people dying ten years sooner than others and successive governments have failed to act”.
“Our doctors and nurses are treating patients in hospitals only to send them back home to the conditions that made them sick in the first place. You cannot have a fit-for-purpose public hospital system without addressing core social issues like poverty, racism, poor housing and unhealthy foods”.
“Currently we wait until people are so sick, they get admitted to hospital to receive diagnosis and treatment. This is without doubt the least cost-effective way to run our health system. It leads to overburdened hospitals, long wait times, and burned-out healthcare workers,” Sarah Dalton says.
The report recommends that cost barriers such as GP user charges must be removed to help the estimated 540,000 adult New Zealanders who can’t access a GP due to cost. In addition, more than 1.7 million adults can’t access a dentist due to user charges.
Health inequities cost New Zealand billions of dollars in avoidable illness and hospitalisations. Addressing them would bring economic benefits such as improved productivity, higher tax revenues and reduced costs in social and government allowances.
Health inequity has been a long time in the making, and recently it has been magnified by the Covid pandemic.
Sarah Dalton says “if we want to rebuild our economy and future proof our health system, health equity must be front and centre, especially as the Government pushes ahead with wholesale health sector reform. Having a Māori Health Authority with full commissioning rights is one very positive step in the right direction”.
The ASMS Creating Solutions report recommends a package of policies to help New Zealand achieve a goal of health equity by 2040.
It is being presented to the Government as an urgent call to target its health and wellbeing spend where it’s most needed.
Read the full report here
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Source: Association of Salaried Medical Specialists – Press Release/Statement:

Headline: Senior doctors call for strong clinical voice to lead health reforms

The Association of Salaried Medical Specialists Toi Mata Hauora welcomes the appointment of one of its members to the interim board of Health New Zealand, saying the voice of frontline clinicians must be heard as the Government pushes forward with sweeping health reform.
Dr Curtis Walker, who is also the Chair of the Medical Council, has been named as one of eight members of Health New Zealand which, along with the Māori Health Authority, will lead the establishment of the new health system.
ASMS Executive Director Sarah Dalton says as a working hospital doctor, Dr Walker can bring a unique clinical perspective to the group’s work.
ASMS believes the scale and timeframe for the implementation of the reforms will pose a formidable challenge.
“It’s fair to say there is both scepticism and trepidation among senior doctors about whether the reforms will actually make a difference to their lived reality of unsustainable workloads, staffing shortages and overstretched services and whether, ultimately, they can deliver improved patient care,” Sarah Dalton says.
“You can change structures all you like but at the end of the day our health system needs to be about patient care and that requires ongoing investment and the right resources in the right places”.
Sarah Dalton says the senior medical workforce is key to making the reforms work.
“Senior doctors and dentists need strong signals that they are valued. They must be given the opportunity to share their views frankly and take a leading role in decision-making at both the national and local level”.
ASMS publicly supported the Māori Health Authority with full commissioning rights as a new pathway to deliver health equity for Māori.
“We look forward to meeting and working with both the Māori Health Authority and Health NZ teams and remind them that ongoing engagement and consultation with health unions will be critical,” Sarah Dalton says.
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