Formal Consultation Research Articles

Summary of the Key Concepts on How to Develop a Perinatal Palliative Care Program.

Purpose of review: The aim of this study is to assess the most significant Perinatal Palliative Care (PnPC) development projects in the literature and summarize the shared key principles.Recent findings: PnPC is a new concept in neonatal intensive care approach. Advancements in perinatal diagnostics and medical technology have changed the landscape of the perinatal world. The threshold of viability continues to decrease, and diagnostic information is available earlier in pregnancy and more rapidly at the bedside; overall outcomes continue to improve. This rapid technological improvement brings ethical debates on the quality of life of patients with life-limiting and life-threatening conditions and the need to involve the family in the decision-making process, according to their wishes and cultural beliefs. Although the Perinatal Hospice concept was developed in the 1980s in the US, the first recommendations on how to develop a PnPC pathway were published in the early 2000s. We considered the most relevant position statements or guidelines on PnPC published in the last two decades. Some of them were more pertinent to pediatrics but still useful for the fundamental concepts and PnPC project's development.Summary: Health care providers and institutions are encouraged to develop PnPC programs, which have the goal of maximizing the quality of life of infants with non-curable conditions. These may generally include the following: a formal prenatal consultation; development of a coordinated birth plan between obstetrician, newborn care, and family; access to other neonatal and pediatric specialties, as needed; comfort palliative care during the prenatal, birth, and postnatal periods; and psychosocial and spiritual support for families, siblings, and staff.

New Classification and Management of Abetalipoproteinemia and Related Disorders

New Classification and Management of Abetalipoproteinemia and Related Disorders

The Structure and the Outcome of Telephone-Based Cardiac Consultations During Lockdown: A Lesson From COVID-19.

BackgroundIn response to COVID-19, Saudi Arabia as many countries, implemented “lockdown” to contain the epidemic. This resulted in suspension of all outpatient services. The reliability of the alternative telecommunication cardiac services during that time is not well studied. Accordingly, the objective of this study is to describe the structure of the telephone-based cardiac consultation (TBCC) and to explore its outcome.MethodsThis is a cross-sectional study that has a prospective follow up on patients who underwent medical intervention. During the period of lockdown, Alre’aiah health care society in Almadinah Almunawwarah, Saudi Arabia, provided a community health service. This was achieved by announcing telephone numbers for consultations in most specialties. This study includes all TBCC of a single cardiologist. Detailed demographic data, medical, social and drug histories of the patients were collected in charts. Individuals were requested to measure blood pressure (BP) and heart rate (HR) at the time of TBCC. Accordingly, cardiovascular assessment and appropriate intervention were executed. Patients who needed medical intervention were followed up in one week. The data were analyzed using appropriate statistical methods.ResultsFrom 01 April till 15 June 2020, a total of 168 individuals sought TBCC. Their median age was 51.5 ± 12.7 years, and (57.1%) were females. Healthy individuals constituted (33.9%), and (59.9%) were non-smokers. The most common reported medical illnesses were hypertension (27.3%), diabetes (23.8%), heart failure (16.1%), and coronary artery disease (14.9%). Palpitations were encountered by 58 patients. None of them had high-risk features or cardiac disease. Stress, excessive smoking, and caffeine intake were thought to be responsible for palpitations in 52 individuals who were reassured and educated, and newly diagnosed hypertension was established prospectively in eight patients and they were started on medications. Chest pain was reported by 51 individuals. The diagnosis of typical angina was made in nine patients and they were instructed to seek emergency care. Atypical angina pain was established in 10 cases who were advised to seek formal consultation once lockdown ends. Reassurance was achieved in 32 individuals who had features of non-angina pain. Uncontrolled hypertension was reported by 32 patients. Blood pressure control was achieved prospectively in 70% of these patients who followed up by adjusting their antihypertensive drugs. Twenty-seven patients with heart failure complained of worsening shortness of breath. New York Heart Association (NYHA) class 1-2 was reported by 21 patients, and they were managed by doubling diuretic dose, 19 of them followed back and reported significant improvement. NYHA class 3-4 was established in 6 patients and they were instructed to seek emergency care.ConclusionsWhen standard face-to-face cardiac consultations are compromised, a structured TBCC is considered feasible, seems effective, and promising alternative method of delivering the utmost cardiac care to the community. When conducted properly, it is useful to triage patients.

Dutch GPs' experience of burden by euthanasia requests from people with dementia: a quantitative survey.

BackgroundIn the Netherlands during the past decade, a growing number of people with dementia requested euthanasia, and each year more of such requests were granted.AimTo obtain quantitative insights into the problems and needs of GPs when confronted with a euthanasia request by a person with dementia.Design & settingA concept survey was composed for GPs in the Netherlands. Expert validity of the survey was achieved through pilot testing.MethodA postal survey was sent to a random sample of 900 Dutch GPs, regardless of their opinion on, or practical experience with, euthanasia. Collected data were analysed with descriptive statistics.ResultsOf 894 GPs, 423 (47.3%) completed the survey, of whom 176 (41.6%) had experience with euthanasia requests from people with dementia. Emotional burden was reported most frequently (n = 86; 52.8%), as well as feeling uncertain about the mental competence of the person with dementia (n = 77; 47.2%), pressure by relatives (n = 70; 42.9%) or the person with dementia (n = 56; 34.4%), and uncertainty about handling advance euthanasia directives (AEDs) (n = 43; 26.4%). GPs would appreciate more support from the following: a support and consultation in euthanasia in the Netherlands (SCEN) physician (an independent physician for support, information, and formal consultation around euthanasia) (n = 291; 68. 8%); a geriatric consultation team (n = 185; 43.7%); the end-of-life clinic (n = 184; 43.5%); or a palliative care consultation team (n = 179; 42.3%). Surprisingly the need for moral deliberation was hardly mentioned.ConclusionThe reported burden and the rise in numbers and complexity of euthanasia requests from people with dementia warrants primary care support. There needs to be easier access to colleagues with expertise, and training on end-of-life care needs of patients with dementia and their caregivers.

Does consultation count for corruption? The causal relations in the EU-28

ABSTRACT Consultation is a policy instrument geared toward stakeholder engagement in the formulation of primary and secondary legislation. It ensures certain categories of actors can access draft proposals, examine the evidence produced by government or regulators, provide comments and receive feedback. Using an original dataset of consultation design across the EU-28, we examine how variations in combinations of consultation design matter for perceptions of corruption. Using Ostrom’s Institutional Grammar Tool (IGT), we develop expectations about the causal effects of combinations of formal consultation rules together with the condition of social capital, which captures important attributes of the context in which consultation operates. We test our expectations using set-theoretic techniques. Our findings indicate: formal consultation rules are rarely sufficient for mitigating perceptions of corruption, legally prescribed procedures are often replaced by informal rules, and the limited effect of formal consultation rules on perceptions of corruption is due to an incomplete design of the procedures.

Youth employment in Ghana: economic and social development policies perspective

PurposeCreating employment opportunities for the youth remains a dilemma for policymakers. In many cases, policies and programmes to tackle youth unemployment have produced little results, because such initiatives have failed to consider some fundamental inputs. In Ghana, youth unemployment rate has doubled or more than doubled the national average unemployment rate in recent years. The current study, therefore, examines how policies in the past two decades have affected youth unemployment rate and other development outcomes.Design/methodology/approachThe study reviewed national economic development policy documents from 1996 to 2017 and other relevant policies aimed at creating employment opportunities for the youth, applying the content analysis procedure. Four main policy documents were reviewed in this regard. Data from secondary sources including International Labour Organisation (ILO), World Bank (WB), United Nations Development Programme (UNDP) and Ghana Statistical Service (GSS) were analysed to examine the trends in youth unemployment rate, human development index and GDP growth rate in Ghana over the years. There were also formal and informal consultations with youth and development practitioners.FindingsThe results of the study show that policies that promote general growth in the economy reduce youth unemployment, while continuation of existing youth programmes, expansion, as well as addition of new ones by new governments reduces youth unemployment rate. In particular, GDP growth and youth unemployment rate trend in opposite direction; periods of increased growth have reduced youth unemployment rate and vice versa. The period of Ghana Shared Growth and Development Agenda I & II witnessed better reduction (5.7%) in youth unemployment rate than any of the policy periods. This was not sustained, and despite the current youth employment initiatives, unemployment among young people still remained higher than the national average.Research limitations/implicationsThe study provides relevant information on how development policies and programmes affect youth unemployment rate over time. In as much as it is not the interest of the study, the study stops short of empirical estimation to determine the level of GDP growth rate that can reduce a particular level of youth unemployment, which is a case for further research. Nevertheless, the outcome of the study reflects the data and methodology used.Originality/valueTo the best of the knowledge of the authors, this is a first study in Ghana that has attempted to directly link development outcomes such as youth unemployment to national economic development policies, although there are studies that have analysed the policy gaps and implementation challenges. This paper, therefore, bridges the knowledge of how development policies affect youth employment opportunities, particularly for Ghana.

Epidemiology and Microbiology of Outpatient Cases of Carbapenem-Resistant Enterobacteriaceae in Connecticut During 2018

Background: Little is known about the epidemiology, microbiology, and clinical management of carbapenem-resistant Enterobacteriaceae (CRE) in outpatient settings. In Connecticut, all clinical CRE isolates are submitted to the state public health laboratory (SPHL) for a customized panel of antimicrobial susceptibility and carbapenemase gene testing. We describe all outpatient cases of CRE in Connecticut in 2018, including location of presentation, risk factors, microbiology and aspects of treatment. Methods: Outpatient CRE cases were defined as CRE infection in a patient not hospitalized at the time of positive CRE culture or within 30 days after culture collection. Outpatient cases were identified from routine statewide CRE reporting by reviewing clinical and laboratory data. A questionnaire was sent to outpatient providers who ordered the cultures that yielded CRE to collect additional clinical information. Antimicrobial susceptibility and carbapenemase gene detection results from the SPHL were also summarized. Results: Among 53 outpatient CRE cases (1 blood, 52 urine), the most common organisms were Enterobacter (25, 47%), Klebsiella (12, 23%), and E. coli (11, 21%). Overall, 21 (39.6%) patients presented in primary care settings, 8 (15%) in urology offices, 6 (11%) in women’s health/OBGYN clinics; the remainder presented across various clinical settings (Fig. 1). Of 42 patients for whom clinical data were available, 45% had been hospitalized within the prior year and 19% had a chronic indwelling device. Among outpatient CRE cases, infectious diseases consultation was reported in 9.5% and lab consultation in none. Median patient age was 83 years. Of 36 CRE samples for which lab data were available, 9 (25%) were carbapenemase-producers (CP-CRE), of which 8 were blaKPC positive. Sensitivity rates to oral antimicrobials ranged from 43% to 75% (Table 1). Conclusions: CRE infections occur in several different outpatient settings, and formal ID consultation in the management of these patients is infrequent. These findings highlight the critical need for providers across different outpatient specialties to be familiar with the clinical management and infection control practices needed in caring for patients with CRE. Hospitalization within the year prior to presentation was frequent among patients who developed subsequent CRE-positive cultures. Most outpatient CP-CRE cases in CT are due to KPC production. Overall, sensitivity to oral antimicrobials frequently prescribed in outpatient settings is low, providing additional challenges to the outpatient management of patients with CRE infection. Fosfomycin, though only approved for E. coli infections, may be an acceptable antibiotic choice for the treatment of these patients.Funding: NoneDisclosures: None

9.8 REFLECTING ON A DECADE OF COLLABORATIVE CARE IN NEW YORK: LESSONS LEARNED AND CUMULATIVE DATA FOR PROJECT TEACH REGIONS 1 AND 3

There are currently over 20 large-scale, statewide child psychiatry access programs across the United States. This study provides updated data on the Child and Adolescent Psychiatrists for Primary Care group Region 1 and 3 providers for Project TEACH (PT), one of the larger programs in the country. With the program reaching its 10-year mark, this would be a good time to reflect on the challenges and successes of establishing a broad-scale, pediatric collaborative care program. PT, established in 2010, is a New York State Office of Mental Health initiative to provide child mental health support to assist primary care in assessing and managing children with mild-to-moderate mental health needs. Child and Adolescent Psychiatrists for Primary Care is 1 of 2 regional providers for PT and provides service to over 80% of New York State. The program is a collaboration between 5 university-based child psychiatry divisions. PT consists of 3 broad efforts: formal education, linkage/referral assistance, and consultation support for primary care physicians. In 2016, the program was re-funded for 5 years through June 2021. A statewide coordinating center (SCC), the Massachusetts General Hospital (MGH) Psychiatry Academy, was also designated at that time. The SCC coordinates and oversees the efforts of the 2 regional providers, markets the program, maintains the website, and oversees education and evaluation.

Understanding the public debate about trophy hunting in China as a rural development mechanism

AbstractThe use of trophy hunting as a wildlife management option has been a highly controversial topic, especially in southern Africa, but trophy hunting has historically also taken place also throughout Asia. In China, trophy hunting was the topic of intense public discussion more than a decade ago, leading ultimately to the suspension of this practice in 2006. Yet, this debate was dominated by urban voices, with no formal consultation of rural populations from minorities such as the Tibetan herders who previously benefited financially from commercial trophy hunting acting as guides and who are also concerned about the negative impact of rising blue sheep numbers on livestock grazing. We used a discrete choice experiment econometric method to better understand the trade‐offs made by both urban and rural populations across China in relation trophy hunting as a rural development and wildlife management tool. We find that trophy hunting is supported by the majority of rural residents but opposed by most urban residents, although there is heterogeneity within both these groups. We recommend that policy‐making in this realm should be informed by a better understanding of the preferences of different stakeholders, including the local people who bear the costs of living with wildlife.

Compliance mechanisms and their implementation: the contrast between the Biological and Chemical Weapons Conventions

ABSTRACT The 1993 Chemical Weapons Convention (CWC) and the 1972 Biological and Toxin Weapons Convention (BWC) are key components of the international arms-control landscape. Yet the two conventions differ widely, particularly in the ways that are available to treaty parties to resolve any questions about compliance with the treaties. Both contain language concerning consultation and cooperation, but the CWC also has extensive procedures available to investigate allegations of noncompliance. This article reviews these differences in the conventions and explains, in part, how and why they came about. The Organisation for the Prohibition of Chemical Weapons (OPCW) has engaged in several consultations regarding compliance issues, but the OPCW publishes virtually nothing about the topics of the consultations or their frequency, findings, or conclusions. An exception, perhaps, is the OPCW’s work regarding Syrian use of chemical weapons (CW). Moreover, thus far, no treaty party has called for a challenge inspection to officially investigate perhaps the most serious allegations of treaty violations: Syrian and Russian alleged use of CW. The BWC states parties conducted one formal consultation raised by Cuba, alleging that the United States dropped biological agents on the island nation from airplanes to cause an animal epidemic. The consultation reached no official conclusion. The article goes on to praise the work of Raymond Zilinskas debunking the allegations through a careful scientific review of the Cuban claims. The article discusses the consequences of secrecy surrounding the CWC consultation process and laments that the BWC does not have the institutional capacity to carry on the type of analysis that Zilinskas undertook discrediting the Cuban allegations.

Racial burdens, translations, and chance

Racial burdens, translations, and chance

How transparent are RFMOs? Achievements and challenges

Transparency has been recognized as a key factor for successful resource management, and in view of the continuing decline of marine fishery resources demands for improved transparency in fisheries governance have been growing. RFMOs have responded to these calls and successfully implemented basic transparency requirements imposed by UNFSA, namely free access to most reports, documents and data, and admittance of IGOs and NGOs as observers at their meetings. The article examines RFMO legal regimes, procedures, and practices related to external and internal transparency. It considers the sharing of information, openness of the decision-making process, level of participation of external and internal actors in policymaking and the role of RFMO secretariats in supporting transparency. The study finds that RFMOs could improve their openness by introducing a process of formal consultation with external stakeholders, as required by the ecosystem approach to fisheries. Furthermore, the participation and influence of developing coastal states in RFMOs is often lacking due to insufficient funds and human resources, and intransparent practices in RFMO decision-making can exacerbate this problem. The study recognizes that well-resourced and independent RFMO secretariats can significantly promote transparency (or intransparency if staff are not neutral). RFMOs are key instruments to address the fisheries dilemma that the conservation of marine resources depends on the cooperation of states although almost all fish are caught in areas under national jurisdiction. Thus, they carry a high responsibility for promoting transparency, best practices, and a fair participation of all members in their activities and decisions.

Curbside Consultation for the Nurse Practitioner: Qualitative Inquiry for Education, Policy, and Practice.

Curbside consultation (CC), defined as pursuing information or recommendation regarding patient care, without request for formal consultation is a favored information source for nurse practitioners (NPs) when making clinical decisions in practice settings. Research and education concerning CC among NPs is lacking. The purpose of this study was to obtain an understanding of NP perceptions of interpersonal aspects of the CC process to inform NP clinical practice and education. Qualitative descriptive design and inductive content analysis was used. Twenty primary care and specialty care NP were recruited using purposive sampling for conduct of individual interviews. Content analysis identified themes describing interpersonal components of the CC process. NP practiced in collaboration with physicians in variable roles within primary care and specialty care settings. These collaborations varied dependent upon supervisory relationships with physicians. Additional themes concerned NP professional experience and characteristics of experts desired for CC. These characteristics included NP perceptions of colleague experience and expertise, trust, and interpersonal relationship dynamics. CC processes for NPs are multidimensional, including interpersonal themes as components of this communication exchange. Given CC is a highly utilized resource for NPs, further inquiry is critical for understanding of its implications for NP practice, policy, and education internationally.

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review.

Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined. Identify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit. Systematic rapid realist review. Bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation. 95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion. Providing alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.

Panel: Dispute Settlement System of the World Trade Organization (WTO)

This entry in the Max Planck Encyclopedia of International Procedural Law, titled Panel: Dispute Settlement System of the World Trade Organization (WTO), comprehensively covers all aspects of dispute settlement before WTO panels, as well as panel proceedings within the overall WTO dispute settlement system. This includes informal and formal consultations; the establishment and composition of panels; the sequence of proceedings; access for non-disputing parties; and the role of of the WTO Secretariat. The article also covers various elements of the panel process, including terms of reference, the standard of review, the applicable rules of interpretation, questions of evidence, the use of experts, the confidentiality of panel proceedings, panel expenses, and impartiality. It finally touches on how developing countries participate in the panel process and what the consequences are of the WTO's Appellate Body suspension.

Evaluation of NICU Healthcare Providers' Experience of Patient Ethics and Communication Excellence (PEACE) Rounds.

Neonatal intensive care (NICU) providers may experience distress due to controversial orders or the close relationships they form with neonates' families. A "Patient Ethics and Communications Excellence [PEACE] Rounds" intervention developed at Indiana University proved to significantly relieve distress by facilitating interdisciplinary discussions of clinically and ethically challenging issues associated with pediatric intensive care (PICU) patient care. NICU healthcare providers face similar challenges and will benefit from understanding the potential efficacy of PEACE Rounds in this setting. This study describes the experiences of NICU healthcare providers who participate in PEACE Rounds and evaluates their perceptions of how it affects their distress levels, contributes to interdisciplinary collaboration, and influences their understanding of ethical decision-making. Researchers conducted semi-structured interviews with 24 intervention participants, observed 12 interventions, facilitated a validation focus group, and performed a constructionist thematic analysis and triangulation based on data from transcribed recordings. PEACE Rounds improved interdisciplinary communication and collaboration and demonstrated restorative value through the benefits of voice and collective support. The intervention may reduce, but not replace, the need for formal ethics consultations. PEACE Rounds may potentially improve interdisciplinary communications and collaboration, relieve employee distress, and reduce ethics consultations. Studies of PEACE Rounds undertaken in other clinical settings, and facilitated by a nurse educator, will help assess the potential benefits of greater reach and access and the efficacy of less structured ethics discussions.

Exploring the use of curbside consultations for interprofessional collaboration and clinical decision-making

ABSTRACT Nurse practitioners utilize curbside consultation, an interprofessional collaboration communication process in which one clinician seeks advice from another, in clinical decision-making practices. Nevertheless, this process is not well-understood. A qualitative design with individual open-ended interviews was used to explore the phenomenon of curbside consultation among nurse practitioners for clinical decision-making. Twenty primary care and specialty nurse practitioners participated. Participants were recruited via purposive sampling from in-patient and out-patient settings in order to reach saturation of themes. Using inductive content analyses, the findings revealed that nurse practitioners made multiple decisions in the course of information-seeking and its application during the curbside consultation process. Motivated by the patient’s best interest, nurse practitioners provided advice in the curbside consultation exchange and sought answers to questions encountered in clinical decision-making. Multiple resources were often utilized with curbside consultation frequently evolving into formal consultation. Dynamics of curbside consultation included (a)synchronous approaches including text, e-mail, telephone, or face-to-face processes. Once information was received, nurse practitioners decided whether they (dis)agreed with advice and if validation was necessary. Nurse practitioners utilized curbside consultation for clinical decision-making and means for interprofessional collaboration, thereby increasing clinical competency and promoting quality patient outcomes. Implications of curbside consultation for education and practice require further exploration to enhance outcomes of curbside consultation processes.

Does pharmaceutical information systems data inform decision-making in public healthcare? Utility of a national system in a limited resource setting.

Globally, weak pharmaceutical information systems (PIS) negatively affect universal health coverage and outcomes. Few studies in sub-Saharan Africa qualitatively and quantitatively assess drivers and utility of data from PIS in public healthcare. A nationwide cross-sectional descriptive study interviewed PIS focal persons in all 14 regions of Namibia. The primary outcome was extent and predictors of utility of PIS data. The extent of utility of PIS data was determined using descriptive statistics and predictors by logistic regression in SPSSv24 or thematic analysis for qualitative data. The study recruited 58 key informants at facility-based 56 (96.6%) and national 2 (3.4%) levels. Of the 56 facility-based respondents, 29 (51.8%) were female and 27 (48.2%) pharmacists. The mean age and PIS work experience were 33.5±7.6years and 4.5±3.3years respectively. The utility level of PIS data was 34 (60.7%) (target >80%). A total of 103 uses of PIS data were cited; of which 38 (36.9%) were informing decisions on rational medicine use, 27 (26.2%) on pharmaceutical stock management and 24 (23.3%) on strengthening pharmacy workforce. The utility of PIS data significantly decreased with lack of systems on routine reporting by health facility in-charge (cOR=0.25, 95%CI: 0.06,0.90, p=0.035). Longer work experience (cOR=1.05, 95%CI: 0.88,1.25, p=0.58), formal consultations (cOR=1.29, 95%CI: 0.14,11.54, p=0.82), and availability of feedback systems (cOR=1.08, 95%CI: 0.33,3.56, p=0.89) appeared to increase utility of PIS data. Two thematic drivers of utility of PIS data were programmatic "feedback and action on PIS; structures,technical supportfor PIS discussion"; technical "training/technical capacity of staff; tools and resources for data collection and utilization"; and human-resource "staff availability and workload; attitude and commitment". The nationwide study shows sub-optimal utility of PIS data in public healthcare in Namibia, which negatively affects delivery of pharmaceutical services. This calls for action to enhance capabilities for utilization of automated real-time pharmaceutical information decision support systems to enhance real-time analysis and feedback on medicines data in resource-limited settings.

Assisted dying in New Zealand: what is known about the values underpinning citizens’ positions?

ABSTRACT In New Zealand, aiding and abetting a person to commit suicide or euthanasia even with consent, is unlawful. The introduction of a third Bill on assisted dying to the House of Representatives following a high profile court case, afforded an opportunity for examining how assisted dying is discussed in the public sphere. Social media postings include the voices of citizens who may not participate in formal public consultation processes. Contributors’ posts reveal deeply held socio-cultural values, as well as tensions about the relationship between citizens and the apparatus of government. In this article, we report on a discourse analysis of a selection of social media postings to illustrate the values that underpin the positions taken by contributors to these fora. These illustrate what many New Zealand citizens perceive to be at stake. The social media debate over how we should die reveals deeper issues about the nature of the society we want to live in, and the relationship between the State and citizens.

0596 Providers Rarely Assess Obstructive Sleep Apnea Symptoms Among Patients with Chronic Obstructive Pulmonary Disease

Abstract Introduction Professional societies recommend providers assess sleep symptoms in COPD, but it is unclear if this occurs. We aimed to evaluate OSA symptom assessment and documentation among patients with COPD, and the patient and provider characteristics associated with this assessment. Methods We conducted a cross-sectional study of adults aged ≥40 years with clinically diagnosed COPD and no prior diagnosis of OSA. We selected patients receiving care at two academic general internal medicine clinics between 6/1/2011 - 6/1/2013. We abstracted charts to assess how often OSA symptoms such as snoring, somnolence, witnessed apneas, or gasping/choking arousals were documented as present or absent. We performed multivariable mixed-effects logistic regression to assess associations of patient and primary care provider (PCP) factors with assessment of OSA symptoms. Patient factors included demographics, body mass index, comorbidities, healthcare utilization, and severity of COPD, and PCP factors including demographics, degree, and years of experience. Results Of 523 patients with COPD, only 26 (5.0%) had documentation of OSA symptom assessment within a one-year period. In mixed effects models, only referral to general pulmonary clinic was associated with the assessment of OSA symptoms (OR: 4.56, 95% CI 1.28-15.52). Among the 26 individuals who had OSA symptoms assessed, 9 (34.6%) reported snoring, 15 (57.7%) reported daytime somnolence, 2 (7.7%) reported gasping/choking arousals, and 5 (19.2%) reported witnessed apneas. Among those assessed for OSA symptoms, providers referred 11 (42.3%) for formal sleep consultation. Conclusion Providers rarely document OSA symptoms for patients with COPD in primary care clinic, but assessment is greater among those with pulmonary specialty consultation. Given time constraints in primary care, external facilitation of sleep symptom assessment may improve symptom recognition and receipt of appropriate services. Support NIH 5K23HL111116-05, VA Center of Innovation for Veteran-Centered and Value-Driven Care.