Section 1 of the Income Tax Act, 58 of 1962 (the Income Tax Act) and other related Revenue Acts empower the South African Revenue Service (SARS) to administer the Acts and to collect revenue for the government of the Republic of South Africa. Sometimes, in order to assess tax liability and collect revenue, the Commissioner and/or officials of SARS have to make certain representations and undertakings to taxpayers in general through interpretation notes, rulings, and other forms of communication. In certain circumstances, SARS is authorised to withdraw rulings made and at times already acted upon, often to the taxpayer’s detriment. This results in lack of clarity, uncertainty and inconsistency in the application of the law. In order to address this problem, an Advanced Tax Ruling System (ATRS) was introduced. In terms of the ATRS, the issuing of rulings is statutorily regulated and binding on both the taxpayer and SARS when certain conditions provided for in the Income Tax Act are met. The purpose of an ATRS is to promote clarity, consistency, and certainty in respect of the interpretation or application of the provisions of tax laws to which it applies. However, the Commissioner is not obliged to follow a policy or undertaking which is in violation of tax laws. Section 76N(3) provides that the Commissioner may withdraw or modify a binding private ruling, or a binding class ruling retrospectively, if the ruling was made in error; subject to sub paragraphs (a), (b) and (c) thereof. This creates uncertainty as opposed to the intention for which the ATRS was introduced. The critical question is, if the Commissioner timeously informed the taxpayer that he has decided not to honour the undertaking made in a valid binding private ruling, which is still in force to the detriment of the taxpayer, can the taxpayer raise a defence of substantive legitimate expectation? It is argued that the issuing of an ATR is an administrative action subject to judicial review, if, in the opinion of the concerned party, it will have an adverse effect. Further, in the event that the Commissioner informs the taxpayer timeously of the intention to withdraw a valid binding private ruling, which the taxpayer has acted upon to their detriment, can they raise a defence of a practice generally prevailing and/or substantive legitimate expectation? The doctrine of legitimate expectation as a defence was authoritatively accepted as part of the South African administrative law in the landmark case of Administrator Transvaal v Traub. However, Chief Justice Corbett expressly stated in a dictum that the content of the expectation may be substantive or procedural in nature, [but] the protection of that expectation, if found to be legitimate, was exclusively procedural. It is argued that the dictum ignores section 33 of the Constitution which introduced reasonableness as an element of the right to just administrative action, which means that the substance of a decision may be reviewed if it is unreasonable. The objective is to examine whether the courts could develop the doctrine of legitimate expectation beyond the procedural protection, as already done in countries in Europe. Copyright / Dissertation (LLM)--University of Pretoria, 2012. / Mercantile Law / unrestricted

Purpose: The purpose of this project is to decrease the likelihood of receiving unwanted treatment at the end of life. The project is conducted in a skilled nursing facility where only approximately 40% of the residents have an Advance Directive (AD) despite experiencing multiple comorbidities and nearing the end of life. Aims: Implementing a quality improvement project, creating a system that addresses AD completion at admission with the outcome of increased recognition of residents’ end of life choices. Process: Residents and their families are presented with a tool to help guide the conversation about AD at the admission care plan meeting. AD will be readdressed at all subsequent care plan meetings, occurring every 45 days, and as needed. Results: Project is still in process and the expected completion date is April 8th, 2022. We anticipate improvement in AD completion rates in this facility. Limitations: This project is limited by the reluctance of some residents and families to discuss issues related to death and dying, which may affect the completion rate. Another limiting factor is the staff turnover and need to reeducate new staff members about the project. Conclusions: Residents in skilled nursing facilities are likely to receive unwanted treatment because families are unsure what their wishes and are left feeling obligated to do everything necessary to sustain life. The implementation of this project may increase the AD completion rates, while recognizing and carrying out residents’ end of life choices.

The Palliative and Therapeutic Harmonization (PATH) program was designed to help frail older adults and their family members prepare for and make medical decisions, in the context of frailty and dementia. This sandwich thesis includes three manuscripts that present the findings from a mixed methods study exploring the implementation and outcomes of the PATH program, in three long-term care (LTC) home settings. The purpose of the first sub study was to describe both the perceived need for the PATH program, and initial reactions following its training and implementation. Quantitative surveys and qualitative interviews with bereaved family members showed that prior to implementation, they were mostly satisfied with their relatives’ end-of-life care. Through qualitative interviews, clinical leaders shared a positive impression of the training and PATH principles. They also explained how the PATH program could help them improve palliative and end-of-life care planning and communication with residents and families. In the second sub study, qualitative interviews were conducted with family members to learn about their experiences with and perceived outcomes from the PATH program. All family members had a positive experience. They shared perceived outcomes such as, opportunities to share and learn about their relative’s health status and trajectory, creating a mutual understanding of directions for care, and receiving support and reassurance for health care decision making. Finally, the purpose of the third sub study was to describe both the perceived outcomes of the staff who implemented the PATH program, and differences in documenting residents’ advance care plans and discussions. Staff described both personal and practice related outcomes. In addition, documentation around advance care planning changed with the program’s implementation. Overall, the PATH program offered frail older adults, their family members and their professional caregivers an opportunity to communicate about and prepare to make decisions for palliative and end-of-life care. / Dissertation / Doctor of Philosophy (PhD)

Patients with life-limiting cancer and their families face unique challenges that interfere with their ability to make decisions or adequately express their health care preferences about end of life (EOL) treatment. As a result, patients at EOL often receive aggressive unwanted treatment that nationally costs billions of dollars and results in surrogate distress about not honoring patient wishes. Respecting Choices® DS-ACP is a disease-specific Advance Care Planning (ACP) intervention that is designed to overcome barriers associated with ACP and potentially decrease the incidence of unwanted, overly aggressive treatments at EOL. The intervention is delivered to patient-surrogate dyads by a trained facilitator who provides an opportunity for patients to identify values and goals that support their EOL choices and communicate these values and goals to their surrogates before they are in a medical crisis. Although Respecting Choices® DS-ACP has been effective with other populations, it has not been evaluated for patients with life-limiting cancer. Thus, the purpose of this study was to evaluate the Respecting Choices® DS-ACP intervention with patients with life-limiting cancer to determine if the intervention increases patient-surrogate congruence about the patient's EOL wishes and reduces decisional conflict without causing anxiety. Study design was a Phase I clinical trial. A volunteer sample of 15 patients with a diagnosis of life limiting cancer and their matched surrogates participated in the study. The Statement of Treatment Preferences for Life-Limiting Cancer Form, the Spielberger Stateanxiety Scale Form Y-1 (STAI) and the Decisional Conflict Scale (DCS) were administered preand post-intervention. The Quality of Communication about End of Life Care Form was administered at post test. Descriptive statistics were used to describe the sample. McNemar Chisquare and Binomial tests were conducted to investigate whether the intervention increased iv congruence for five different situations on the Statement of Treatment Preferences for LifeLimiting Cancer Form. The Zar’s Multiple Comparison Test of Differences was conducted to investigate the proportion of congruence observed across the five situations. A paired-sample t test was conducted to evaluate post-intervention changes in anxiety (STAI) and decisional conflict (DCS). Frequencies and percentages were conducted for the five items on the Quality of Communication about End of Life Care Form to evaluate patients' and surrogates' satisfaction with the intervention. Anecdotal comments about timing were content analyzed and summarized. Congruence between patients and surrogates improved significantly in all five situations (range of p =.001 to .031), decisional conflict lessened significantly (t (14) =4.49, p < .001), and anxiety did not change (t (14) = 1.75, p = .102) pre- and post-intervention. Participants reported satisfaction with the intervention, including its delivery and timing. Findings from this study provide guidance on how to assist patients with life limiting cancer and their surrogates with EOL decision making. Study findings also support making the Respecting Choices ACP intervention part of usual care for patients with life limiting cancer and timing the intervention so that it is delivered before a medical crisis occurs. The lack of change in post-intervention anxiety scores suggests that ACP does not add to patient distress when ACP is conducted by a trained facilitator. This finding can be used to persuade health professionals to refer their patients for ACP. Additional research is needed to determine if increased patientsurrogate congruence leads to patients' wishes being followed and reduces surrogate decisional conflict and distress at EOL. Future research is also needed to determine if the Respecting Choices DS-ACP intervention is equally effective with racial and ethnic groups whose reluctance v to engage in EOL discussion has been documented in the literature or if the intervention needs to be culturally adapted.

Choosing a surrogate to make medical decisions for a patient is an emotionally challenging task. In hospital settings, it is estimated over 86% of life saving medical decisions have been made by a surrogate (Swigart, Lidz, Butterworth, & Arnold, 1996). For the marginalized populations of lesbian, gay men, bisexual, and transgender persons (LGBT), decisions are especially difficult, compounded by issues of discrimination, lack of legal support, level of relationship commitment,, and complicated disclosure to family and medical professionals (Riggle, Rostosky, Prather, & Hamrin, 2005). Limited research has been presented regarding environmental and social factors that impact the choice of a surrogate decision-maker for a LGBT individual. This in-depth literature review will examine factors influencing individual surrogate choice, identify obstacles and gaps in the literature findings, and explore services required by the LBGT population.

Canadians are living longer with multiple complex illnesses. In turn, older adults are often in need of complex medical attention in crisis situations in acute care hospital settings. Although acute care settings are equipped with a growing variety of life saving technologies, hospitals are still the setting in which most people die. Yet, almost half of the Canadians who have been admitted to acute care centres with chronic life-limiting illnesses have not had advance care planning (ACP) conversations with their substitute decision-maker (SDM) about the personal values that bring quality to their lives. In fact, only 8% of the general Canadian population are ACP ready. Consequently, many SDMs are unprepared to make end of life (EOL) treatment decisions for their loved ones. One way to promote patient-centred care and ease the burden of in-the-moment EOL treatment decisions made by SDMs, is for nurses to engage their patients in ACP. However, very few registered nurses regularly engage their patients in ACP. The purpose of this research is to better understand the organizational factors influencing nurses’ decisions related to ACP in their hospital-based work. This ethnographic study was conducted on three acute care wards in two hospital sites located in Northern Ontario. Data collection methods included observational fieldwork, semi-structured interviews with administrators and registered nurses (n=23), and the collection of documents pertinent to the study purpose (i.e., accreditation reports, practice guidelines, etc.). Findings reveal that the work of nurses in hospital settings is embedded within a context that prioritizes patient flow, and efficiency. Consequently, hospitals often function at overcapacity, and nurses have extremely heavy workloads caring for complex patients with diagnoses that do not match the medical specialty of the units. Although participants state that they value ACP, they maintain that nurses have very little capacity to engage patients in these conversations in their practice. Findings support that expectations for hospital nurses to fully engage in ACP with their patients may be unrealistic given the context within which they work. Alternative models for considering ACP in acute care could be explored to ensure that patients with life-limiting conditions receive care that is best matched to their needs, values, and wishes. / Graduate

Background: Numerous studies demonstrate benefits of using advance care planning (ACP) in the general practice setting. Despite this, providers do not regularly initiate ACP and only one third of Americans have completed an advance directive (AD). This number is even lower among ethnic and minority groups. Community health center (CHC) providers have the opportunity to improve the quality of end-of-life (EOL) care and reduce healthcare disparities affecting medically underserved populations, yet no research has been conducted to identify CHC providers' practices, knowledge and attitudes towards ACP. Addressing this query may assist researchers in identifying optimal strategies for improving ACP delivery in this setting, ultimately leading to improved quality of EOL care for the populations served. Purpose: The study purpose was to assess Arizona CHC providers' practices, knowledge and attitudes towards ACP. Setting: The study setting was federally qualified community health centers located in urban and rural sites throughout Arizona. Participants: Study participants (N = 38) were predominantly middle-aged females practicing for an average of 13 years. 60% of providers were Master's or Doctor of Nursing Practice (DNP) prepared providers while 40% were Doctor of Medicine (MD) or Doctor of Osteopathy (MD). Methods: This study used a descriptive correlational quantitative research design. The "EOL Decision Making Survey" instrument was adapted into an electronic survey and distributed to 514 physician and non-physician CHC providers. Data analysis was performed using PASS and SPSS statistical software. Results: This sample of Arizona CHC providers was reasonably knowledgeable about Arizona state law and clinical application of ACP. Physician providers had greater knowledge and greater confidence in their answers related to Arizona state law compared to non-physician providers. Participants were largely comfortable with counseling patients in ACP and exhibited mostly positive attitudes toward ACP. Older respondents with greater years' experience tended to have greater knowledge of the clinical application of ACP as well as greater positive attitudes towards ACP. Providers with greater years' experience tended to have greater comfort in counseling patients in ACP. Despite these positive findings, routine initiation of ACP in this setting was low (44%). Conclusions: Though Arizona CHC providers have reasonable knowledge related to ACP, are comfortable with counseling patients in ACP and have positive attitudes towards ACP, less than half routinely initiate ACP conversations with their patients. Though more research is needed to validate these findings, targeted educational interventions and process changes may help improve ACP delivery rates in this setting.

As diretivas antecipadas de vontade para o fim da vida são documentos que expressam os desejos da pessoa relacionados aos procedimentos que podem ser aplicados a ela em uma situação de assistência médica no fim da vida. Nesse sentido, as diretivas são úteis para informar as equipes de assistência médica a respeito dos tipos específicos de tratamento que o paciente permite, ou não permite, quando não estiver apto a manifestar suas vontades em uma hipotética situação futura de incapacidade. Este tipo de documento foi elaborado nos Estados Unidos na década de 1970, e foi introduzido no ordenamento ético brasileiro pela Resolução 1995/2012 do Conselho Federal de Medicina. O objetivo desta dissertação é estudar essa norma ética sob o enfoque do direito penal, uma vez que as diretivas antecipadas de vontade para o fim da vida possuem uma íntima relação com a ortotanásia e a eutanásia, que são passíveis de sanção penal no Brasil. Assim, é fundamental analisar as diretivas antecipadas utilizando as ferramentas da doutrina penal, e princípios como os da dignidade humana e razoabilidade. O objetivo é pesquisar as qualidades, imperfeições e limites das diretivas antecipadas sob o ordenamento jurídico nacional, e também compreender as bases legais das diretivas antecipadas, que são os institutos da autonomia e do consentimento. Concluímos que, ainda que as diretivas antecipadas de vontade sejam uma norma ética bem-vinda, demandam algumas melhorias e refinamentos, que poderiam ser representados pelos planejamentos antecipados de tratamentos, um tipo de documento direcionado aos valores de vida das pessoas. Além disso, uma mudança de paradigma relacionada à eutanásia, particularmente a eutanásia passiva e a ortotanásia, no sentido de descriminalizá-las, seria importante para que as diretivas antecipadas tenham eficácia no Brasil. / Advance directives for dying patients are documents which express personal desires related to procedures that may be applied to people in a situation of medical assistance in the end of life. In this sense, they are useful to make health assistance teams know about what kind of specific treatment the patients permit, or do not permit, when they are not able to communicate their wishes in a hypothetical and future situation of disability. This kind of document was created in the United States in the seventies, and entered Brazilian ethical law by Resolution 1995/2012 of the Federal Council of Medicine. The aim of this dissertation is to study this ethical rule by means of the criminal law, because advance directives have a close relation to euthanasia and ortothanasia, which are prone to criminal sanction in Brazil. Therefore, it is paramount to analyze the advance directives using the doctrinal tools of criminal law and principles like human dignity and reasonability. The goal is surveying the qualities, inadequacies and limits of advance directives under Brazilian law, and also to understand the legal basis of the advance directives, which are the institutes of autonomy and consent. We concluded that, although advance directives for dying patients are a welcome ethical law, it demands some improvement and refinement, which could be represented by the advance care planning, a kind of document that is focused on the life values of people. Furthermore, a change of paradigm related to euthanasia, particularly passive euthanasia and ortothanasia, in the direction of making them apart of criminalization, would be vital to promote the adequate efficacy of the advance directives in Brazil.

Orientador: Edison Iglesias de Oliveira Vidal / Resumo: No Brasil atual a maior parte dos profissionais e instituições de saúde ainda se encontram longe de constituírem uma rotina de discussão sobre preferências de cuidados no fim da vida junto a pacientes com prognóstico reservado. Esta corresponde a uma grande lacuna na atenção à saúde em nosso país, a qual frequentemente se associa a sofrimento evitável de pacientes e familiares. Em 1991 nos EUA foi iniciado um programa de discussão de preferências de cuidados no fim da vida denominado POLST (Physician Orders for Life-Sustaining Treatment). Trata-se de um sistema coordenado para evocar, documentar e comunicar as preferências de pacientes/familiares quanto a tratamentos prolongadores da vida para enfermos com expectativa de vida reduzida. Atualmente o POLST representa uma das melhor sucedidas estratégias para a elicitação e documentação de preferências de cuidados no fim da vida naquele país. O objetivo dessa pesquisa foi realizar a Adaptação Transcultural (ATC) do formulário POLST para o contexto brasileiro. A metodologia de ATC baseou-se nas recomendações da International Society for Pharmacoeconomics and Outcomes Research. Foram realizadas 3 traduções diretas e independentes do instrumento fonte para o português, as quais passaram por uma reunião de reconciliação de forma a gerar uma versão síntese. Essa versão foi submetida a duas traduções reversas para o inglês e posteriormente foi realizado um teste piloto do formulário com 20 médicos e 10 pacientes. Versões do instrument... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: In Brazil most health care professionals and institutions still have not included discussions about preferences of care at the end of life with patients with decreased life expectancy as part of their daily routine. This represents a major gap for the care at the close of life in Brazil that is frequently associated with avoidable suffering of patients and their loved ones. In 1991 the Physician Orders for Life-Sustaining Treatment (POLST) program was started in the USA. It embodies a coordinated system to elicit, record and communicate patients’ and families’ preferences about life-prolonging treatments for individuals with decreased life expectancy across a variety of health care settings. The POLST paradigm has spread across the USA and currently represents one of the most successful strategies to elicit and record preferences of care at the end of life in that country. The present research aimed to conduct the Cross-Cultural Adaptation (CCA) of the POLST form to the Brazilian context. The cross-cultural adaptation methodology was based on the principles of good practice for the translation and cultural adaptation process recommended by the International Society for Pharmacoeconomics and Outcomes Research. Three independent direct translations of the source instrument to Portuguese were performed. Those translations were synthesized into a single version after a reconciliation meeting. Two independent native English speakers performed 2 back translations of that version in... (Complete abstract click electronic access below) / Mestre

As diretivas antecipadas de vontade para o fim da vida são documentos que expressam os desejos da pessoa relacionados aos procedimentos que podem ser aplicados a ela em uma situação de assistência médica no fim da vida. Nesse sentido, as diretivas são úteis para informar as equipes de assistência médica a respeito dos tipos específicos de tratamento que o paciente permite, ou não permite, quando não estiver apto a manifestar suas vontades em uma hipotética situação futura de incapacidade. Este tipo de documento foi elaborado nos Estados Unidos na década de 1970, e foi introduzido no ordenamento ético brasileiro pela Resolução 1995/2012 do Conselho Federal de Medicina. O objetivo desta dissertação é estudar essa norma ética sob o enfoque do direito penal, uma vez que as diretivas antecipadas de vontade para o fim da vida possuem uma íntima relação com a ortotanásia e a eutanásia, que são passíveis de sanção penal no Brasil. Assim, é fundamental analisar as diretivas antecipadas utilizando as ferramentas da doutrina penal, e princípios como os da dignidade humana e razoabilidade. O objetivo é pesquisar as qualidades, imperfeições e limites das diretivas antecipadas sob o ordenamento jurídico nacional, e também compreender as bases legais das diretivas antecipadas, que são os institutos da autonomia e do consentimento. Concluímos que, ainda que as diretivas antecipadas de vontade sejam uma norma ética bem-vinda, demandam algumas melhorias e refinamentos, que poderiam ser representados pelos planejamentos antecipados de tratamentos, um tipo de documento direcionado aos valores de vida das pessoas. Além disso, uma mudança de paradigma relacionada à eutanásia, particularmente a eutanásia passiva e a ortotanásia, no sentido de descriminalizá-las, seria importante para que as diretivas antecipadas tenham eficácia no Brasil. / Advance directives for dying patients are documents which express personal desires related to procedures that may be applied to people in a situation of medical assistance in the end of life. In this sense, they are useful to make health assistance teams know about what kind of specific treatment the patients permit, or do not permit, when they are not able to communicate their wishes in a hypothetical and future situation of disability. This kind of document was created in the United States in the seventies, and entered Brazilian ethical law by Resolution 1995/2012 of the Federal Council of Medicine. The aim of this dissertation is to study this ethical rule by means of the criminal law, because advance directives have a close relation to euthanasia and ortothanasia, which are prone to criminal sanction in Brazil. Therefore, it is paramount to analyze the advance directives using the doctrinal tools of criminal law and principles like human dignity and reasonability. The goal is surveying the qualities, inadequacies and limits of advance directives under Brazilian law, and also to understand the legal basis of the advance directives, which are the institutes of autonomy and consent. We concluded that, although advance directives for dying patients are a welcome ethical law, it demands some improvement and refinement, which could be represented by the advance care planning, a kind of document that is focused on the life values of people. Furthermore, a change of paradigm related to euthanasia, particularly passive euthanasia and ortothanasia, in the direction of making them apart of criminalization, would be vital to promote the adequate efficacy of the advance directives in Brazil.