End-of-life care decision making by HCPs appears largely patient centered, although familial determination still wields significant influence with implications for advance care planning.

Background:“Do not resuscitate” (DNR) orders are put in place where cardiopulmonary resuscitation is inappropriate. However, it is unclear who should be involved in discussions and decisions around DNR orders.Aim:The aim was to determine the views of oncology and palliative care doctors and nurses on DNR orders.Materials and Methods:A questionnaire survey was conducted on 146 doctors and nurses in oncology and palliative care working within a tertiary specialist cancer center in Singapore.Results:Perceived care differences as a result of DNR determinations led to 50.7% of respondents reporting concerns that a DNR order would mean that the patient received a substandard level of care. On the matter of DNR discussions, majority thought that patients (78.8%) and the next of kin (78.1%) should be involved though with whom the ultimate decision lay differed. There was also a wide range of views on the most appropriate time to have a DNR discussion.Conclusions:From the viewpoint of oncology and palliative care healthcare professionals, patients should be involved at least in discussing if not in the determination of DNR orders, challenging the norm of familial determination in the Asian context. The varied responses highlight the complexity of decision making on issues relating to the end of life. Thus, it is important to take into account the innumerable bio-psychosocial, practical, and ethical factors that are involved within such deliberations.

Background The factors considered in decision making at the end of life is largely unknown. Aim To explore the importance of factors influencing end-of-life decision-making of healthcare professionals (HCP). Methods This short survey reviewed the significance of regularly reported factors and scenarios involving the patient, family and HCPs themselves in discerning end of life decision making and was carried out among physicians and nurses from the Oncology and Palliative Medicine department at the Singapore General Hospital and the National Cancer Centre between 1 and 31 March 2011. A response rate of 78.6% was acquired from the 187 questionnaires distributed. The ages of participants ranged from 19 to 68 years (mean 32.1, median 29) and their experience in oncology or palliative care ranged from 0 to 40 years (mean 5.87 years, median 4). Results First, respondents rated patient's wishes (96.6%), their clinical symptoms (93.9%) and the patient's beliefs (91.1%) as the pivotal factors determining their decision making process. Least important were the HCP's own beliefs (54.79%). Second, 94.6% of HCPs reported that they would respect the wishes of a competent patient over the family's wishes should there be a conflict of goals, but 59.9% would switch to the family's wishes when the patient loses capacity even if it ran against the patient's previously stated wishes. Third, of the 57.1% of respondents who had read the hospital's end of life care policy, most felt it useful in guiding their decisions and rarely required for them to be overruled. Conclusion End-of-life care decision making in Singapore appears to be largely patient-centred with patients' wishes and objective factors such as clinical symptoms taking precedence over HCP-related factors. However, familial determination remains influential especially when the patient is incapacitated. A better understanding of the factors can help inform future decision-making framework or guidelines.

BACKGROUND The clinical management of type 2 diabetes mellitus (T2DM) presents a significant challenge due to the constantly evolving clinical practice guidelines and growing array of drug classes available. Evidence suggests that artificial intelligence (AI)-enabled clinical decision support systems (CDSS) have proven to be effective in assisting clinicians with informed decision-making. Despite the merits of AI-driven CDSS, a significant research gap exists concerning the early-stage implementation and adoption of AI-enabled CDSS in T2DM management. OBJECTIVE This study aimed to explore the perspectives of clinicians on the utility and impact of an AI-enabled prescription advisory (APA) tool, developed using a multi-institutions diabetes registry and implemented in specialist endocrinology clinics, and the challenges to its adoption and application. METHODS We conducted focus group discussions using a semi-structured interview guide with purposively selected endocrinologists from a tertiary hospital. The focus group discussions were audio recorded and transcribed verbatim. Data were thematically analyzed. RESULTS A total of 13 clinicians participated in four focus group discussions. Our findings suggest that the APA tool offered several useful features to assist clinicians in effectively managing T2DM. Specifically, clinicians viewed the AI-generated medication alterations as a good knowledge resource in supporting the clinician's decision-making on drug modifications at the point of care, particularly for patients with co-morbidities. The complication risk prediction was seen as positively impacting patient care by facilitating early doctor-patient communication and initiating prompt clinical responses. However, the interpretability of the risk scores, concerns about over-reliance and automation bias, and issues surrounding accountability and liability hindered the adoption of the APA tool in clinical practice. CONCLUSIONS Although the APA tool holds great potential as a valuable resource for improving patient care, further efforts are required to address clinicians' concerns and improve the tool's acceptance and applicability in relevant contexts. CLINICALTRIAL N/A

Background It has been established that families play a significant role in decision making in Asian societies, particularly those imbued with family centric ideals and Confucian ethics. Yet the implication of familial determination and its anticipated effect upon end of life decision-making, particularly ‘do not resuscitate’ (DNR) orders remain unstudied in this region. Aims To determine the views of oncology and palliative care doctors and nurses on who should be involved in DNR discussions and the implications and perceptions of such orders. Methods 146 doctors and nurses in oncology and palliative care working within a tertiary specialist cancer centre in Singapore participated in a questionnaire survey. Results Majority thought that patients (78.8%) and their next-of-kin (78.1%) should be involved in DNR discussions, but only 24.7% thought as many family members as possible should be involved. On a 5-point Likert scale, 15.1% thought doctors should always ultimately decide on the DNR order, while 22.6% felt that the patient/family should always take on the responsibility. Between patients and their families, 21.2% felt that patients should always be more involved as opposed to just 4.8% who opted for the family always being more involved. 35.6% felt that a DNR should be discussed as early as possible and 10.2% felt it should be discussed when prognosis was a week or less. Conclusions From the viewpoint of oncology and palliative care healthcare professionals; this paper suggests that local healthcare professionals do subscribe to the patient autonomy albeit with limitations. This for the most part does tally with other studies conducted in Asian contexts that suggest to a greater family involvement than patients in decision-making. This reflects the complexity of decision-making at the end of life and the importance of considering the innumerable psychosocial, cultural, financial and physical factors involved.