Clinical Snippets – October 2021

1.  EOLC Act snippet

The EOLC Act requires the SCENZ (Support and Consultation for End of Life Choice in New Zealand) group to oversee assisted dying service lists for:

• Replacement attending medical practitioners (where a person seeks the name of a practitioner to provide the service for them). This practitioner will support someone who is terminally ill to make an application for assisted dying, and undertake a first assessment
• Independent medical practitioners (to undertake the second independent assessment)
• Psychiatrists (required if one or both of the initial assessments was unable to determine that the person is competent to make a decision).
• The SCENZ group will also hold a list of willing nurse practitioners. Nurse practitioners can be involved in the planning of assisted dying with the person and their whānau, and can be with the person to administer medicines or supervise self -administration if that is what the person chooses

A medical practitioner who does not provide assisted dying services due to a conscientious objection (or belief it is outside their scope of practice) is legally required to:

• inform the person asking about assisted dying of their objection

• tell the person they have the right to ask the SCENZ group for the name and contact details of a ‘replacement’ medical practitioner who is willing to participate in assisted dying.

A person will also be able to contact the SCENZ group directly for help to find a medical practitioner if they do not want to speak to their own medical practitioner about assisted dying.

The schedule of payments for providing EOLC services is now available and additional learning modules are available on the Learnonline website.     

2.  Concussion

• The current ACC referral system poses significant barriers to both GPs and to patients. As it stands, patients wait an average of eight weeks before being able to access the appropriate concussion treatments through ACC. A new treatment and referral model which involves funding for extended primary care consults and embedding of specific management tools into the PMS is currently being trialled.  In the meantime…

• The ACC Concussion Clinical Expert Group has reviewed current tools for TBI assessment and found for the most part they were limited, overly complicated, and didn’t support decision making. As a result, a tool has been developed to help health practitioners assess and treat TBI patients, called the Brain Injury Screening Tool (BIST). 

• BIST runs patients through a checklist of 16 items and takes six minutes from start to finish, leaving the practitioner enough time within the 15-minute consult to also provide treatment advice. It is simple enough to use even with young children. The series of questions look at the impact of the patient’s symptoms in the context of their life and the results categorise the patient in terms of their risk factor (low, medium, or high risk).  

• The tool indicates problem areas to be aware of, suggests additional questions or assessments to be completed, and supports the healthcare professional to confidently assess and treat the TBI patient. Each assessment results in a total symptom score, allowing practitioners to graph their patient’s recovery over time using a standardised outcome assessment. 
  
  

3.  Prostate cancer

The Prostate Cancer Quality Improvement Monitoring Report is now available on the Te Aho o Te Kahu website.  Some key findings in relation to equity included:

• Pacific and Asian men were in some cases more likely to be diagnosed following presentation at an ED (10.7 percent and 8.0 percent) than European/Other ethnic group men (5.8 percent).

• Men aged 75 and over were more likely to be diagnosed around the time of presentation at an ED (17.2 percent) compared to men in younger age groups (5 percent or less).

• Men who lived in areas of high social deprivation were more likely to be diagnosed following presentation at an ED (8.7 percent) than men living is areas of low social deprivation (3.9 percent).

• Māori are less likely than non-Māori to be diagnosed with prostate cancer and are more likely to have poorer survival rates once they are diagnosed.

The primary care management of suspected prostate cancer is clearly outlined in the Ministry of Health Prostate Cancer Management and Referral Guidance which has a useful algorithm for quick reference.  The relevant HealthPathway provides similar guidance.  The PSA ‘discussion’ is not so clear cut and useful resources to aid this discussion are available on the Kupe website (including a PSA decision support tool).  The Health Navigator website also contains useful resources (including two videos on the pros and cons of PSA screening). 

4.  Early Pregnancy Treatment Clinic (Waikato DHB)

EPAC is now EPTC. The clinic is aimed at pregnancies of <16 weeks gestation and the role of the EPTC is to:

• Establish a MANAGEMENT plan following a DIAGNOSIS of a miscarriage (expectant, medical or surgical management.)
• Establish a MANAGEMENT plan where a confirmed presence of RPOC exists following miscarriage in a symptomatic patient.
• Coordinate molar pregnancy management.
• Coordinate follow up for a woman who has received methotrexate or expectant management as part of her ectopic pregnancy of unknown location treatment as per Waikato DHB protocol.

Appropriate referral to EPTC requires CONFIRMED miscarriage by ultrasound or CONFIRMED RPOC following a miscarriage. The clinic will not accept referrals for ultrasound scans for uncertain dates, viability or seeking confirmation of miscarriage. Patients with hyperemesis gravidarum, those patients deemed too clinically unstable to delay assessment and patients who have high suspicion of ectopic pregnancy should be referred to Acute Gynaecology.

This is NOT an acute service.  patients can expect to be called within 5 working days.

Advice on management of suspected miscarriage and ectopic pregnancy is available on HeathPathways although has not yet been adapted for the Waikato region.   Some important reminders:

• Always consider an ectopic pregnancy if positive pregnancy test and abdominal pain or bleeding
• Check haemodynamic stability and palpate the abdomen
• Consider if anti-D immunoglobulin might be required (first trimester miscarriage is an indication but the NZ Transfusion Medicine Handbook notes before 12 weeks gestation, in cases of either spontaneous complete miscarriage where the uterus is not instrumented or mild painless vaginal bleeding, the risk of fetomaternal haemorrhage is negligible.
• If monitoring hCG, ongoing intrauterine pregnancies are usually expected to have a rise of 67% or greater over 48 hours in the first trimester. Rarely, smaller rises have been reported in normal pregnancies.  Pregnancies that are miscarrying usually see hCG levels fall by 50% or more. Continue to monitor weekly until the hCG returns to zero.   Referring to an hCG doubling time calculator can be helpful given the wide range of ‘normal’ hCG levels.   

5.  Educational relaxation…

The Good GP is a series of relatively brief (usually around 15-20 minutes) educational podcasts on a huge range of primary care-related topics.  A new podcast each week.  Most recently:   OCD, venous disease, LARCS.  

6.  More on conscientious objection

New abortion legislation enacted in March this year includes some changes in the responsibilities of a health practitioner who is requested by a patient to provide, or assist with providing, any of the following services: contraception services; sterilisation services; abortion services; information or advisory services about whether to continue or terminate a pregnancy.

If the practitioner has a conscientious objection to providing, or to assisting with providing, to the patient the service requested, the practitioner must tell the patient at the earliest opportunity—

(a) of their conscientious objection; and

(b) how to access the contact details of another person who is the closest provider of the service requested.

The closest provider is to be determined taking into account:

• the physical distance between the providers; and
• the date and time the patient has made their request
• the operating hours of the provider of the service requested.

This section does not override a health practitioner’s professional and legal duty to provide prompt and appropriate medical assistance to any person in a medical emergency.

PS

Dave’s  opera recommendation :

Elīna Garanča – Saint-Saëns: ‘Mon coeur s’ouvre à ta voix’ from Samson et Dalila (Romantique)