Medicine (St Vincent's) - Theses

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End date: 2014 × Start date: 2014 × Type: Doctorate ×

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    Determining standards of care in the context of medical negligence, professional practice and informed consent in Victoria
    Mahar, Patrick David ( 2014)
    The proposed Doctor of Medical Science by compilation seeks to describe recent medicolegal issues, with a focus on determination of standards of care with respect to clinical practice in Victoria in the context of professional negligence and informed consent. In the course of medical care, professional negligence can occur at any point during a doctor/patient relationship including assessment, diagnosis, advice and/or treatment. Integral to professional standards and negligence, and during any of these steps, lies the concept of informed consent and how information is communicated to patients in order to not only promote patient autonomy and beneficial outcomes, but also to protect medical practitioners from potential litigation. The proposed doctorate is comprised of 12 manuscripts and explores the question of by whom and how reasonable standards of care in clinical practice are determined in the context of professional negligence, and by virtue of this, who and how informed consent in clinical practice is determined. Causation, although a fundamental element in the tort of negligence, is excluded from this thesis. The doctorate commences with a general discussion around two of the fundamental elements in the tort of negligence in common law jurisdictions, the identification of a relationship which implies a duty of care, and the fundamental breach of that duty. Written for a medical audience, the doctorate discusses case law and legislation specific to medical professionals, and manuscripts will refer to practical and emerging issues for a medical readership such as interpretation of diagnostic tests, misdiagnosis, informed consent for procedures, standards of privacy and consent in the communication of information, the use of protocols to minimise breach of standards of care, refusal to treat and end-of-life decision making. In so doing, the doctorate explores specific clinical examples and situations which explore by whom and how professional negligence and informed consent are determined, whether it be by the medical practitioner, the courts or the patients themselves.
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    The clinical utility of serum tumour markers prostate specific antigen and carcinoembryonic antigen in evaluating the effectiveness of chemotherapy for advanced prostate and colorectal cancers
    Dowling, Anthony John ( 2014)
    Palliative chemotherapy for the treatment of metastatic castrate resistant prostate cancer (mCRPC) and metastatic colorectal cancer (mCRC) should only continue if the patient is deriving some benefit. Clinicians assess benefit using a variety of methods. The tumour markers, prostate specific antigen (PSA) and carcinoembryonic antigen (CEA) can be used as part of this assessment. I explored the clinical utility of using PSA and CEA to guide decisions on palliative chemotherapy for mCRPC and mCRC patients. I evaluated if falling levels of PSA predicted for a palliative response (decreasing pain and/or pain medication), and improved survival in 161 patients with mCRPC treated with mitoxantrone and prednisone in a randomised clinical trial. I also performed a phase IV analysis of 133 patients treated at Princess Margaret Hospital, Toronto, Canada to see how they compared with the clinical trial. Also, a retrospective cohort of 142 patients with mCRC treated with oxaliplatin-based chemotherapy at St Vincent’s Hospital Melbourne were evaluated to see if falling levels of CEA predicted survival and shrinkage of secondaries. A PSA response of 50% occurred in 34% of patients in the mitoxantrone and prednisone arm of the study and in 28% of the post trial cohort (P=0.36) A PSA response of 50% is predictive of a palliative response, although the strength of the association was relatively weak (phi coefficient =0.28, P = 0.001). The positive predictive value of a PSA response for a palliative response was 53%. Using a landmark analysis, PSA responders lived longer (P=0.0004). A CEA response of 50% occurred in 74% of the mCRC patients. Using a landmark analysis, CEA responders lived longer (P<0.0001). CEA response did correlate with radiological responses. Seventy per cent of the CEA responders had a complete or partial response on computed tomography (CT) scanning, but 42% of the CEA responders also had stable disease, and 36% of the CEA non-responders had a partial response. Both PSA and CEA responses yield useful adjunctive clinical information and should be part of the clinical assessment of the palliative benefit from chemotherapy for mCRPC and mCRC.