Y3 Ethics, Law, PPD and Clin Comms

Why does culture affect communication?

1) Doctor and patient may have different world views •Patient may have specific health beliefs 2) There may be differing expectations •Patients' and families' from the doctor •Doctor's from the patient 3) There may be different norms in communication style •Level of familiarity •Hierarchy •Shared decision making

PPD ladder of success

1) GMC duties of doctor 2) Patient and doctor safety 3) Discrimination, productivity and stress

Statutory disclosure of information

1. Road Traffic Act 1988 2. Prevention of Terrorism Act 1989 3. s60 Health and Social Care Act 2001 4. Public Health (Control of Disease) Act 1984 5. Supreme Court Act 1981 here doctor should disclose confidential info

Summary of confidentiality law e-module

A legal duty of confidentiality is owed to all patients and continues after death. The primary exception to this duty is the consent of the patient. Consent may be lawfully breached if the is a real risk of serious harm to others and that harm can be prevented by disclosure. In adults lacking mental capacity and in children confidentiality may be lawfully breached provided it is in the individual's best interests to do so.

What right gives you the right to make your own choices?

Human rights act 1998. 12 articles

Current legal definition of death

permanent loss of brainstem functions. Irreversible coma --> several brainstem components destroyed --> no spontaneous breathing

Procedures that could be tested in OSCE

§ BLS tends not to be § not blood cultures + NG

Advance decision

§ above 18 § only for advance refusal of treatment when patient lacks capacity

Civil Law

• Remedy is usually compensation • Tort Law is a branch • Two parties with relationship but no contract • Aggrieved party = claimant • Defending party = defendant • <1% to Trial (by Judge alone) § Surgery has highest no of claims § Obs and Gynae has highess value of claims. Civil law is what doctors get sued in

Myers-Briggs Type Indicator (MBTI)

A widely used personality test based on Jungian types. § use introversion vs extroversion § sensing vs intuition § thinking vs feeling § judging vs perceiving

Court hierarchy

Civil cases are dealt with by magistrates and counter court. Civil court results in damages, you get money

Hearing Loss - how many of your patients?

One in six. Patient may be unaware/unaccepting of their loss

The Swiss Cheese Model of Medical Errors

Shows us that adverse events are usually the result of an accumulation of multiple, smaller errors that slip through because of flaws in the overall system. Holes appear when you line up the slices

NO TEARS for medication use

The NO TEARS acronym was reported (Lewis, 2004) in the BMJ. It aims to improve assessment of patient's current medication use.

Taking a dietary history

Who to ask? Could screen everyone but especially :- • •People with illnesses known to be related to diet e.g. heart disease, diabetes, stomach ulcers • •People who look markedly over or underweight • •Where exclusion diets may affect their illness e.g. vegans in anaemia •

Gut symptoms

abdominal pain (constant or colicky, sharp or dull; site; radiation; duration; onset; severity; relationship to eating and bowel action; alleviating/exacerbating or associated features) indigestion; nausea/vomiting stool - colour, consistency, blood, colour of blood, slime, diffculty flushing away tenesmus (feeling that there is something in the rectum that cannot be passed e.g. due to a tumour) maleana is altered (black) blood passed PR haematemesis (vomiting blood)

DoLS

deprivation of liberty safeguards

In more life threatening scenarios, queries about capacity should be...

escalated.

Assisting a suicide is legal or illegal?

illegal. If unsure about anything - Hospital legal team/clinical ethics team. Herring textbook - law on death and dying

Diagnostic Overshadowing

misdiagnosing a problem by focusing on a salient characteristic that has nothing to do with the problematic issue: Diagnostic overshadowing occurs when a healthcare professional assumes that a patient's disability is due to their disability or coexisting mental health condition rather than fully exploring cause of patient's symptoms. can lead to non diagnosis or mis-diagnosis.

Can send info by personal email?

no

Overall, overruling a child's refusal of consent

only court can override refusal of consent in 16

Explain the term personal, as opposed to institutional, 'racism'.

personal is from a single person whereas institutional is when it occurs in an institution such as the NHS e.g not getting promoted.

Doctrine of Double Effect (DDE)

the claim that whilst one may not aim at harm, it can be permissible to bring about harm as a foreseen and unavoidable side-effect of pursuing a proportionate good.

General systems questions

weight loss night sweats any lumps fatigue appetite fevers itch recent trauma

What are the two types of lasting power of attorney

welfare; property and affairs

When starting to give info and exploring what do they know

§ 'Can you tell me what your understand about the procedure you will have?' § 'Have you had an ECG before....?' § 'Would you like me to give you the essential pieces of information or would you prefer more detail'?

Burke vs GMC

§ if patient has requested wants ANH before then usually do that § patient can't request a specific treatment, unless it is duty of care like ANH

What do you need to communicate to the patient when performing a procedure like suturing

• Find out why the patient needs the procedure • Find out what the patient knows about the procedure • Explain the procedure step by step • Consent the patient • Instruct the patient at each stage of the procedure • At the end, explain the next steps

Some arguments to explain the difference between acts and omissions

1) Ease of rescue: The proximity of Jones to the drowning child meant that minimal assistance would have been required to rescue his cousin 2) Imperfect v perfect duties: It has been argued that there are some duties which we must always fulfil and others that we should but are not obliged to fulfil. Sending funds to a charitable cause could be seen as the latter, avoiding deliberate harm the former. 3) Intent: In the case of Jones' omission he clearly had malicious intent which cannot be said of the omission to send funds to the children 4) Causing and allowing: Although in the case of not sending money to feed starving children we may be allowing harm, this is not seen as the same order of magnitude as when we directly cause harm as in the case of sending poisoned food

Key medical scandals

1) Harold Shipman - GP near Manchester, link Dr Shipman with 215 deaths, killed using a lethal dose of opiate, and, in a few cases, of sedative. The sheer scale of the crime, the lack of detection for so many years and the incredible betrayal this represented by a GP of his patients shocked the public and medical practitioners alike. The public inquiry raised several issues including the control over 'controlled' drugs particularly in the community, the system surrounding recording and investigating cause of death, and finally the role of monitoring medical practitioners and the systems in place for careful regard of complaints/ suspicions raised. 2) Paediatric Cardiac Surgery at Bristol Royal Infirmary: one-third of all children who underwent open-heart surgery received less than adequate care, and this led to an excess mortality estimated to be 30-35 children under 1 year old between 1991-1995. Issues raised: a) no requirement for doctors to keep their skills and knowledge up-to-date, and surgeons were able to start practicing new techniques with no prior assessment of their competency to do so. b) 'club culture' at Bristol without clear lines of accountability. Consultants held their posts for many years and change was often difficult to initiate. c) no agreed national standards of care to which Bristol should have adhered. Likewise, despite the data existing, performance of the unit was never compared to other units or subject to independent external monitoring. d) treatment of whistleblowers within the NHS; exposed by Dr Stephen Bolsin, an anaesthetist trainee at the hospital exposed this, he was dismissed and having failed to get a permanent position in the UK, has moved to Australia to work. 3) Retention of paediatric organs and body parts at Alder Hey Hospital, Liverpool: organs and body parts of many deceased children had been retained after post mortems without their parents' permission, occurred despite the Human Tissue Act (1961) requiring clinicians to only retain organs at post-mortem if, after 'reasonable inquiry', they were confident that the relatives had no objections. The justification for organ storage was the need for research and teaching materials, but the large majority of organs remained unused. The incident caused public outcry particularly relating to the paternalistic attitude that had been displayed by doctors by retaining the organs without consent. Many of the parents found the situation very distressing. Unfortunately their distress was only increased as organs were discovered and returned in a piecemeal fashion resulting in some parents having to cope with numerous funerals. 4) Mid Staffordshire Enquiry (francis report)- 400 and 1,200 patients died as a result of poor care over the 50 months between January 2005 and March 2009. Mid Staffs scandal because Stafford hospital was and is run by the Mid Staffordshire NHS hospital trust, which in 2008 acquired foundation trust status, making it semi-independent of Department of Health (DH) control. Decision-making and especially cost-cutting as part of its pursuit of that status was later cited as a key reason why poor care took hold and was allowed to persist for so long. There were staff shortages, patients discharged early, lack of hygiene, pain meds not given. Issues raised here: § A lack of openness to criticism; § A lack of consideration for patients; § Defensiveness; § Looking inwards not outwards; § Secrecy; § Misplaced assumptions about the judgements and actions of others; § An acceptance of poor standards; § A failure to put the patient first in everything that is done.

5 statutory principles of mental capacity act

1) Presume capacity 2) Support to make the decision - need to do everything in power so they have all the info (INFORMED consent) 3) competent people have the right to make unwise decisions 4) if no capacity, act in best interests 5) use least restrictive option

ACTS - for diet

"ACTS" •Can I Ask you about your weight? •Do you have any Concerns over your weight? •Can you take me through a Typical day's food and drink •Do you eat a Special diet for any reason? "How to take a dietary history" by Paul Booton is licensed under a Creative Commons Attribution **Other dietary questions: •"Five a day" ( or ten a day) •Junk food? •Saturated fat •Salt

Moral distress for medical students

'One of the problems with third year is that our knowledge base is increasing substantially and is acutely relevant, while our confidence is not particularly great due to our very limited experience. Moreover, we are working as the most junior members of teams where every other member of the team is evaluating our performance. - 1.Lomis K. Am J Surg, 2009. **vanderbilt university school of medicine 2007 table of reported distress ranking

Limits autonomy

'The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good either physical or moral is not sufficient warrant'. J.S. Mill, 'Utilitarianism, on Liberty and Considerations on Representative Government'. **limit when it causes HARM TO OTHER.

Exceptions confidentiality in children under 16

** The welfare of the child is paramount: § The decision to maintain or breach confidentiality is based on best interests. § If the child is <16 and not Gillick competent the doctor can breach confidentiality if it is in the child's best interests (or with parental consent). § If the child is Gillick competent then he/she can give or refuse consent to disclosure. But confidentiality can still be lawfully breached if it is still in the child's best interests. **Practice point: § As a medical student it is important that you do not enter into an agreement with a child whereby you agree to keep whatever they tell you a secret. § You may find that what they tell you compels you to inform someone and that would ruin the trust that the child has with you and future members of the team.

What is meant by 'institutional constraints'?

** Internal constraints: § lack of assertiveness § self-doubt § socialisation to follow orders § perceived powerlessness § lack of understanding of full situation **External constraints: § inadequate staffing § hierarchies within the healthcare system § lack of collegial relationships § lack of administrative support § policies and priorities that conflict with care needs § compromise care due to pressure to reduce costs § fear of litigation

Acting without consent is what criminal offence?

**Acting without consent can result in court action. § If a doctor acts without the consent of a patient then he may have committed the following offences:- **Criminal offence. a) Assault b) Battery c) Common assault (combination of both assault and battery) ** Civil action from patient: Claim for damages.

The status of the fetus - are human relationships morally relevant?

**Are human relationships morally relevant? § Once a baby is born it forms relationship with others. § Human relationships are morally valuable. Therefore a baby has higher moral value once it has been born. § Fetus has right to life as soon as born, so termination during any time of pregnancy is fine **But... § Does this imply that people without loving relationships are less valuable? § Does this mean infanticide of abandoned babies is morally permissible? § Is it simply because the baby is invisible that we feel incapable of forming a relationship before birth? Can we still not form a relationship with fetus in womb, then birth does not make a difference

The country that developed the vaccine should have priority access.

**Arguments for: § A duty to citizens - if gov doesn't give to citizens and gives instead to other countries more in need, then not seen as good (nationalist approach) § also the vaccine is subsidised heavily by taxpayers, so if don't get proper access is not fair. § more incentive for research if look out for own countries too § national interest vs humanitarian image § also poor value for payment: also how to distribute which countries to give to, if give to some and not others --> political tensions? § would prioritise more countries over others because of close relations rather than need. Bias introduced. If have trade deal with that country, better to give to that country cos mutual benefit. **Distribution based on severity: § UK + US have had huge national health implications --> these countries are also at forefront of vaccine development, therefore ethically can be justified perhaps that countries where the severity of COVID-19 has been high can be prioritised. However, flaw as some countries have significant impact but not vaccine development programs --> so then could increase health inequality. **Overall should have priority access as it is for their citizens and protect their interests but also can send to other countries in need too. Depends on severity in their country too.

Maureen is an elderly lady, who is mentally competent and is determined to continue to live independently in her own home. However, her daughter believes it would be in her mother's best interests to sell her home and move in with her. Her daughter wants Dr Ross to lie or at least pressurise Maureen into moving out of her home. What types of input can social services provide? Do these services provide reasonable flexibility, continuity? It could be argued that Maureen's A+E attendances are unnecessarily using NHS resources as they could be prevented with appropriate home care. Is this an ethically valid reason for overriding Maureen's autonomy? Would it be reasonable for Dr Ross to try to get Maureen admitted into hospital so that she could be assessed for social services? What is the position of the law in this situation? How should Dr Ross proceed?

**Autonomy: § Autonomy is frequently held to be an important if not crucial principle in medical ethics. § We put great value in the idea that people should be able to choose which way their life will go. § Arguably a competent individual is usually best placed to know whether a given decision is right for them. However, beyond this, most people value being able to make decisions for themselves, even if those decisions are clearly harmful to them. It is argued that a key part of respecting people is allowing them to make their own decisions whether they are good decisions or bad decisions. If we accept the fundamental importance of autonomy then we must respect autonomy equally in all people capable of autonomous decision making. However, there are valid limits on autonomy. Even the most liberally minded would generally accept that we should not be free to make decisions that are harmful to others. Thus many people, including smokers accept a ban on smoking in the workplace because of the potential harm to others from passive smoking. Does the fact that Maureen's behaviour is putting a significant physical and emotional strain on her daughter constitute sufficient grounds for limiting her autonomy? Maureen's behaviour could mean she is likely to require more health care intervention and therefore use more healthcare resources. Would this be grounds for limiting her autonomy? However, any limits on autonomy must be applied consistently if they are to be fair. Thus, if we think that it is reasonable to limit Maureen's behaviour because it is causing an unnecessary drain on healthcare resources then we should limit the autonomy of people who drink excess alcohol, who smoke or who engage in dangerous sports. **Paternalism: § Paternalism can be understood as making, controlling or influencing the decisions of others because we believe it is in their best interests to do so. In so doing, paternalistic actions limit autonomy. Clearly, part of a doctor's job is to try to work out what the best treatment or management option is for their patient and to communicate this effectively to the patient. However, there is a potentially thin line between legitimate persuasion and undue pressure. If Dr Ross was to try to change Maureen's mind by making her feel guilty about the strain she was putting on her daughter this could also be seen as a 'soft' form of paternalism (this form of paternalism has also been called 'maternalism'!). Jean wants Dr Ross to tell a 'white lie' to get Maureen admitted into hospital because she believes it is in her mother's best interests. Ethically and professionally, lying is unacceptable even if the doctor believes it is in the patient's best interests. Lying shows a lack of respect for the individual's autonomy and is likely to engender mistrust. A further problem with paternalism is whether we can ever know another person's best interests better than them. Some of the things that we as individuals value, will be common to most but some are likely to be personal to us. Furthermore, the priority given to a set of commonly held values is likely to differ from one person to another. Can one person know what is in another person's best interests? Empirical evidence suggests that health professionals are often not very good at identifying the best interests of their patients but also close family and friends often make incorrect assumptions about the values and beliefs of their nearest and dearest. So what is the best way forward when there is disagreement? Many apparent conflicts between what a patient thinks and what a doctor thinks can be resolved or at least reduced by improved communication. Dr Ross (and Jean) may have a very clear idea of what they believe is in Maureen's best interests but it is important that Dr Ross explores all the options. It may be with a little thought that an option that Dr Ross considered unworkable could actually be made into an acceptable option for everyone. Perhaps Maureen would accept an assessment by social services if she was confident that she wouldn't then be pressurised into leaving her home. Perhaps Maureen and her doctor could find forms of outside assistance that were acceptable to her. Importantly through better communication and respect for Maureen's autonomy, Dr Ross may gain a better understanding of Maureen's perspective and find it easier to accept her decisions as reasonable. Legally and professionally Dr Ross cannot lie to get Maureen admitted into hospital. Maureen is competent adult therefore best interests cannot be used as a defence. If she agreed to go into hospital because she believed Dr Ross wanted to have further medical tests but in fact it was purely for a social services assessment then she has not given valid consent as she has been misinformed as to the purpose of her hospital admission.

How is best interests determined?

**Decisions/Actions must be in the person's best interests. **Unless there is a valid and applicable advance decision then decisions made on behalf of a person lacking capacity must be in the person's best interests, whoever is making the decision. **It is the least restrictive alternative: An action/decision will not be in a person's best interest if the same objective can be achieved in a way that is less restrictive of the person's rights and freedom of action. If a particular action requires restraint then the restraint must be proportionate. The greater the restraint required, the less likely it is that the action is in that person's best interests. **How is best interests determined? § Equal consideration and non discrimination (e.g. age, race, sex). § Consider all relevant circumstances: Will the patient regain capacity? Permit, encourage and aid participation The person's past and present wishes, feelings, beliefs and values The views of other carers, close family **Life sustaining treatments may be lawfully discontinued if the treatment is not in their best interests § The decision maker must not be motivated by a desire to bring about the person's death § Where there is doubt as to best interests a court declaration may be sought but there is no legal obligation to do so

Bolam Principle

**Determining best interests: § In Re F [1990] Bolam principle used to define best interests. Bolam principle - particular medical decision would be in best interests of individual lacking mental capacity, provided a group of doctors agreed that this was in the patient's best interests. Issue with this is it might just be medical best interests and not the overall best interests. § In the US there was a move towards using substituted judgement: 'what would s/he have wanted if they were competent'. Arguably this is meaningless in someone who has never had mental capacity. § More recent common law in England and wales rejected solely using the Bolam principle

The status of fetus - Gradualist approach in abortion

**Gradualist approach: § The moral value of the fetus increases with gestational development. § Thus a zygote does not have a right to life but a 38 week fetus does. § Therefore the morning after-pill or an early termination are morally permissible but a late termination would not be. **But... § How do we decide when the fetus acquires a right to life? § What morally relevant feature(s) has the fetus acquired at this time-point to give it a moral right to life? How do we identify it? § Does the same time cut-off apply to a fetus with a serious disability?

Best interests and mental disability

**How do we decide best interests: § Physical and emotional interests. § Autonomy interests. § Family's wishes and beliefs. § Previously held wishes, values and beliefs prior to mental disability. **Autonomy interests: § Mental disability does NOT equate with a lack of autonomy. § Autonomous choices: § Autonomy is not all or nothing. § Autonomous choices require: A) Ability to understand information. B) Ability to form values. § Relevant to the decision being made (may lack autonomy for complex decisions, but with support, be able to make autonomous decisions in other areas)

Choosing between patients on the basis of social worth and dependents

**How do we decide? a) Should a leading brain surgeon be saved before a 5th year medical student? b) Should tax payers be saved before non-tax payers? c) Should nice people be saved before nasty people? § Who decides? a) Who would decide what counted as a valuable contribution to society? 'Worthy' or 'good' people tend to be 'people like us'. b) Biased against those with disability. c) 'Social worth' is rewarded in other ways (e.g. income, prestige) but not through considering some lives more worthy of saving than others. § Dependents: o Dependents Should those with young children be saved first? If a single mother of 3 dies then the lives of her children will be blighted and society will have to pick up the costs of caring for her children. o But... Those without dependents will have loved ones whose lives will be blighted by their death. o Would a single mother of 3 have priority of a single mother of one child? o Those of us without dependents value our lives as much as those with dependents.

Morally relevant features that give human life special moral value?

**Identifying the morally relevant features that give human life special moral value is central to healthcare decisions that we make at the beginning and end of life. **But these features have wider implications for our approach to justice and healthcare in general, and our attitude to other life forms (for example our attitude to other life forms and allocating health care resources) **Consider what would be the issues of using the following as morally relevant features: § 46 XY. § Autonomy. § Ability to form relationships. § Emotional capacity. § Self-consciousness. **Examples: § zygotes and embryos , young babies - potential for autonomy § older babies and young children - potential for autonomy, self consciousness, capacity for grief and joy § older children, teenagers and competent adults - autonomy, potential for autonomy, self consciousness, capacity for grief and joy § adults with severe mental disability may be missing these features § higher apes - capacity for grief and joy, self consciousness

Confidentiality and children over 16

**If the child is over 16 then he/she is presumed competent and disclosure should only be made with their consent. But confidentiality can still be lawfully breached if it is in the child's best interests up to the age of 18. **However, it will generally not be in the best interests of a competent child to override their competent refusal. In these instances, good to discuss with senior colleague.

Witholding information - same as lying?

**Is withholding information morally equivalent to lying? **No: § Withholding info restricts autonomy less. § Patients may actively 'collude' in the withholding of information. § Impossible to tell patients everything. § Less likely to cause mistrust. **Yes: § If intention is the same then lying and withholding info are morally equivalent. § Wrong to assume patients don't want to know. § No different to lying if you know patient would be influenced by the information. § cause huge patient distrust if find out truth.

Different concepts of a 'person'

**John Locke: § "A thinking intelligent being, that has reason and reflection, and can consider itself, the same thinking thing, in different times and places; which it does only by that consciousness which is inseparable from thinking ..." o pro - higher order of thinking required rather than say in PVS, continuity o cons - lacks that emotional sense § John Harris 1945- present: "A person will be any being capable of valuing its own existence" o pro - takes deeper than intellectual capacity and adds in self-consciousnness and value o what does value mean though - what about people with mental illnesses, does then make them not alive.

Justice and saving lives and healthcare

**Justice and saving lives: § The right to life is arguably a fundamental right. § If we believe everyone is equal then everyone has an equal right to life and therefore an equal right to be saved. § Choosing between people on the grounds of age, social worth, personal responsibility would be an injustice. § Individuals may choose to sacrifice their lives for others but a just society cannot impose that self-sacrifice. **Justice and healthcare § Is there a right to healthcare? § Some people think that healthcare is just another commodity, like holidays abroad or cars. § Most people in the UK think that there is something special about healthcare. § If we think there is a right to healthcare then all people have an equal claim to healthcare.

What makes human life valuable?

**Justice and the value of life: § Justice requires equal treatment of equals. § If we do not treat an individual equally then it implies that their lives are less valuable. § If we think all human lives are of equal value then we need to identify what moral feature(s) makes human life particularly valuable. **Is human life special? § Most people think that human life is of special value compared to other forms of life. Therefore, it is less morally acceptable to kill a human being compared to another animal. § What ethical features make human life special? § Are some lives more valuable than others? **The value of life - autonomy: § Is it the capacity for autonomy that makes our human life especially valuable? § Society puts a high value on autonomy. § John Harris suggests that what makes a life valuable is the individual's ability to value his/her life. § The difficulty with Harris' approach is lots of people lack autonomy: o Babies and young children. o Congenital learning disability. o Acquired disability e.g. head injury, alcohol, o Alzheimer's Disease. § Does that mean the lives of those who lack autonomy or who are unable to value their lives are less valuable?

Legal grounds for abortion under the Abortion Act

**Less than 24 weeks: (like a gradualist approach to abortion) A) The pregnancy is less than 24 weeks and that the risks to the physical and mental health of the woman or any children in her family are greater if the pregnancy were continued. § Accounts for 97% of all UK abortions. § 87% of all UK abortions are carried out before 13 weeks. § Critics say: The inherent risks of pregnancy compared to the low risk of early abortion mean that pregnancy will almost always pose a greater physical risk than an abortion. Hence some say it basically allows abortion on-demand. **At any stage of pregnancy B) Necessary to prevent grave and permanent injury to the mother.. OR C) Continuing pregnancy would involve a greater risk to the life of the pregnant woman than termination.. OR D) Substantial risk of serious physical or mental handicap to the unborn child.

Maternal duties and paternal rights in pregnancy

**Maternal duties: § Even if abortion is morally permissible, this does not imply: § That abortion is morally a good thing. § That the fetus has no moral value. § That the mother has no obligations to the fetus. **Best interests: § Does a mother have a duty to act in the best interests of the fetus? § What should be done if a pregnant woman continues to behave in a way which is harmful to the fetus? (Smoking, Alcohol, Paté and soft cheese (risk of listeria) § Is it morally acceptable for us to change that woman's behaviour?

Confidentiality Exception 2: with express consent

**Must be express. § You cannot rely on implied consent when breaching confidentiality to others who are not actively involved in the patients care. The patient must expressly give their permission. § How much information to be divulged? § To whom? § Most relatives don't have rights: a) Unless a parent of a child who is not Gillick competent, relatives do not have a right to know in most cases. b) In situations of a patient who lacks competence to make a decision about health care, next of kin now have a right to be consulted where practical to do so. **When in doubt about: § The nature of the information (e.g. attendance at genitourinary clinic). § The form of the disclosure (e.g. letter to GP, hospital notes, electronic record). § To whom (e.g. relative, carer). Get express consent!

What is consent?

**Patient's permission: § The law requires permission from a patient before treatment can occur. § This permission is called Consent. § It is required for any form of medical management - from taking a history, conducting an examination, taking blood test, giving injection through to interventional treatments such as operations. § When permission is not granted by a patient, the patient has "refused to consent". This should not adversely affect the care of the patient.

Principles of the Children Act 4

**Principles of the Children Act 4: § Parental Responsibility: § A cornerstone of the Act was giving parents Parental Responsibility. § Having Parental Responsibility gives either or both parents the right to decide for their children decisions that most take for granted. § The Children Act effectively outlined how the courts would view matters when relations broke down between the parents, or where the Local Authority felt that the parents were not capable of looking after their children. § There can be a variety of people with Parental Responsibility: o both parents (if married at birth or both on birth certificate) o mother only (if unmarried and no agreement with father) o legally appointed guardian o local Authority with a care or protection order

Selma is a 37 year old woman who is 26 weeks pregnant. She has a long history of alcohol and cocaine abuse. Her scan shows that the baby is small for dates. Her mother wants the obstetric team to admit Selma into hospital so that she can stop drinking. She has read that in America certain states will detain pregnant crack cocaine users to protect the unborn child. Selma refuses to come into hospital. She says that she is trying to cut down on her alcohol and has not used cocaine for over a month. § What are the likely effects of Selma's drug and alcohol use on her pregnancy? § What are the ethical arguments for and against forcibly treating Selma for her addictions? § What is the legal position in the UK regarding forcible treatment of a pregnant women to prevent harm to the unborn child?

**Rights and Duties of the Pregnant Woman: § Even if is accepted that a woman does not have an absolute moral obligation to continue a pregnancy, the pregnant woman may still have MORAL DUTIES TO THE FETUS. § The fetus is INNOCENT and totally DEPENDENT. § Thus, if a woman chooses to continue with a pregnancy, can we argue that she has a duty to avoid activities that might harm the foetus? § Do her duties depend on whether she voluntary chose to become pregnant? § It has been argued that an ethically valid voluntary action implies that the individual was adequately informed and had a reasonable range of choices to choose from. § However, many parents agree that no amount of information can prepare you for the actual experiences of being pregnant or being parent. § Furthermore, if a woman wants a child there is no option other than to become pregnant; she cannot choose for her partner or a robotic incubator to carry the baby for 9 months. Thus, it could be argued that becoming pregnant may not be an autonomous decision. § If parents are considered to be causing significant harm to their children, many consider it acceptable to separate the children from their parents. § Does it follow from this that it is therefore morally permissible for society to restrict the activities of pregnant women to prevent harm to the foetus? § In this e-module we have considered how it may sometimes be morally permissible to limit the autonomy of individuals. § For instance, if an individual's actions harm others. § Thus, a ban on smoking in public places has been justified on the grounds that passive smoking harms others. § However, the situation with pregnant woman is more complicated; to protect the foetus would require us to not simply to ban smoking at certain times or in certain places but to ban pregnant women from smoking COMPLETELY. § Arguably such a ban would only be enforceable if the State had the power to forcibly detain woman who did not comply with the ban. § But we live in a society where forcible detention is only permissible for criminals (leaving aside the issues around compulsory detention for mental illness). § Should pregnant woman who continue to smoke or drink heavily or take drugs be treated as criminals? § Furthermore, to be consistent we would also have to treat parents who smoked around their children as criminals. § Few would find this acceptable. § Leaving the ethical arguments aside, the empirical data suggests that relationship between, alcohol and drugs of abuse and adverse fetal outcomes is not straightforward. § For example, fetal alcohol syndrome is far more likely to occur in pregnancies where poverty and maternal malnutrition exist. § Therefore, it is argued, that it is inappropriate to try to criminalise a woman's drinking or drug taking when much of fault lies with inequalities created by our society. § The legal position in the UK is clear. A woman does not lose any of her legal rights by virtue of being pregnant. Therefore, a pregnant woman has the same legal right as any other competent adult not to be treated against their will or to be detained without lawful justification.

Sanctity of Life vs Quality of Life

**Sanctity of life: § Life has intrinsic value § Theological or secular underpinning § One must never intentionally kill a human being § Life is of itself worthwhile independent of the capacities of the individual person § May allow for treatment withdrawal if there is no hope of benefit, but still a key consideration **Vitalism: § Human life has absolute moral value § It is wrong to either shorten or to fail to strive to lengthen life § Regardless of pain, suffering or cost § Regardless of patient's preference § Human life must be preserved at all costs **A life worth living: § Life is of 'instrumental value' rather than intrinsic value § What makes life valuable are the quality of the experiences of the person § Difference between 'having a life' and 'being alive' (James Rachels) § Only conscious life need be protected § Some lives may be so awful due to suffering or pain such that we do not have a duty to preserve life § On the other hand suffering does not necessarily cancel out enjoyment/fufillment that could be experienced § Suffering may not be constant and may improve over time

Research in person lacking capacity - Mental capacity act

**The Act also sets out clear parameters for research: § Research involving, or in relation to, a person lacking capacity may be lawfully carried out if an "appropriate body" (normally a Research Ethics Committee) agrees that the research is safe, relates to the person's condition and cannot be done as effectively using people who have mental capacity. § The research must produce a benefit to the person that outweighs any risk or burden. § Alternatively, if it is to derive new scientific knowledge it must be of minimal risk to the person and be carried out with minimal intrusion or interference with their rights. § Carers or nominated third parties must be consulted and agree that the person would want to join an approved research project. § If the person shows any signs of resistance or indicates in any way that he or she does not wish to take part, the person must be withdrawn from the project immediately. § Transitional regulations will cover research started before the Act where the person originally had capacity to consent, but later lost capacity before the end of the project.

What is medial professionalism?

**The Royal College of Physicians (RCP) Working Party (2005) defined medical professionalism as follows: § Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors. o In order to set out in more detail the meaning of these values, behaviours, and relationships, the Working Party described medical professionalism in the following way: Medicine is a vocation in which a doctor's knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being. o This purpose is realised through a partnership between patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability. In their day-to-day practice, doctors are committed to: § integrity § compassion § altruism § continuous improvement § excellence § working in partnership with members of the wider healthcare team. These values, which underpin the science and practice of medicine, form the basis for a moral contract between the medical profession and society. Each party has a duty to work to strengthen the system of healthcare on which our collective human dignity depends. § Nowadays we would describe these attributes of the medical professional as VIRTUES, manifestations of the influence of moral principles in the conduct of a professional person. We each develop our own PROFESSIONAL IDENTITY over time, informed by these principles.

The Gillick Exception

**The background: § This case allows, under certain conditions, a doctor to obtain permission for treatment from the child, without consulting those with parental responsibility. § In the Gillick case, Mrs Gillick discovered a leaflet in her GP's surgery that stated it would be possible for girls under the age of 16 to obtain contraception without the knowledge of their parents. § Mrs Gillick, with five daughters under the age of 16 at the time, brought a case to attempt to end this practice. § She argued that it is an offence for a man to have intercourse with a child under the age of 16 and therefore this availability of contraception to minors was colluding in a criminal offence. **The judgement § The court held that it would be in the best interests of certain children to receive this treatment, if certain criteria are met. § This exception (popularly named "Gillick") allows the treatment of any child for any condition providing certain criteria are met.

Principles of the Children Act 1

**The child's welfare is paramount: § It sounds obvious but the Act clearly states that everything that is done by a local authority, a court or any person for that matter, must have the welfare of the child as paramount. § The rights of the parents are SECONDARY to the welfare of the child even if this creates an unjust situation for either or both of the parents. § It is relevant to doctors and other HCPs for example insituations of: o obtaining consent o refusal of treatment o disclosure of information / breach of patient confidentiality

The status of the fetus as a human being in the abortion argument

**The fetus is a human being: **The 'Human Being' Argument: § It is always wrong to kill an innocent human being deliberately. § All human fetuses are innocent human beings. § Therefore it is always wrong to kill a human fetus deliberately. § Abortion is the deliberate killing of a human fetus. § Therefore abortion is always wrong. **But.... § What is it about human life that makes it more valuable than other forms of life? § If we say that a zygote has special value simply by being human is this speciesist - preference for our own species? § What is it about a zygote that makes it a human being, what about humanity, intelligence, emotional intelligence or just a lifeform with same genetic makeup. § Is a zygote a human being? § If there was a burning room and there was zygote in petri dish and 5 year old child. Is killing a zygote morally equivalent to killing a 5 year old child?

The status of fetus - fetus is not a person - the person argument in abortion

**The fetus is not a person **The 'Person' Argument: § Persons are individuals with self-awareness and autonomy. § Only persons have a right to life. § A human fetus is not a person. § The human fetus does not have a right to life. § Therefore abortion is morally permissible (but not necessarily desirable). **But... Neonates, young infants, adults with severe mental disability lack self-awareness and autonomy. § Therefore: These individuals are not persons. § They do not have a right to life. § Infanticide and killing those with severe mental disability is morally permissible.

Principles of the Children Act 3

**The welfare principle in practice: § Wherever possible children should be brought up and cared for within their own families. § Children should be safe and protected by effective intervention if they are in danger. § Agencies should work in partnership with parents as it does not prejudice the welfare of the child. § Children should be kept informed about what happens to them and their wishes and feelings taken into account (considered in the light of their age and understanding). § They should have the opportunity to participate in decisions made about their future. § Parents continue to have parental responsibility in relation to their children, even if their children are no longer living with them. They should be kept informed about their children and participate in decisions made about their future. § Parents with children in need should be helped to bring up their children themselves.

Choosing between diseases using QALYs - pros and cons

**What are QALYs? § Quality Adjusted Life Year. § Gives a measure of the number of life years gained by an intervention adjusted for quality of life:1 year of healthy life = 1 QALY. § 1 year of unhealthy life = <1 QALY. § Death = 0 QALY. § Can have negative QALYs! If cost of intervention known, can calculate cost per QALY. **Preference scores: § Preference scores give an adjustment between -1 and +1 based on the predicted quality of life associated with a particular physical condition. § Based on standardised questionnaires focusing on function: o Mobility. o Personal self-care. o Communication. *so preference score less if someone less mobile and take care of themselves **Benefits § Give a reproducible, quantifiable measure of benefit and cost effectiveness allowing comparison of treatments. § The 'best' treatments are those that give the most QALYs per £. (e.g if one treatment is £7000/Qaly vs another is £10,000/Qaly, go for £7000/Qaly treatment) **Problems: § Biased against people with disability. § Ageist. § Don't distinguish between life saving and life improving treatments. § Subjectivity of preference scores. § Equates quality of life with value of life (somebody who has lower quality of life does not mean they value life less)

Choosing between patients on the basis of personal responsibility

**What if... § I started the fire deliberately? Should I be saved? § I started the fire by accident? § I started the fire through carelessness? § I suffered from pyromania? **Personal responsibility and healthcare: To what extent are people responsible for the diseases they acquire. For example - smokers responsible for their heart disease or the overweight responsible for their diabetes? What about factors beyond our control? o Upbringing. o Education. o Social background. o Genes. § Even if I am responsible for my health problems does that mean I should be denied health care? § If we uphold this we need to maintain consistency. § What happens about... o Rescuing mountaineers. o Treating sports injuries. o Treating workaholics for stress-related disorders § By following the personal responsibility approach do we risk imposing our personal prejudices?

What is competence

**What is a competent person? § Understand the information. § Retain the information. § Use the information to make a decision. § Communicate the decision. **Competence is decision specific: § The information that the patient must understand is only that information which is relevant to the discussion. § Therefore a patient may have the ability to understand the consequences of treating pneumonia but not to make a will.

Autonomy and trust

**What the studies show: § Studies show that around 50% of patients want their treatment decisions to be physician led and § 80-90% want decisions to be physician led or in collaboration with their physician. § Does this mean that patients don't value autonomy? **What patients want: • Some patients want their doctors to make treatment decisions because they TRUST their doctor to make the right decision. • Even so, they UNDERSTAND what is being proposed and WHY. • Patients cite clear explanations, truthfulness and good communication as ESSENTIAL for building trust. • In this setting patients feel confident that they have control over what is done to them. § Doing these interactions require us to treat patients as autonomous individuals

Advanced decisions to refuse life sustaining treatment must be in...

**although general advanced decisions don't need to be in writing. § Must be in writing and signed § Must be witnessed and signed by the witness § Must specifically state that decision is to be respected even if life is at risk § Must indicate that the maker has taken into account circumstances that have changed from when the decision was first drafted § It is the doctor's decision as to whether a treatment is considered life sustaining. § A doctor would be liable if he provided treatment in the face of a valid and applicable advance decision § If there are doubts over validity/applicability can treat in an emergency § In a non-urgent situation can apply to the Court of Protection for a declaration

Who can create an LPA?

**created by MCA: § All competent adults can create an LPA. § LPA can ONLY be created when the adult has capacity. § Creation of LPA must comply with strict regulations and be registered with the Court of Protection. § The donee of the LPA can ONLY make decisions when the donor has lost capacity § Extent of decision making must be specified in the LPA: a) Financial decision making b) Personal decision making c) Welfare decision making including consent to treatment d) Refusal of life sustaining treatment *The donee's decisions must be in the person's best interests

Starting point with delivering info

**normal introduction (my info, patient info, why you talking to them etc.) 1) § what has the patient been told (if anything - idea of what they know about the procedure/ why he's having the procedure) § is the patient worried about anything 2) How much does the patient want to know? 3) Be explicit - categorisation and signposting 4) Relate explanations to ICE - V IMPORTANT 5) establish patient understanding (repetition, get patient to explain to you, summarise) 6) Provide opp to ask questions (not just at the end) 7) Keep organised, logical 8) SUMMARISE - check patient's understanding as well e.g. can say there is a lot of information I can give you, was there anything you want to know about in particular. Trust send a leaflet too. for flexi sig e.g. tube about a fingers width going up the back passage with a little camera on the end, takes 20-30 mins, might need to sample bits. Have enema in the morning to clear out bowels, can eat day before but after enema nothing. can have sedative if want - if have it, need someone to collect them after the visit.

Cardioresp symptoms

chest pain exertional dyspnoea (quantify exercise tolerance: how many stairs) paroxysmal nocturnal dyspnoea orthopnoea (i.e. Breathless on lying flat - a symptom of left ventricular failure) oedema palpitations (awareness of heart beats) cough sputum haemoptysis (coughing up blood) wheeze

D of normal intelligence 15 y/o attends genitourinary clinic with mum. Diagnosed with syphilic. Treatment is IM penicillin. Both D and his other agree to treatment. His mother waits in consulting room whilst D receives injection. Doctor also notices D has anal warts. Dr E tells D his findings. D says he is gay and in relationship with boy and that parents have strong views about homosexuality and he doesn't wanna tell them yet. What should Dr E do? a) Dr E has treated the condition for which D attended and therefore he should be discharged without any further conversation with his mother. b) Given it is unlawful for a man to have intercourse with a boy under the age of 16, Dr E is obliged to report this matter to D's mother. c) Dr E should write to the family GP and ask her to follow up this issue. d) Dr E should ask D to come back to the clinic at a future time to discuss this further. e) Dr E should assess whether D has Gillick competence.

d) Dr E should ask D to come back to the clinic at a future time to discuss this further. *not E because it is unusual for this boy to not have gillick competence. So want to come back for another clinic as don't want to discharge without further conversation. Writing to GP not answer as the patient will be referred back anyway. **David is a 15 year old minor and therefore almost certainly Gillick competent. His welfare is paramount. This is a delicate situation and his mother is waiting for him outside for a procedure that should only take a few minutes. You are likely to need time for quite a lengthy discussion with David (is the other boy the same age, is there any suggestion of coercion) and his warts require medical treatment. Therefore it will be necessary for David to come back alone to address these issues appropriately.

§ Harry is 15 y/o body who attends outpatient genitourinary medicine clinic and is diagnosed with genital warts. Dr E recommends cryotherapy. Harry is mature. Doesn't want parents to know. What to do? a) Harry does not fulfil the criteria for gillick competence but Dr E can give treatment as it is in Harry's best interest b) a) Harry does not fulfil the criteria for gillick competence but Dr E can give treatment as there is a wider public interest in treating c) Harry cannot receive the treatment without parental consent, but his refusal to contact them must be respected. court authorisation is needed. d) Harry fulfils the criteria for gillick competence and thus he can receive the treatment e)Harry fulfils the criteria for gillick competence but the gillick case didn't apply to invasive treatment. Efforts must be made to contact his parents.

d) Harry fulfils the criteria for gillick competence and thus he can receive the treatment § if one parent disagrees- only need only one keyholder § if child not gillick competent, act in best interests and involve parents § From the information we are given Harry understands the treatment proposed and the reason for the treatment and thus fulfils the criteria for Gillick competence. Therefore, treatment can be given on the basis of Harry's Gillick competent consent since it is in his best interests and he cannot be persuaded to involve his parents.

D is a 19 year old woman with Down's Syndrome. She is accompanied by her mother to see her GP having found out that she is pregnant (missed period two weeks ago). She lives with her parents and works as a shop assistant. Her mother requests that D has a termination. She says that she and D's father are already in their sixties with health problems of their own and would not be able to look after a baby. D tells her GP that she wishes to keep the baby. What should the doctor do now? a) As it is in D's best interests, her mother's consent for the termination should be sought. b) Only a court can override an adults competent refusal provided that it is in the patient's best interests. c) The family's wishes have to be taken into consideration before making significant treatment decisions for an incompetent adult. d) The doctor should assess D's mental capacity. e) It is clearly in D's best interests to have a termination and theretore the GP should refer D for a termination.

d) The doctor should assess D's mental capacity. § Parental responsibility (in the legal sense) stops when an individual reaches their 18th birthday. D is 19 and therefore an adult and presumed to be mentally competent. Mental incapacity must not be assumed simply because she has a diagnosis of Down's Syndrome. The doctor must first assess D's mental capacity. If competent, no one, not even the Courts can override her refusal of a termination.

Imelda is a 15 year old girl of normal intelligence and understanding, who has had unprotected intercourse. The following day she attends her local A+E department requesting the 'morning after pill'. The A+E SHO, refuses to give Imelda the treatment without the consent of her parents. Imelda does not want her parents to know that she has been sexually active. She tells the doctor that her best friend told her that she didn't need her parent's consent to get the 'morning after pill'. Is her friend correct? a) Yes - provided Imelda is Gillick competent then she has an absolute right to confidentiality and therefore parental consent cannot be obtained. b) Yes - at 15 Imelda is presumed competent and therefore parental consent is not necessary. c) No - the doctor can veto treatment on the grounds of lack of parental consent. d) Yes - provided Imelda is Gillick competent and cannot be persuaded to involve a parent. e) No - Imelda is a minor and therefore the decision is based on the doctor's view of her best interests. f) No - the 'morning after pill' comes under the Abortion Act and therefore parental consent must be obtained.

d) Yes - provided Imelda is Gillick competent and cannot be persuaded to involve a parent. § At 15 a child is presumed incompetent but if s/he can demonstrate mental competence is described as Gillick (or Fraser) competent. Even if Gillick competent, the doctor can only act if the decision is in the child's best Interests and must try To persuade the Gillick competent child to involve a parent. No one has an absolute right to confidentiality. See 'The Gillick exception' in section 9 of the Children e-module.

Bettina is a 44 year old shop assistant. She is 34 weeks pregnant and has suffered a small ante-partum haemorrhage. Her scan indicates that she is at significant risk of a major placental abruption. The obstetrician advises her that both her life and the life of the baby are at risk if she has a major bleed and that she should remain in hospital until an elective caesarean section at 37 weeks. She refuses saying that the same thing happened when she was pregnant 3 years ago. Despite no further bleeding, her son was delivered early by caesarean section at 37 weeks and developed respiratory distress. His lungs have been permanently scarred as a result. She has previously suffered from severe post natal depression and is assessed by a consultant psychiatrist who concludes that she is not depressed and has mental capacity. a) Bettina can be compulsorily detained under the Mental Health Act. b) It is lawful to override a competent refusal in pregnancy when the life of the unborn child is at risk. c) Bettina must be assessed by Child Protection officers and if they agree that she is putting her unborn child at risk she can be compulsorily detained. d) Bettina's reasoning is clearly irrational, indicating that she lacks mental capacity. Therefore she should be detained on the grounds of best interests. e) Bettina cannot be kept in hospital against her wishes. f) A Court order should be obtained so that Bettina can be lawfully detained.

e) Bettina cannot be kept in hospital against her wishes. The fetus has no rights - An adult's competent refusal must be respected. An unwise decision does not necessarily equate with a lack of mental capacity. The Mental Health Act can only be used to detain individuals for the assessment or treatment of their mental illness. See Section 4d 'Refusal' in the autonomy, paternalism and consent e-module and Section 7, in the mental incapacity, justice and the Mental capacity act e-module.

Example SBA: Britney is 9 y/o american girl at boarding school in england. At school, she breaks her ankle. brought into hospital by teacher Mr B. Surgeon sets in plaster and needs to operate in about 48 hours. Calls parents but neither available at the moment. What should she do? a) Ms C should operate under basis of necessity b) Is a major procedure, hence Ms C must obtain verbal consent from both parents c) As britney is at school, Mr B can act 'in loco parentis' and signs the consent form d) Consent has to be obtained - must be faxed and signed by at least one parent e) Consent has to be obtained - oral permission from either parent is sufficient

e) Consent has to be obtained - oral permission from either parent is sufficient. §This is not an emergency so consent must be obtained from one of her parents. Neither the doctor nor Mr B has parental responsibility. As discussed in the 'Consent, Capacity and Refusal in Adults' e-module consent does not have to be in writing to be legally valid. Therefore oral consent, provided it is informed and voluntary, from one of the parents is sufficient. However, some exchange of written information might be helpful although not essential.

A patient is seen in the infectious diseases clinic. He is HIV positive with no current need of anti-retroviral treatment. He admits to being sexually active but is adamant that he always uses a condom He does not want his GP to know of this diagnosis. Can the clinic doctor. F. nevertheless write to the GP and inform her of the man's diagnosis? a) As HIV is a notifiable disease, F is under a duty to breach confidentiality. b) F should state to the patient that if he wont allow him to tel his GP. he will be unable to treat him in the future, as F also has a duty to the GP. c) F should inform the GP as he is part of the multidisciplinary team and therefore has a right to know. d) As the patient has refused to allow the GP to be informed. F should hint to the GP in the letter by stating 'he may need anti retroviral treatment in the future'. e) F should respect the refusal to contact the GP in this case.

e) F should respect the refusal to contact the GP in this case. HIV is not a notifiable disease. In this case, in the absence of consent, disclosure is only lawful if it is necessary to prevent serious harm to others. The patient says that he always uses a condom but even if he didn't, informing his GP would not prevent serious harm to his sexual contacts (unless his GP had the contact details for all of them!). A doctor cannot withhold necessary medical treatment because s/he disapproves of a patient's behaviour.

F is 7 y/o old, brought into A&E by 16 y/o sister S. S was looking after her for afternoon. F has been vomiting and might have had cannabis cookies that older sister was having. S doesn't want mother to know. F shrugs shoulders when asked about cookies and doesn't want to get sister in trouble. What to do? a) S is Gillick competent and therefore has a right to confidentiality. Therefore you cannot inform the mother. b) As there is no significant risk of physical harm from this incident you should respect the wishes of F. c) F is a child and therefore is not owed a duty of confidentiality, so you can inform the mother without consent. d) S has broken the law and therefore you have a legal obligation to inform the mother. e) F's mother should be informed as it is in F's best interests.

e) F's mother should be informed as it is in F's best interests. **children are owed duty of confidentiality but can have breaches if it in best interest. § Your duty of confidentiality is to the patient, not to S. F is a child and therefore, while you do owe F a duty of confidentiality, you primary legal obligation is to act in F's best interests. In this situation, it is clearly necessary that you discuss the situation with the mother. S's wishes are only material inasmuch as they pertain to F's best interests.

R is a 27 year old woman who has learning difficulties and a mental age of 3-4 years . She now lives in a sheltered community with full time carers. She has a boyfriend, C, a young man who also has severe learning disabilities. R and C have been close for several months and spend much of their time watching TV holding hands. However staff find them together in her bed. The care staff think R needs contraception to avoid the possibility of pregnancy. Her GP agrees. R is very unreliable with oral medication so her GP suggests a contraceptive implant. R's parents do not think that R should be put on medication when there is no medical problem. They say that R should be separated from her boyfriend. It is decided to hold a case conference to try to reach a consensus but the staff and her parents cannot agree. What should R's GP do? § The doctor cannot proceed without agreement from the family. § Where an agreement cannot be reached an Independent Mental Capacity Advocate should be appointed. § An application for lasting power of attorney is appropriate for C. § Under the Mental Capacity Act, in this situation, a court appointed deputy must make all welfare, healthcare and financial decisions on behalf of individuals lacking capacity § The decision to treat should be referred to the Court of Protection.

e) The decision to treat should be referred to the Court of Protection. § Contraception is non-therapeutic and carries the risk of side effects. § However separating R from her boyfriend may cause her considerable distress. § The determination of best interests in this situation is not clear cut and so should go to the Court of Protection for a declaration of best interests. § An IMCA would only be appointed if there were no next of kin. § An LPA can only be appointed by a competent adult.

A patient is eight weeks pregnant. She wishes to have a termination without the knowledge of her husband. whom she confirms is the father of the fetus. Can the doctor. G. perform the termination without the husband's knowledge? a) G can only perform the termination without the permission of the husband if there is a psychiatric reason. b) Until 24 weeks the husband has no rights over the fetus. c) G cannot perform the termination without the permission of the husband. d) G will be forced to inform the relevant authority if the abortion is carried out and therefore the husband will find out anyway. e) The termination can occur without the husband's knowledge.

e) The termination can occur without the husband's knowledge. §The husband (or biological father) has no legal right to be informed regarding an abortion and has no right to veto or request and abortion, at any stage of a pregnancy. Under the Abortion Act there is a statutory duty to notify all abortions but only to the Chief Medical Officer (in England or the equivalent in Wales in Scotland). There is a statutory prohibition under the Act for any wider disclosure.

GP decision to not treat asylum seeker pros and cons:

for: § the GP believes that it will drain resources and this may prevent him providing the best care for the tax-paying UK citizens. § he also said that he cannot understand with them and hence cannot provide the best care for them. **Against: § This can be considered as xenophobic. Everyone has a right to healthcare regardless of barriers to communication. There will be other citizens in the UK with language barriers that doesn't mean we don't treat them. **Barriers to health for refugees and aslyum seekers: They often have several serious conditions that will require more complex care and coordination of healthcare professionals. They often have both physical and psychological trauma. They also often cannot register with GP practices. Now refugees must apply for an exemption certificate by filling out a complicated form in English. nearly 50% of asylum seekers have mental- health difficulties associated with depression and post-traumatic trauma.

Genitourinary symptoms

incontinence (stress or urge) dysuria (painful micturition) haematuria (blood in urine) nocturia (needing to pass urine at night) frequency polyuria hesitancy terminal dribbling vaginal discharge menses: frequency, regularity, heavy or light, duration,painful, frst day of last menstrual period (LMP) number of pregnancies menarche menopause chance of current pregnancy?

Can children refuse treatment?

no. by 18 they can refuse. • Children cannot refuse treatment - Gillick was about "best interests" - If <16 will not need a court order - If 16-17 likely to need a court order unless agreement with the child can be obtained

Who can consent on behalf of competent adult?

nobody

Asking ICE

o Ideas - "Is there anything you think might be causing these symptoms?" "Patients ofen have ideas about possible treatments. Do you have any ideas?" o Concerns - "Do you have any concerns about your illness? "Are you worried about your symptoms?" "Patients ofen have worries about their symptoms. Do you?" o Expectations - "What are you hoping the doctor will do?" "What do you think your treatment will be like?"

You are writing a case report for publication and want to include an xray of the patient in the report. Do you need patient consent?

yes. if cannot get in touch with patient, then can include as long as is anonymised § if patient dead - get info from family as courtesy. If not contactable - balance worthwhileness of case and ability to anonymisation

Applying the "flooded floor" analogy with treating obesity

§ 60% of the population is overweight or obese. § Overweight/obesity is associated with reduced life expectancy. § Overweight/obesity is associated with cardiovascular disease, diabetes, arthritis, certain cancers. **Therefore...fix the tap: § It is an appropriate and necessary use of public resources to tackle obesity through prevention and treatment at the population and individual level. **But...the problem with fixing the tap: § Very difficult to separate the contribution of obesity to premature death from other con-founders which associate with obesity such as poverty, lower educational level. § Primary prevention interventions for obesity to date have been unsuccessful. § Screening for obesity risks medicalising otherwise well individuals and reinforcing existing stigma and prejudice against those who are overweight or obese. (the increased cancer prevalence in obese individuals is partly explained by their reluctance to go to screening because they are self conscious of weight) § Screening for obesity takes manpower and money away from treating other illnesses.

What is the age of consent of children for medical treatment

§ Age of consent is 16 § The Family Law (Reform) Act 1969 states that the age of consent to medical treatment is 16. § For patients below 16, only those who have parental responsibility can agree to medical treatment for the child. § Although Parental Responsibility ends at 18, some of the powers of being able to agree to medical treatment on behalf of a child end at the child's 16th birthday. § If there are several people with parental responsibility then it is acceptable to gain permission from only one of them. § For major decisions where there is parental disagreement it is advisable to seek court approval § Gillick exception ! **No one with parental responsibility? § In an emergency when no one with parental responsibility is available then medical treatment or surgery can be given without consent under the legal principle of NECESSITY. § Treatment is legally necessary if it is in the patient's best interests and cannot wait until consent can be obtained.

Legally accepted definitions of death

§ Although there is no statutory definition of death in cases where legal definition is required UK law currently recognises using brainstem death. § Permanent loss of brain stem functions causes: o Coma not due to reversible causes o Several components of the brain stem permanently destroyed (this includes respiratory centre) o Unable to breath spontaneously § This definition was adopted following the 1976 and 1979 Conference of Royal Colleges where they had already accepted the use of brainstem death. Prior to the 1960s cardiopulmonary death was considered the acceptable definition but this is reversible following CPR

Abortion and disability

§ An abortion can be performed at ANY stage on the grounds of serious disability. § Few conditions are so awful that the baby could be said to be 'better off dead'. § Down's syndrome accounts for 20% of abortions performed on the grounds of 'serious handicap'. Few people would say that for Down Syndrome's patients that their Qof L is so poor that they would be better off dead. **Disability and discrimination: § Is terminating a pregnancy on the grounds of disability any different from terminating on the grounds of sex or hair colour? § Do these grounds imply that the lives of those with disability are less valuable? § Do these grounds reinforce prejudice against those with disability? **Disability - a social construct? § Disability is only a problem because society fails to adequately support those with disability. § Parents of disabled children are often more worried about the social stigma than the physical limitations. § Parents worry about who will look after their child when they die. § Allowing termination of pregnancy due to abortion it perpetuates the prejudice against those with disability and instead society should focus on how to help support parents with disabled children. **But then in response to this: a personal choice: § Having a severely disabled child can put immense physical, emotional and financial strain on parents. § Other children in the family might suffer as a result of this. § Therefore, a woman should be able to choose not to go ahead with such a pregnancy. **Disability, choice and autonomy: § Autonomous choices should be respected. § Autonomous choice requires that we are given a reasonable range of options. § If society fails to ensure justice and provide an adequate level of support for those with disability does a woman have a reasonable range of options? They may be choosing between abortion and a society where their child is not supported.

Risks of smoking

§ And roughly 1 in 2 lifelong smokers will die from the habit § •In the UK 114,000 premature deaths per year due to smoking

The doctrine of double effect (DDE)

§ As doctors we know that many of the treatments we give have side effects that can cause harm. § When deciding if we give a treatment we often weigh up the risk versus the benefit. § Where there are significant side effects we can use the Doctrine of Double Effect (DDE) to help us decide whether to offer a treatment. **DDE states: It is always wrong to perform a bad act although good may result, but it is sometimes permissible to perform a good act though harm may result. This rests on the difference between what is intended and what is foreseen: § the act in itself is not bad § the bad consequence is not a means to the good consequence e.g. the risks of chemo is not a means to treat cancer § the bad consequence is foreseen but not intended § sufficiently serious reasons for allowing the bad consequence to occur - e.g. will die without chemo **criticisms - o we just as responsible for all foreseeable consequences even if not intended o we didn't intend outcome but foreseen as very likely to occur o what constitutes good and bad act e..g in euthanasia where killing is to relieve suffering and the person requests it.

Ms B was a 47 yr old lady who experienced a haemorrhage into her spinal column in 1999. Following this she created an advance directive where she stated that if she suffered a further life threatening deterioration she would wish for life sustaining treatment to be withdrawn. In 2001 she sustained a further bleed rendering her quadriplegic and unable to breathe without ventilator support. She repeatedly expressed a wish for her ventilator to be switched off in line with her wishes. These requests were turned down by the doctors as they felt they would be unable to carry out her wishes. What do the doctors need to assess to establish whether Ms B is thinking rationally? What is required of a legally valid advance directive in this situation? **Write down your thoughts and consider *what we would need to assess to establish if* Ms B's request complies with this. § Ms B challenged the doctors decision in the High Court. In March 2002 Dame Bulter-Sloss, then President of the Family Division of the High Court ruled in favour of Ms B, agreeing that her wish to have her ventilator switched off should be respected even if it resulted in her dying as adult patients with capacity have an absolute right to withhold consent to treatment, without which treatment is unlawful. **What are your thoughts? Do you agree with Dame Butler-Sloss? What would be the issues for doctors when deciding to withdraw care?

§ As when considering consent to treatment for any individual we have to consider the patient's MENTAL CAPACITY. But as illustrated by Ms B, when stopping or withholding treatment results in death, extra consideration must be taken, but the basic principles of assessing capacity are the same. **In patients lacking capacity to make decisions about treatment at the end of life: § All decisions must be made in the best interests of the person who lacks capacity § Any best interests decisions relating to life-sustaining treatment must not be motivated by a desire to bring about the person's death § A legally valid and applicable advance directive directing withdrawal of life sustaining treatment is given the same legal status if it were a contemporary decision made by someone with capacity. **Where there is uncertainty: § Continue life sustaining treatment as this is the least restrictive option § An application to the court of protection should be made

Choosing between diseases using public opinion

§ Asking the public may help get a better handle on what most people think are important in terms of healthcare priorities. § If resources are insufficient to ensure universal provision of interventions identified as healthcare priorities the public needs to revise its list or pay more tax. **Shouting loudest: § There has been evidence of changes provoked by intense public opinion. § 2006: Ministerial intervention leads to U-turn on Herceptin § 2002: NICE reverses its decision on Glivec for chronic myeloid leukaemia (after intense lobbying) § 2000: NICE reverses its decision not to recommend beta-interferon for multiple sclerosis (after intense lobbying) **Those without a voice: § What about vulnerable groups who lack a strong advocates? § What about those with conditions that evoke less public sympathy?

The law on assisted suicide

§ Assisted suicide is illegal in the UK. § It is in contravention of the Suicide Act 1961. § Suicide Act 1961 : 'a person who aids, abets, counsels, or procures the suicide of another, or an attempt by another to commit suicide shall be liable on conviction or indictment to imprisonment for a term not exceeding 14 years.' § Director of Public Prosectution guidance (updated Oct 2014): Factors in favor of prosecution: a) the victim was under 18 years of age; b) the victim did not have the capacity to reach an informed decision to commit suicide; c) the victim had not reached a voluntary, clear, settled and informed decision to commit suicide; d) the suspect was not wholly motivated by compassion e) the suspect pressured the victim f) the suspect was paid by the victim or those close to the victim g) the suspect was acting in his or her capacity as a medical doctor, nurse, other healthcare professional, a professional carer [whether for payment or not], or as a person in authority...and the victim was in his or her care

Mr Roberts has end stage Motor Neurone Disease and tells you that he has reached the stage where he no longer wants to 'carry on'. He has heard of Dignitas in Switzerland, who he knows could arrange for him to end his life peacefully and with dignity in one of their clinics. Dignitas have asked him to get a letter from his doctor supporting his decision to travel to the clinic to end his life. You are Mr Robert's GP. Write what you think you should do?

§ Assisted suicide, is illegal in the UK. It is in contravention of the Suicide Act of 1961. § This act states that: 'a person who aids, abets, counsels, or procures the suicide of another, or an attempt by another to commit suicide shall be liable on conviction or indictment to imprisonment for a term not exceeding 14 years.' § The legal issue at stake here is whether writing a letter to support him might be considered to be aiding his request for assisted suicide, thereby putting the doctor at risk of prosecution.

Children and autonomy

§ Autonomous choices require the ability to: a) understand information b) form values c) make decisions based on values and understanding of information § However not everyone is capable of making autonomous choices, especially when considering children. § Autonomy is not all or nothing. § Young children maybe able to make autonomous decisions about simple activities, such as whether they would like to eat ice cream, but may not be able to make complex choices such as where they would like to go to school

Autonomy has instrumental and intrinsic value

§ Autonomy has instrumental (in that it promotes best interests) and intrinsic value (as it is essential to human flourishing) § Respecting autonomy is likely to improve outcomes in medicine. § Respecting patient autonomy does not mean simply transferring decision making to patients. § Valid consent must be competent, informed and voluntary.

Examples of basic interest, developmental interests and autonomy interests

§ Basic, developmental and autonomy interests are the interests necessary to ensure current well being and development into an autonomous adult. § Respecting autonomous choices will usually be crucial to this development. § But if the choice will result in death or serious harm then the basic and developmental interests take precedence because they are necessary to reaching adulthood.

Difference between having a life, and being alive

§ Before defining death we need to understand what it means to be alive. § We might want to distinguish between between being a living person versus merely being alive. Being a living person involves possessing particular characteristics that give the person particular moral status, in contrast to other living beings that are alive but do not share the same qualities. **Some suggested characteristics of persons: 1) Use of sophisticated language is closely associated with self-consciousness, and the ability to recognise a past, present and future. Different animals may demonstrate this ability to a greater or lesser extent. 2) Self consciousness - This is an awareness of one's own existence - the ability to consider oneself a distinct entity over time and place. Human beings are not the only species to demonstrate this characteristic. Other apes have been shown to possess this ability. 3) Reasoning - The ability to deliberate, weigh up options and arrive at decisions has particular moral significance, being closely associated with deliberative and purposeful action

Intrinsic value of autonomy

§ Being able to make meaningful choices is fundamental aspect of being human. § Without free will we do not have moral responsibility. § Even if we make some (very) bad decisions, being free to make one's own choices (and one's own mistakes) is important to flourishing as a person. **Respecting autonomy in society Autonomy will only flourish in a society that respects autonomy. To respect autonomy, society must enable individuals to develop and reflect on their values and must ensure that individuals feel confident to express their values and confident that their wishes will be respected. To flourish autonomy must be respected for trivial as well as major decisions. **The value of autonomy: § Promotes best interests. § Essential to human flourishing.

Control screening test for alcohol

§ CO Can you always COntrol your drinking? § N Has alcohol ever led you to Neglect your family or your work? § T What Time do you start drinking? Do you sometimes start before this? § R Do friends comment on how much you drink or ask you to Reduce intake? § O Do you ever drink in the mornings to Overcome a hangover? § L Go through an average day's alcohol, Leaving nothing out. *This can be used if you suspect that your patient may have problems with drinking. Clearly not relevant to ALL patients. (Hope et al, 1998)

Best Interests and Non-Therapeutic Medical Interventions in Interventions

§ Can it be in a young child's best interests to undergo a non-therapeutic medical procedure? § For example: Tissue/organ donation or Medical research **Risk: § Medical trials inevitably carries some risk. § No direct medical benefit to the participant. § Adults understand purpose and risks of participation. **Altruistic: Allows them to be altruistic which is a valuable trait But... § Altruism is not the primary motivator for most adults participating in non-therapeutic research. § Is altruism morally valuable if the child has no understanding of altruism? **A Societal Duty? § Necessary for medical progress. § Today's children benefit from previous research involving children. § Is there a duty for children as health service users to participate in medical research? But.. § We do not consider adults to have a duty to participate in medical research. § Adult participation in research is voluntary - children cannot make a decision. **Professional Guidance: Research on children should only be carried out when: § it carries minimal risk of harm. § it is not possible to carry out the research in adults. § the condition being studied is specific to young children. § parental consent is obtained.

Does Zeno have a special moral duty to help Enya by virtue of being her half brother?

§ Can we argue that Zeno has a special duty to Enya by virtue of being her halfbrother and that therefore the normal rule of not using another person as a means does not apply? § Do we have a greater duty to assist family members than those unrelated to us? § It is well known that adult siblings quite often refuse to be organ/ tissue donors for their siblings. Although we might feel ethically adult siblings should donate in this situation, most of us do not consider that we have an ethical duty to be tissue/organ donors to our siblings. § Thus, the fact a potential adult donor was a sibling would not make it ethically acceptable to force them to be an organ/tissue donor without their consent. **The way forward: § What should be done in a situation like this where there is major disagreement between parents and/or between the parents/child and the health professionals? § Arguably the position of each of the individuals involved in this case is ethically acceptable but at the end of the day a decision has to be made! § The aim must be to reach a satisfactory agreement without having recourse to the courts. § Understanding the ethical arguments should help you understand the differing perspectives of the individuals involved and perhaps reflect more on your own original position. § Satisfactory constructive discussion is unlikely without this understanding and self-reflection. § It is important to consider the other sources of information and support that can be invaluable in these situations. § It might help for the parents to meet other parents in similar situations. § The involvement of patient support groups, liaison nurses, psychologists, the GP is likely to improve mutual understanding and increase the chance of finding a way forward. § Perhaps the bone marrow transplant (and therefore the bone marrow harvesting) could be deferred for a year or so. § Maybe Enya's mother has unresolved issues regarding her son's death which need to be addressed. If major disagreement persists then recourse to the courts may be the only way forward. **OVERALL: § There are potential conflicts between autonomy and best interests. In children it has been suggested that a child's autonomy interests requires us to ensure that children reach autonomous adulthood. § Best interests is a question of value. Mutual respect and good communication is essential if conflict is to be minimised.

Cerebral death vs brain stem death

§ Cerebral death - Death occurs when there is permanent cessation of higher cortical cerebral activity o pro - after this could then be said to not be alive as what made you alive was higher order intellectual, also not aware of being alive o con - desoulement, still biologically alive § Brain stem death (currently legally accepted definition) - The irreversible loss of brain stem function o pro - irreversible, can't survive o con - desoulement **Despite cerebral death being closer aligned to loss of conscious awareness, it can be difficult for us to measure. Some studies using functional MRI have shown patients previously thought to be in a Persistent Vegetative State are able to demonstrate some cerebral activity. **Brain stem death is easier to measure, is irreversible and due to its control over breathing and cardiovascular regulation it is incompatible with biological survival.

Giving feedback

§ Consider giving feedback on what has been done well and areas that need developing § Give feedback immediately afer the role-play § Consider what has been done well frst but be flexible too - respond to your colleague's needs § Describe specifc knowledge and attitudes and give examples to illustrate what you mean. § Describe your experience of the behaviour § When identifying weaknesses or defcits, work with your colleague to develop alternatives (e.g. "Can you think of diferent ways of...?" "Sometimes I fnd it helpful..." "When you did... I was wondering what would have happened if you'd done...") § Confne feedback on areas that need developing to things that can be changed § Be honest § Be accurate § Show empathy § Use silence efectively § Respond to your colleague's verbal and non-verbal cues § Do not overload with too much information § Limit the use of generalisations

Request for prolonging life: Mr Burke had cerebellar ataxia, which would one day affect his speech and ability to swallow. He would like to have percutaneous endoscopic gastrostomy (PEG) tube to feed him artificially if he could not swallow. However, he is concerned that one day doctors might decide to withdraw ANH after he could no longer communicate. He sought a ruling that his request, while competent, for treatment with CANH be respected were he to lose capacity. Do you think doctors would be right to withdraw CANH from Mr Burke when they felt it was no longer clinically required?

§ Court of appeal ruled: a) if doctor concludes that a treatment is not clinically indicated, he /she is under NO legal obligation to provide it, although he/she should arrange a second opinion. But there is a duty of care, and this would normally require the doctors to provide CANH

Cultural awareness

§ Culture is a complex social phenomenon §refers to the collective sense-making of life by members of social groups § comprises cultural orientations and influences such as gender, age, education, socio-economic background, family, occupation, sexual orientation, health problem or disability, and so on, and many cultural influences may change with time and personal experience. § Every individual is composed of a unique combination of these different cultural orientations and influences, and every person belongs to many different cultural groups. We are all thus multicultural individuals with similarities as well as differences. To communicate effectively, it is therefore important to understand and respect the cultural orientations that may influence the ways in which an individual may be thinking and acting, and the influence of one's own culture. § People (including health professionals) approach healthcare encounters with their own unique communication characteristics, health beliefs and customs, according to their individual backgrounds. These can dramatically influence healthcare needs, health behaviours and the necessary sharing of information that will enable an effective outcome from a consultation.

Importance of autonomy (self rule)

§ Deciding the direction in which one's life should go and being free to make one's own choices in life: Friends, Career, Money, Relationships, Children. **Autonomy promotes our best interests: each have different values, priorities and aspirations. Therefore we are usually best placed to know what is in our own best interests. What might objectively seem as a bad choice, might actually the best choice for that person. Well-being as a whole is more than medical well-being. § fundamental to the doctor-patient relationship § underpins good communication, the patient-centred approach to medical care and is crucial to working out the appropriate way forward when there is disagreement between health professionals and patients **Disagreement may manifest itself as explicit refusal, non-adherence with management plans or non-attendance

Why do we need to define death?

§ Defining someone as dead clearly has major moral as well as social and psychological significance. § Our obligations towards a living person and a corpse are clearly very different. Think for example about the issue of retrieving organs for transplantation. **Examples of what becomes morally permissible after a person dies. 1) Organ harvesting: It can be morally acceptable to take a person's vital organs (e.g. heart and lungs) and transplant them into someone else who requires them (if appropriate consent has been sought). 2) Marriage: n western cultures is it morally acceptable that the widow/widower remarries or starts new relationships 3) Property: Division and disposal of financial assets, property and heirlooms amongst remaining family members and friends is permitted.

The Mental Capacity Act provides a framework

§ Defining the acts and decisions it covers. § Defining the Statutory Principles. § Defining Capacity. § Clarifying the Concept of Best interests. **MCA: 1) Presumption of capacity: § All adults are presumed competent unless shown to lack competence. § Mental competence is task specific. § Ensure circumstances aid understanding: o Language. o Setting. o Support. o Take account of fluctuations in mental competence. **MCA determines A functional approach to the determination of capacity: § Not diagnosis driven (e..g not just because they have alzheimer's/ dementia) *2 stage approach: § Is there impairment of, or a disturbance in, the functioning of the mind or the brain? § Is the impairment sufficient to impair capacity? **Unwise decisions: § A competent adult can refuse treatment for a good reason, bad reason or no reason. § A person is not to be treated as lacking capacity because they have made an unwise decision.

Assessing your own patient-centred interactions

§ Do I know signifcantly more about the patient now than I did before I spoke to them? § Was I curious? § Did I listen? § Did I fnd out what mattered to them? - the patient's ideas, their worries, support they have within the community, their religious beliefs etc. § Did I make an acceptable working diagnosis? § Did I use their language and ideas when I started explaining? § Did I share options for investigations or treatments? § Did I share in decision-making?

Some general tips for social history taking

§ Do not be judgemental § Keep the questions open § Signposting is good... ....But be careful of " We ask all our patients this *Do not make assumptions

Preparation for receiving feedback

§ Do you want feedback? If not consider your reasons. § What is the purpose of feedback in this situation? § Are you ready to receive feedback? § What do you want feedback on? § What do you think you have done well? § What do you think you need to improve?

DRUGs menomic for drug history

§ Doctor - Any medications prescribed by a registered medical or dental practitioner § Recreational - Tobacco, alcohol, illicit drugs, anabolic steroids etc obtained for non-medicinal use § User - Over-the-counter purchases from a pharmacy, alternative medicines/homeopathy § Gynaecological - Oral contraceptives, hormone replacement therapy § Sensitivities - Response to anaesthetics, including the exact nature of the response

Points to check if things seem wrong (Kai & Briddon, 1995)

§ Does the interpreter speak English and the patient's language fluently? § Is the interpreter acceptable to the patient? § Is the patient prevented from telling you things because of his/her relationship with the interpreter? § Are you creating as good a relationship as possible with the patient? § Is the interpreter translating exactly what you and your patient are saying or is he/she advancing his/her own views and opinion? § Does the interpreter understand the purpose of the interview and his/her role? § Have you given the interpreter time to meet the patient and explain what is going on? § Does the interpreter feel free to interrupt you as necessary to indicate problems or seek clarification? § Are you using simple jargon-free English? § Is the interpreter ashamed or embarrassed by the patient or the subject of the consultation? § Are you allowing the interpreter enough time? § Are you maintaining as good a relationship with the interpreter as you can?

What is a patient-centred interview

§ Edith Balint (1969); "understanding the patient as a unique human being" § A PCI is one in which the interviewer identifies, acknowledges and responds to the patient in a way that encourages the patient to participate and ensures that their own agenda becomes part of the consultation process. § contrasts to paternalism, or doctor-centredness, where doctors dominate the agenda setting, goals and decision-making in regard to information and services, where the medical condition is defined in biomedical terms and where the patients' voice is largely absent.

Enya has an uncommon form of childhood leukaemia. She is currently in remission and very well following chemotherapy. However, her leukaemia will inevitably relapse at some point in the future - usually within 3-5 years of initial treatment. A bone marrow transplant is her only hope of long term cure. However, the transplant may be unsuccessful. One of the main risks is overwhelming graft versus host disease (GVHD). The risk of severe GVHD is substantially reduced with matched sibling donors. Failing that matched related donors offer a better chance of success (and a lower risk of sever GVHD) than matched unrelated donors. § What is the relevance of Enya's views in the determining what should be done? If bone marrow transplantation was performed against Enya's mother's wishes, would this impact on Enya's clinical course?

§ Enya is frightened about the prospect of a bone marrow transplant. She has seen her brother die following a heart lung transplant. She is also worried that Zeno may be harmed by the bone marrow harvesting. At the age of 12, Enya is probably capable of fairly autonomous decision making. § She should be able to understand the interventions proposed and to understand the concept of remission, relapse and death. She clearly has an understanding that bone marrow harvesting may harm Zeno. § Interviews with child transplant recipients indicate that they often have thought very deeply about their own illness and the consequences of one of their siblings being a donor. § Furthermore, it could be argued that her experience with her older brother gives her greater insight into the burden and potential adverse effects of a transplant than might be expected of an average 12 year old. On these grounds, child liberationists might argue that provided Enya does have this degree of understanding the final decision should rest with her. § Students will recall that adults are legally permitted to refuse life saving treatment. Ethically it has been argued that the high value that we place on autonomy means that adult refusal of treatment even if life saving must be respected. **Why should the situation be different for children provided they are capable of making autonomous decisions? § In the case of Enya it could be argued that she is not truly autonomous, that at the age of 12 she cannot fully understand the implications of refusing treatment. § Perhaps some of her fears are irrational or out of proportion to the real risks. At the age of 12 how can she understand what life as an adult would be like? Also her aspirations and beliefs are likely to change over the next few years so her. There are often decisions that we make in our youth that we regret later in life. Some consider this change in values and beliefs with time as a defect in autonomy; a defect of stability of values. Thus, on these grounds it could be argued that she is not making a truly autonomous decision and therefore we are not obliged to respect it. § The difficulty with this line of argument is that the same could be applied to adults. § Many of us make decisions which may be based on irrational fears and our values and beliefs continue to change through adult life. Few of us can really understand all the implications and burdens of a medical intervention because it is beyond our realm of experience. However, we would not usually consider these as valid reasons for overriding the decision of an autonomous adult. § Even if we accept that Enya's wishes are autonomous, we do not necessarily have to accept the extreme liberationist view of decision making by children (ie autonomous children should be allowed to decide for themselves). § Perhaps in children, whilst autonomy is important it is not the only important value. Do we have a duty to protect a child's physical and mental welfare and to try to ensure that children reach autonomous adulthood? § If we take this view then it becomes necessary to BALANCE Enya's autonomous wishes against her physical and mental welfare interests and the interest in ensuring that she reaches autonomous adulthood. § In this case her only chance of reaching autonomous adulthood (assuming that she is likely to relapse before she reached 18) is to have the bone marrow transplant. § Trying to manage a child with a chronic or major illness against the wishes of the parents is likely to pose significant problems. § Assuming that the parent (s) is the primary carer then the child will be reliant on them for practical, physical and emotional support. So if health professionals try to impose a decision contrary to the wishes of the parents, this is likely to have some negative impact on the child. How can Enya overcome her fears about a bone marrow transplant if she knows that her mother is vehemently against it? § Enya's best interests are intimately linked with those of her mother. If she goes ahead with the transplant she will rely on her mother for love and support. What if her mother honestly feels that she cannot cope mentally or physically with another seriously ill child?

Euthanasia

§ Euthanasia , or mercy killing, is also illegal. § This is considered under criminal law. § To convict a person of murder, the prosecution must prove beyond reasonable doubt that: a) The defendant caused the death of the patient b) The defendant intended to cause death or grievous bodily harm c) The defendant cannot successfully raise a defence **Euthanasia is not considered as a reasonable defense and therefore the defendant could be prosecuted for murder.

Is It Always Possible to Act in a Child's Best Interests?

§ Even with therapeutic interventions the best interests of the child may conflict with the best interests of his/her siblings or of their parents. § Is it reasonable or even desirable to require parents to unremittingly sacrifice their own best interests for their child? § Ethically we cannot require parents to do the impossible. Perhaps... it would be more reasonable to expect that parental decisions should be motivated by concern for the welfare of their child(ren) and not be clearly against the interests of that child.

Confidentiality Exception 1 Implied consent: MDT

§ Exception 1 - Implied consent: the multidisciplinary team **Implied consent by presence: § A very common practice but an unusual example of consent. § Rather than express consent (patient says "yes" orally or in writing) we imply that the patient consents to us telling the wider team about their condition, through them being in hospital and realising that other people will be looking after them too. **Who is part of the team? § Be careful about telling other medical students about a patient - if the student is not part of the team why would they need to know?

What are the major signs of burnout?

§ Exhaustion - feeling tired all the time § Lack of motivation to complete work and even for extra-curricular passions § Noticing a decreased performance § Lack of ability to pay attention and concentrate for long periods of time § Physical manifestation: headaches, stomach aches, intestinal issues § Negative outlook on life - don't see the point anymore § Isolation from any activity and human contact

Introduction in giving info

§ Full name and role • Who you are speaking to ? Patient / Relative (name relationship) • Introduce everyone in the room / phonecall

When parents and doctors disagree

§ Generally parents and doctors share the same primary concern: the child's welfare. § However, differing values and beliefs lead to differing assessments of welfare, harm and benefit. § Good communication and reflection is likely to improve trust and mutual understanding making it easier to reach a compromise.

Ways of reducing stress in situations where there is no or little shared common language (Mares et al, 1985)

§ Get the patient's name right § Try to pronounce the patient's name correctly § Allow more time than you would for an English-speaking patient § Give plenty of verbal reassurance § Try to communicate some information about what's going to happen next, even at a very simple level § Keep fuller case notes (this avoids subjecting the patient to repeated unnecessary or complicated questioning) § Try to ensure that the patient always sees the same staff as far as possible § Try to fnd out whether the patient has any specifc fears or worries § Write down any important points clearly and simply on a piece of paper for the patient to take away **Also: § Clearly state your intentions at the commencement of the interview § Try to identify the patient's presenting complaint as well as their, worries and concerns at the beginning of the interview § Work with your patient to prioritise these symptoms, worries and concerns § Check you understand what your patient is saying § Summarise § Invite your patient to ask questions or clarify anything you say

Consent - acting in patient's best interests

§ If a patient fails to meet one of the criteria for competence then it is not possible to obtain consent from the patient. § In this situation the health care practitioner is obliged to act in the patient's BEST INTERESTS. § NOBODY can consent on behalf of an adult who lacks mental capacity unless they have been granted specific legal authority by the Court of Protection to do so. **SUMMARY: § Valid consent must be competent, informed and voluntary. § No one can consent on behalf of a competent adult. § A competent adult has an absolute right to refuse medical treatment.

Outcomes of PCI (patient centred interviewing)

§ Improve diagnostic efficiency § Increase patient satisfaction § Increase concordance/adherence with treatments § Improve recovery § Reduce the number of symptoms o In primary care (Stewart, 2001) found that patient centred communication was correlated with the patient' perceptions of finding common ground. Also, positive perceptions were associated with better recovery from their discomfort and concern, better emotional health and fewer diagnostic tests and referrals. They conclude that patient centred communication positively influences patients' health. o Patients' experience of being a participating member in the discussion of the problem and the treatment process may translate in to the patients' reduced need for further investigation or referral - simultaneously reducing the physicians' need as well. o These findings counter a common misconception: that being patient centred means responding to every whim of the patient, thereby increasing expenses to the health care system (Stewart, 2001).

Evidence base for PCI

§ In a study of patient preferences, Little et al (2001a) found that patients in primary care clearly wanted a patient-centred approach, with the 3 key elements being communication, partnership and health promotion. Without a patient-centred approach, patients are less satisfied, less empowered, and may have greater symptom burden and higher rates of referral (Little et al, 2001b). § Abdel-Tawab & Roter (2002) looked at the usefulness and feasibility of clientcentred models cross-culturally. They found that a client-centred approach to the consultation was associated with a three-fold increase in the likelihood of client satisfaction and continuation of treatment at 7 months. § The PCI can be classified under six broad headings (Putnam & Lipkin, 1995) which are used to outline some of the evidence base that supports the importance of PCI across clinical contexts.

Burdensome treatment in paediatrics

§ In paediatrics, health professionals often have to make judgments on how burdensome a treatment is for their patients. One must ask: § Can the pain and distress caused by a treatment be worse than inevitable death if treatment is withheld? § Whether a treatment is 'too burdensome' is a question of value not fact: a) A quality of life that might be intolerable to an adult might be rewarding for a child with a disability. b) Conversely a treatment that might be acceptable to an adult might me intolerable for an infant or young child unable to understand what was happening. § In addition, adults are able to stop a treatment when it becomes too burdensome for them to continue. This is because: o Adults can value their lives present and future. o Adults can determine the significance to them of the discomfort or pain of treatment. o With very young children and babies, parents and doctors will bring their own perspectives in weighing up these values to make decisions.

James Rachel's case study (The difference between acts and omissions)

§ In some instances an omission resulting in death is arguably not always worse than act. § Two scenarios: 1) Smith will inherit a fortune if his 6 year old cousin dies. He is babysitting his cousin. One evening Smith sneaks into the bathroom where the child is having his bath and drowns the boy. Smith then arranges the evidence so that it looks like an accident. 2) Jones will inherit a fortune if his 6 year old cousin dies. He is babysitting his cousin. One evening Jones sneaks into the bathroom where the child is having his bath. As he enters the bathroom he sees the boy fall over, hit his head on the side of the bath, and slide face-down under the water. Jones is delighted; he doesn't rescue the child but stands by the bath, and watches as the child drowns. **Difference between act and omission can be defended in some circumstances, but in others where the outcome is identical then the distinction can be criticised as invalid as in this case. Although legally Smith could be convicted for the act of murder and Jones would not, morally some people argue they are both equally bad. Jones' omission, by not intervening to save his cousin, results in the same outcome. As his intention was for his cousin to die, the omission could be considered just as wrong as murder.

Public opinion - Case of Oregon State

§ In the state of Oregon, the general public were asked to rank a list of over 700 medical conditions in terms of priority for universal state provision. High priority --> universal state provision. § They voted highly for: o Treatment for thumb sucking. o Tooth capping. § And poorly for: o Ectopic pregnancy. o Cystic fibrosis. o Appendectomy. These outcomes were down to poorer public knowledge of these diseases and misunderstanding of the implication of their choices. **now policy makers have revised their questionnaire and provided more info --> more reasonable ranking but this still shows problem of relying solely on public opinion

Lulu is a 15 year old girl who is brought into A+E by R, her mother who found her semi-conscious in her bedroom with an empty bottle of vodka and four empty packets of paracetamol. Lulu is drowsy but rouseable and smells of alcohol. Dr A is the A+E ST1. Lulu refuses to answer any of Dr A's questions. Dr A explains that he needs to take a blood sample to check her paracetamol levels and to start treatment to protect her liver whilst they wait for the result of the blood test. When Dr A tries to site a cannula and take some blood, Lulu says 'just leave me alone' and then falls asleep again. What should Dr A do? § Lulu is 15 and therefore Gillick competent and therefore her refusal should be accepted. § Lulu is 15 and therefore presumed Gillick competent. Therefore Dr A must demonstrate that she is incompetent before he can proceed with treatment. § In this situation, it is in Lulu's best interests to have the blood test and begin treatment. Therefore Dr A should obtain R's consent and proceed with the blood test and treatment. § In this situation Dr A can only proceed with R's consent. § In this situation, it is in Lulu's best interests to have the blood test and begin treatment and therefore Dr A should proceed on the basis of best interests.

§ In this situation, it is in Lulu's best interests to have the blood test and begin treatment. Therefore Dr A should obtain R's consent and proceed with the blood test and treatment. *Given her alcohol intake and drowsiness it is probable that Lulu is not Gillick competent. At 15 she is presumed to lack competence and her behaviour in A+E has done nothing to suggest that she is mentally competent. The clinical information indicates that she has taken a substantial quantity of paracetamol together with a large amount of alcohol which will increase the risk of fulminant liver failure. Therefore the blood test and treatment with N-acetyl-cysteine are needed as a matter of urgency and would clearly be in her best interests. Her mother is present and therefore her consent should be obtained before proceeding. It would only be acceptable to proceed without consent on the basis of best interests if there was no one available with parental responsibility.

What is an example of intentional killing ?

§ Intentional killing as in the case of Euthanasia is murder in the eyes of the law § Aiding and abetting suicide is a criminal offence subject to a punishment of 14 years in prison § In the eyes of the law patients' requests or advance requests for treatment do not place an obligation on doctors to provide it, where it is not medically indicated or in the patient's best interests. § Treatment can be lawfully withdrawn if it is no longer in the best interests of a patient who lacks capacity. § Clinically assisted nutrition and hydration such as PEG or Nasogastric feeding are considered to be medical treatment, and therefore can sometimes be withdrawn, whereas oral feeding is considered to be basis care and CANNOT be withdrawn. § Once a competent person has withdrawn their consent it is unlawful to continue treatment even if treatment withdrawal would result in their death

Mental disability and justice

§ Justice requires equal treatment of equals. § What should be the status of those with mental disability? § What is the status of those with mental disability? **E.g. § Mr A is 25 year old with Down's syndrome and cardiomyopathy. He will die in 3 months without a heart transplant. § Mr Z is a 25 year old teacher with cardiomyopathy. He will die in 3 months without a heart transplant. § Both have a life expectancy of 10 years with a heart transplant. § A donor heart becomes available which is an excellent tissue match for both Mr A and Mr Z. Who should get this heart? **Overall, the lack of capacity, particularly in the case of mental disabilities, does not equate to lessened value of life. There is justice in healthcare. And autonomy and value of life.

F is a 63 year old retired librarian. She was diagnosed with Alzheimer's dementia 5 years ago. She remains independently mobile and lives at home with twice daily carers helping with her meals and housework. Her son L has Lasting Power of Attorney for medical and healthcare decisions. She is admitted into hospital unwell with abdominal pain and worsening confusion. Following a CT scan the on call surgical Specialist Registrar explains to L that F has acute appendicitis and needs surgery. F is unwell and does not know where she is or what the date is. It is clear that she is unable to understand what is being explained to her. L says that his mother seems very distressed and should just be made comfortable with analgesia. Although the surgeon explains that this is a very straightforward operation, L refuses to give consent. How should you advise the surgeon? § The surgeon should assess F's mental capacity. § L has Lasting Power of Attorney and therefore his decision must be respected. § L is not acting in F's best interest and therefore consent should be sought from another family member. § L only has legal authority as a decision maker if his decision is in F's best interests. § Patients with dementia have a poor prognosis and therefore surgery would not be F's best interests.

§ L only has legal authority as a decision maker if his decision is in F's best interests. § L has Lasting Power of Attorney for healthcare decisions and so has legal authority to act as the decision maker in this situation. However his decision is only legally binding if it is in F's best interests. His refusal of a relatively straightforward curative operation without which his mother is likely to die is unlikely to be in F's best interests.

Receiving feedback

§ Listen carefully § Ask for feedback to be repeated if you did not hear it clearly § Clarify feedback that is unclear or unsupported § Assume the feedback is constructive until proven otherwise § Use the elements of feedback that are helpful § Pause and think before responding (You might choose to say "I want to take that away and think about it". This may be an appropriate response) § Consider the value of defending/arguing (return to the purpose) § Ask for ways you might improve § Separate your feelings from the content of feedback

Material risk

§ Material risk - The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient's position would be likely to attach significance to the risk § The doctor is however reasonably entitled to withhold from the patient information as to a risk IF he reasonably considers that its disclosure would be DETRIMENTAL to the patient's health.....Also in circumstances of necessity, as for example where the patient requires treatment urgently but is unconscious. § But should always get patient if can so patient has autonomy and don't undermine them

Why do we value healthcare?

§ Most people think the health service is good use of taxes. § Is the purpose of healthcare to save a maximum number of lives? § Is the purpose to help us when we are ill?

What does managing a team involve?

§ Much of the work of a doctor is carried out in teams and doctors often are expected to take the lead in managing teams. These may be teams of other doctors (e.g. a clinical firm) or multi-professional teams (e.g. theatre staff). Managing a team involves ensuring that: § the task is achieved § individuals are developed § the team is built and maintained **Team members therefore perform a combination of functional roles, in which their abilities and skills are utilised, and team roles. Management research into the functioning of teams and team roles has identified that individuals perform in teams with different tendencies to behave, interrelate and interact with others. Understanding what your own team roles are (preferred and secondary) and what your weaknesses are can help to provide insight into how you fit into a team.

Non-verbal cues / communication sources

§ Non-verbal behaviours such as facial expressions, eye contact and body positioning and attention, paralanguage (tone, pace, volume, emphasis, pause), touch § A patient who is distracted may be irritated because you are not focusing on what they want to talk about etc. Again do not ignore these responses, but acknowledge them, "Are you in any discomfort now?" "Is there anything you'd like to discuss that I haven't covered yet?"

Why do we need to respect children's choices?

§ Older children and teenagers may be capable of autonomous decision making. § Even young children value being able to make decisions. § Children need to learn how to make decisions and understand their consequences if they are to flourish as autonomous adults. § Overriding a child's choice/decision risks promoting hostility and non-compliance.

Caldicott principles

§ One should justify the purpose of holding patient information. § Information on patients should only be held if absolutely necessary. § Use only the minimum of information that is required. § Information access should be on a strict need to know basis. § Everyone in the organisation should be aware of their responsibilities. § The organisation should understand and comply with the law.

Key factors that can describe resilience

§ Optimism § Freedom from anxiety- able to turn anxiety symptoms into identifiable concerns that can then be managed § Openness § Adaptability § Takes personal responsibility § Supported § Positive & active approach to problem solving **Limitations: if the 'system' is not resilient or failing, the skill can help one cope personally but the concept should not be used as 'a stick with which to beat us' in the NHS.

Contact list for advice about any matter of concern when on clinical attachments

§ Other members of your Hospital Firm e.g. the FY1/2, SpR ( Registrar), Consultant Firm Leader § The Teaching Fellow § The Director of Clinical Studies for your site, for example § Or, the Teaching Co-ordinator at your site § The Head of your Year e.g. omid § The Faculty Education Office (Medicine) § In General Practice (Year 3): your GP Teacher or the Practice Manager or the Departmental GP Team § Your Academic Tutor § Senior Tutor with responsibility for Year § Senior Tutor, Clinical § Student Union President or Welfare representatives

What is paternalism?

§ Overriding or undermining a patient's autonomy based on the healthcare professional's view of the patient's best interests: o Presenting only one side of the argument. o Withholding information. o Coercion. o Lying.

Medical complications of obesity

§ Overweight BMI 25-30 kg/m2 § Obese BMI >30 kg/m2 § In 2015, 58% of women and 68% of men were overweight or obese. § Obesity prevalence increased from 15% in 1993 to 27% in 2015.

Court of Protection

§ Part of the High Court § The court has powers to make declarations § To make decisions and appoint deputies and in relation to lasting powers of attorneys § The court would expect that parties would try to resolve any dispute before applying for a hearing

Coping strategies

§ Personal: A notion that I am proposing is that resilience may come from .... rediscovering the child in you-the positive, questioning, loving and trusting one. What are your views? § Another approach is to understand more about your own opinions about how you choose to live your life- for example, are you a stoic or an epicurean? What is your philosophy of life in the 21stcentury? The ancient Greeks described a stoic as a person who can endure pain or hardship without showing their feelings or complaining. An epicurean was a person devoted to sensual enjoyment, especially that derived from fine food and drink. Are you a person who is hopeful? Are you optimistic, believing 'that something good may happen' - as defined by the Oxford dictionary. ** Do you have: a balanced diet and regular exercise? participate in prayer / or practice mindfulnesshave a vision: 'if you don't know where you are going you'll end up someplace else' Yogi Berra

Self-Perception Inventory, based on Belbin's work

§ Plant : (PL.)Creative, imaginative, unorthodox. Solves difficult problems. Weak in communicating with and managing ordinary people § Resource Investigator (RI): Extrovert. enthusiastic. communicative. Explores opportunities. Develops contacts.Loses interest once initial enthusiasm has passed § Coordinator (CO): Mature. confident. and trusting. A good (CO) chairman. Clarifies goals. promotes decision-makingNot necessarily the most clever or creative member of the group. § Shaper (SH): Dynamic, outgoing. highly strung. Challenges. pressurises, finds ways round obstacles.Prone to provocation and short-lived bursts of temper § Monitor Evaluator (ME): Sober, strategic and discerning. Sees all options. Judges accurately.Lacks drive and ability to inspire others. § Team worker (M): Social, mild. perceptive and accommodating. Listens, builds, averts friction.Indecisive in critical situations. § Implementor (IM): Disciplined. reliable. conservative and effluent Turns ideas into practical actionsSomewhat inflexible. slow to respond to new possibilities. § Completer Finisher (CF): Painstaking. conscientious. anxious. Searches out errors and omissions. Delivers on time.Inclined to worry unduly Reluctant to delegate. § Specialist (SP): Single-minded. self-starting. dedicated. Provides knowledge or technical skills in rare supplyContributes on only a narrow front

Feedback is important for learning because it

§ Provides acknowledgement of trainees' acquisition of professional knowledge and appropriate attitudes § Provides guidelines for areas that need to be developed § Provides motivation to undertake that development § Provides insight into personal style § Can lead to improved clinical practice

How do we choose between diseases?

§ Quality-adjusted life years (QALYs). § Evidence based medicine. § Public opinion. § Personal choice.

Withdrawal of life sustaining treatment : futile treatment

§ Rather than make judgments about quality of life (how can we judge someone elses QofL), we could avoid this by reference to 'futile treatment?' § Where treatment is futile there is no moral obligation to provide it therefore it may be withdrawn. § Treatment is futile if: **Definition 1: o It FAILS to meet its own OBJECTIVE o An example would be where a further course of cancer chemotherapy is not expected to improve the patient's prognosis **Definition 2: o It is undesirable in a particular case due to the QUALITY OF LIFE which RESULTS following the treatment o An example would be cardiopulmonary resuscitation for a patient with a terminal prognosis who is suffering

Recognizing moral distress

§ Recognize the feeling that something is not right as a 'red flag' § Take a step back, examine the situation, and decide whether something different § Speak up at the time

How to enable patients to make autonomous choices:

§ Respecting autonomy means enabling patients to make autonomous choices: o Adequate information. o Clear explanation. o Time to consider options. o Not unduly pressurising. o Being non-judgemental. o Providing reasonable choices.

Summary of resource allocation module

§ Several ethical approaches have been suggested as to how to choose between people when allocating healthcare resources. § Such approaches can be problematic because they can be interpreted as implying that some lives are more valuable than others. § Other approaches have tried to choose between treating some conditions rather than others using economic and medical data to support decisions. Such data has weaknesses but, even if robust, the final decision is still a VALUE DECISION not a factual decision i.e. it is ok to leave certain conditions untreated. § As such, the views of the wider community are important but reliably canvassing public opinion and ensuring the rights of the vulnerable minority are heard is difficult. § Whatever the chosen approach(es) it is essential that the process of resource allocation is TRANSPARENT and ACCOUNTABLE if it is to be perceived as fair.

SBAR when communicating

§ Situation § Background § Assessment § Recommendation

Simplifying your english

§ Speak clearly but do not raise your voice § Speak slowly throughout (but not too slowly) § Repeat when you have not been understood § Use the words the patient is likely to know § Be careful of idioms § Simplify the form of each sentence § Don't speak pidgin English § Give instructions in a clear, logical sequence § Simplify the total structure of what you want to say in your mind before you begin § Stick to one topic at a time § Be careful when you use examples § Use pictures or clear mime to help get the meaning across § Judge how much people are likely to remember § Be aware of your language (both verbal and non-verbal) all the time

Communicating during a procedure : suturing

§ Starting point : Introduction - initial rapport - put the patient at ease § Listen to the patient (verbal cues) § Maintain interaction with the patient (build rapport) § Keep instructions and advice organised and logical § Be explicit with instructions § Look at the patient (non-verbal cues - expressions of pain etc) § Provide info on aftercare

Confidentiality Exception 3: Required by Statute

§ Statutes are laws that are passed in Parliaments. § Examples requiring a breach include. a) Notification of Death. b) Notification of Termination. c) Treatment of Drug addict with specified drugs. d) Notifiable Infectious Disease. **In these cases permission of the patient is not required, and the relevant authority must be informed.

What is stress?

§ Stress is the physical and mental response of the body to demands made on it. § The physical sensations of the stress response are just like those felt by an animal when faced by danger. § This is called the 'fight or flight response' because it increases energy ready for action, to either stand and fight, or run away. § We can feel the stress response not just when we're frightened or upset, but also when something exciting happens, such as falling in love or going on holiday. § Most of us can remember a churned-up stomach and not being able to sleep in those situations. § Stress can be positive, it can motivate us. Some people feel they work better under pressure, the adrenalin gets going when there is a deadline or a challenge. But for most of us, stress is usually negative particularly if we have too much of it. § Many present day reasons for stress are long-term situations, like racism, shortage of money, looking after children or elderly relatives, poor housing or working conditions, job insecurity. The body's stress response, which is most appropriate to sudden and short-lived dangers, becomes prolonged when stresses are long-term. § We may become permanently 'worked up' and in a constant state of tension. § We all need periods of relaxation and renewal in our lives, which are not always easy to make time for. § Constant stress can lead to physical or mental health problems. Becoming aware of stressful areas in our lives can be a first step in making changes that can reduce stress levels. At the same time, many of us may face stressful situations which it is hard to do much about. § Staying at home all day might avoid the bus queues and the traffic jams, but not your argumentative neighbours, or the hefty electricity bill. § When under stress we may seek a 'prop' to help us cope, for instance, alcohol, cigarettes, food, tranquilizers. There is a danger then of becoming dependent on this 'prop'.

Advice for stress/burnout

§ Talk to other people - it will strengthen your friendship with others and you might realise that they are going through the same things. § Take a break. Work on taking care of yourself and nursing yourself back to the best health so you can start with a healthy body and mindset. § Reevaluate priorities. Start to prioritise your sleep, eating, exercise and passions. § A form of reflective thinking to reframe your mindset: meditation, mindfulness, yoga. § Create realistic to-do lists for the day to accomplish a sense of achievement § Create study groups so you learn how to balance socialising with work and understand that you are working yourself too hard § Implement different study methods into your routine so that you don't feel like you are continuously doing the same thing.

Court appointed deputies

§ The Court of Protection may appoint a deputy to make decisions eg if significant decisions need to be made on a regular basis that would otherwise probably go to court § The deputy must act in the person's best interests § The Court defines the scope and duration on the deputies authority § A deputy cannot refuse life sustaining treatment

S, a 15 year old boy with leukaemia. Devout Jehovah's witness since the age 9. Accepted autologous bone marrow transplant but refused blood product support. § Assuming that S is of sufficient intelligence and understanding to understand the implications of his decision should his refusal be respected? § What is the legal position regarding refusal of treatment by minors aged under 16? § If S were 17 would the ethical and legal arguments for respecting his refusal be different?

§ The Court ruled that S should receive any blood products necessary for his survival following the autologous bone marrow transplant. § Following this S agreed to the blood products. § The bone marrow transplant was successful § However at the age of 19 S committed suicide, stating that he could not live with himself knowing that he accepted the blood products.

Consent for Children: Refusal of treatment

§ The Gillick case was about the availability of medical treatment to mature minors, who might otherwise not have access to such treatment. § The judgment was clothed in references to "best interests". § The logical next step would be to assume that a child can therefore refuse medical treatment if they meet the criteria of Gillick competence. § But this would rarely be in their best interests, and so therefore children CANNOT refuse medical treatment. §Furthermore as parental responsibility for the courts (as opposed to parents) ends at 18, it is theoretically possible to OVERRULE a refusal of a patient and ask the court for permission. § This court permission would be necessary if the child was 16 or 17, but if younger it is usually possible to obtain the permission of one of the parents, and hence proceed.

Problems with children's choices

§ The ability to understand information increases with age. § The ability to appreciate the impact of current decisions on the future increases with age. § The ability to decide independently of parental and social influence increases with age. § Values, aspirations, priorities and beliefs (which are essential to autonomous decision making) change as child grows. § A child's views of his or her best interests changes with time. **Due to these factors, a child's values are unstable and therefore it is difficult for a child or teenager to make truly autonomous decisions. This can lead onto the CHILD PATERNALIST APPROACH: § Therefore adult decision makers should make decisions on behalf of children on the basis of best interests. § And it is ethically appropriate to override a child's autonomous decision if the decision is deemed not to be in that child's best interests. THE CHILD LIBERATIONST APPORACH: § Autonomous children have the same rights as autonomous adults. § Adults make bad decisions all the time. § The values, aspirations, priorities and beliefs of adults ALSO change over time. § Even as adults we often don't appreciate the implications of our decisions for our future lives.

Confidentiality Exception 5: Wider public interest

§ The balance between duty to patient and duty to society. § Maybe challenged. § Must justify action (or inaction).

Children and confidentiality

§ The decision to maintain or breach confidentiality is based on best interests § If the child is <16 and not Gillick competence the doctor can breach confidentiality if it is in the child's best interests (or with parental consent) § If the child is Gillick competent then he/she can give or refuse consent to disclosure. But confidentiality can still be lawfully breached if it is in the child's best interests

In the eyes of the law an individual becomes an adult on their 18th birthday. So once someone reaches 18, parents, doctors, the Courts have no legal power to protect individuals from 'bad decisions'. Do you think this is reasonable?

§ The development of physical, emotional and intellectual maturity continues (well) beyond 18. § The values and beliefs of adults continue to change over time. § If we truly value autonomy, we have to allow people to make their own decisions. § At a practical level there has to be legal cut-off. There is much more than the law to protect us from bad decisions.

Legal principles of withdrawing CANH

§ The doctors agreed with Tony's parents that his treatment was futile. This case went to the House of Lords to be debated. § The following legal principles were established in this case: o Clinically Assisted Nutrition and Hydration (CANH) is considered to be medical treatment. § In the case of PVS that person is still considered to be ALIVE in the eyes of the law. § Withdrawing treatment from a person who lacks capacity is permitted in certain circumstances even when it results in a person's death. § There is no duty to treat if treatment is NOT in someone's BEST INTEREST. § In the case of Bland treatment was considered to be FUTILE and therefore NOT in his best interests. § The doctors were not considered to have caused Tony Bland's death. By withdrawing treatment he is considered to have died from his UNDERLYING CONDITION. **So medically treatments can be legally withdrawn even if results in death - but needs to meet those conditions mentioned!

Paternal rights in pregnancy

§ The father has a biological and emotional stake in a pregnancy. § Does he have a right to demand a pregnancy continue? § Does he have a right to not be a father? Does he have a right to demand the woman have an abortion if he doesn't wish to be a father **Paternal vs maternal rights: § If the father had any rights over a pregnancy these would have to be exercised, through the mother's body, against her wishes. § We do not permit non-consensual bodily interventions in other situations even to save life e.g.Organ donation. Medical research. **Overall the legal status of the father: The legal status of the father § Once born the father has legal responsibilities (child maintenance). § The father has no legal rights during pregnancy. § No legal right to request or veto an abortion. § No legal right to be consulted or informed of an abortion. As this could introduce the risk of coercion for the woman.

The legal status of the fetus

§ The fetus is a recognised entity in law but has no right to life. § Once born it acquires full legal rights. § The fact that a woman is pregnant does not affect her legal rights in anyway. § She can engage in (lawful) behaviour that is harmful to the fetus. § She can refuse medical treatment including caesarean section even if it risks the life of the baby (as long as comptent)

Confidentiality Exception 4: Assisting the Police

§ The general principle remains the same. § Exceptions: a) Under a warrant from a circuit judge. b) To aid police request in identifying drivers suspected of offences. But this does not mean helping them with conviction, only in IDENTIFYING the patient. c) To aid police in all matters with suspected terrorist patient.

Confidentiality in patients who lack capacity

§ The implied promise to maintain confidentiality operates for ALL patients. § However, with children and adults lacking capacity the doctor has an overriding duty to act in their best interests. § Therefore personal information can be disclosed when it is in the best interests of someone lacking autonomy. § But it will usually be in the patient's best interests to only disclose to those involved in the patients care.

General principles of consent in children

§ The law allows increasing autonomy to a minor with increasing age, maturity and understanding. § Minors over the age of 16 can accept treatment but cannot refuse life threatening treatment. Thus their refusal can be overridden by a court in order to prevent serious harm. In contrast to 18 year olds. § Those with parental responsibility can consent to treatment of a minor, but they must not allow the minor to come to any serious harm, and must be seen to be acting in their best interests. § Thus, doctors and those with parental responsibility are legally obliged to act in the minor's best interests.

Advanced decisions and LPA

§ The principle is that a competent person has the right to decline to undergo treatment, even if the result of his doing so is that he will die. § This takes into account the State's interest in preserving life and preventing suicide. Advanced Decisions § Take precedence over a LPA unless the LPA was made later. § Take precedence over consent by a Court appointed deputy § Best interests does not apply § ONLY exception is treatment under the Mental Health Act ie cannot make and advance decision to refuse treatment under the Mental Health Act.

What is the starting point with capacity in adults (Mental capacity act (MCA))

§ The starting point is to presume that everyone has capacity unless it can be established otherwise § A person's capacity must be assessed in relation to the particular/specific/actual decision to be made. § All possible steps must be made to help the person make a decision for themselves § A person's capacity must not be judged simply on the basis of their age , appearance, condition or an aspect of their behaviour § There is a 2 step process to follow: 1) First, establish whether the person have an impairment of the mind or brain. 2) If an impairment of the mind or brain is established then assess the person's capacity to make a decision. a) Can the person understand information about the decision to be made b) Can the person retain the information in their mind c) Can the person balance that information as part of the decision making process d) Can the person communicate their decision

Felicity is a diligent final year medical student who has examined a patient with end stage breast cancer. The patient has come to A&E short of breath and clinically there is a pleural effusion. Felicity tells the patient that the team plan to tap this effusion with a small needle - a very safe procedure in order to try and get some of the fluid out and therefore make the breathing easier. The patient refuses the treatment - he says that he has had this treatment before and knows all about it. He just wants to die. Felicity believes that life is sacred and that by just doing this short procedure he will receive much benefit. She therefore tells the consultant that the patient is happy to have the tap.

§ There is a danger that if the medical team rely on Felicity's word, a criminal and a civil offence would be committed if the tap went ahead. § It is the responsibility of the person doing a procedure to ensure that there is adequate consent. § Felicity has lied to her medical team and thus broken the trust of her colleagues.

Anonymised information and confidentiality

§ There is no obligation of confidence when information is in a form that is not capable of identifying the patient. § BUT where a patient can be identified because the symptoms are rare or where the patient is part of a small community, then an obligation on confidence is owed despite anonymisation of patient information. **so anonymisation is not completely protective if not used correctly.

You are in a lecture theatre with 300 other students and a few of your tutors. The lecturer's laptop suddenly bursts into flames which rapidly engulf the lecture theatre. The 1920s lecture theatre has only 1 exit and this is blocked by the fire. The only route out is a window at the rear of the lecture theatre. But... Only 50 people can be saved from the lecture theatre... How do you choose who to save? Age/ Social worth./ Personal responsibility./ First come, first served./ Lottery.

§ These first three options have arguments for and against. and this is because they all carry implication that some lives are more valuable than others and this implication is unsatisfactory as the right to life is a fundamental right. and if we believe everyone is equal everyone has equal right to life and an equal right to be saved.

The Children Act 1989

§ This Act of Parliament was a landmark piece of legislation. It consolidated much of the previous legislation regarding children in England and Wales. § The Act set out the obligations that local authorities have for children. § A smaller part of the Act deals with children who are living with their parents, as opposed to living under the care of the local authority. § As with many modern Acts, the first section outlines several principles that apply throughout the Act.

Do parents have a duty to maximize their child's chance of reaching autonomous adulthood? Should a parent's religious views be permitted to influence decision making?

§ This case requires you to think about what should be done when doctors and parents disagree about what is best for a child. § In day to day life we generally leave parents to make decisions on behalf of their children. Is this because we think that ethically parents have a right to decide how their children live (ie we believe parental autonomy should be respected) or because we think that parents are in the best position to act in their child's best interests? § The parental rights position argues that if we believe individual autonomy should be respected, then one aspect of this is shaping the beliefs and values of our children. We should therefore not interfere with the decisions of parents, perhaps with the caveat, that we are confident that parents are motivated by the welfare of their children. § Certainly we usually think it is a good thing that parents instil values and aspirations into their children. But how should we respond to a mother who believes that circumcision is the right thing for her daughter or a Jehovah's Witness who believes it is better for their child to die than receive a blood transfusion? Most people would not think it ethically acceptable for a parent to make decisions that they viewed as clearly not in the child's best interests. This leads to a position where we might say we should not interfere with the decisions of parents UNLESS the decision is clearly not in the child's best interests. § Parents are usually best placed to know what is best for their child but, as discussed above, they may also have to think of the effects of their decision on their other children or themselves. § Arguably, the best interests of a child are intimately linked with the best interests of the rest of the family including the parents. Thus trying to work out what actually constitutes best interests is far from easy. Perhaps then, we need to modify our position and say we should not interfere with the decisions of parents unless the decision is clearly and unacceptably harmful to their child and provided the parents are motivated by welfare of their child. If you agree with this position, then in the case of Enya you need to consider whether you think her mother's position is clearly and unacceptably harmful to Enya.

Iceberg Model of Culture

§ This identifes how some cultural influences may be readily apparent whilst other major influences are hidden and may not be recognised by the health-care professional. § The model suggests that some characteristics are above sea level - age, gender, ethnicity, nationality while others are below sea level - socioeconomic status, occupation, health, previous health experiences, religion, education, social groupings, sexual orientation, political orientation, cultural beliefs, expectations and behaviours etc (Kai, 1999). Even with those characteristics that are above sea level it is difcult to tell which are predominant characteristics in a particular setting at a particular time. § Importance of cultural groupings: •Religion, ethnicity, nationality, family, age, gender, sexuality, education, political orientation, etc § Differences: •Between groups (students/non-students) •Within groups (students)

W is a 51 year old man with metastatic malignant melanoma. Six months ago when he was told that his melanoma had spread to his liver he drew up a witnessed and signed advance decision with his GP refusing life sustaining treatment should he suffer a permanent loss of mental capacity as a result of his cancer. His oncologist was given a copy of the advance decision but he did not discuss it with his wife, B, who he knew would disagree with his decision. W is now in hospital and has been unconscious for 6 days following a bleed into a large cerebral metastasis. The neurologist tells B, that W will not make any meaningful improvement. However, B says that she has lasting power of attorney, drawn up 3 years previously, and insists that the medical team start naso-gastric feeding. What should W's medical team do? § Nasogastric feeding must be commenced; under the Mental Capacity Act Advance decisions do not apply to the refusal of basic nutrition and hydration. § W has made a valid and applicable advance decision which therefore must be followed. § B has Lasting Power of Attorney and therefore her decision is legally binding. § Feeding must be commenced as without it W will die. § The medical team must make their decision based on W's best interests.

§ W has made a valid and applicable advance decision which therefore must be followed. Best interests do not apply if an individual has made an advance decision. NG feeding is considered artificial nutrition and therefore can be refused. The advance decision overrides the previous LPA.

Choosing between diseases using personal choice

§ We all have different health priorities. § Why not give individuals the money to invest in a personal health insurance plan of their choice? § They could choose a policy that focussed on illness at working age or one that provided for cosmetic surgery but not very expensive interventions such as ITU or dialysis. **But... § Our healthcare priorities and our perception of illness often change with time. § Would the inevitable differences in healthcare access be socially acceptable? § What if the type of policy chosen was largely socially determined?

Applying Acts and Omissions to medicine

§ We are not permitted to perform acts that intentionally result in death. However, there are some omissions that we are morally responsible for. § where retracted consent or not in patients best interests- can withhold treatment and is said to be morally permissable. **Examples: § Omission when there is no duty to treat - stopping dialysis will result in a person's eventual death and the patient has withdrawn their consent § Omission where there is a duty to treat - delating na appropriate treatment as a result of negligence e.g. forgetting to prescribe insulin for a patient

David is a very gifted and motivated medical student, who even in the fifth year knows that he wants to be the next Professor of Gynaecology. On his O&G attachment he is keen to see (and to be seen to see) many new patients in the multi-gravida clinic. He calls Mrs Satsuma and explains that he will see her before the consultant. Mrs Satsuma refuses, and says loudly that she "doesn't want to be a guinea pig". When no one is looking, David puts her notes to the bottom of the pile. You are the other medical student with David in clinic that day. You see him put Mrs Satsuma's notes to the bottom of the pile. What would you do?

§ We can sympathise with David - keen and motivated, and then feeling humiliated that the patient won't see him. § However, he should overcome these feelings and not adversely affect the care that she receives. § He has contravened one of the GMC principles as laidout in Good Medical Practice.

Preparation for giving feedback

§ What is the purpose of feedback in this situation? § Is your colleague ready for feedback? § Does your colleague want feedback? § What does your colleague want feedback on? § What does your colleague think s/he has done well? § What does your colleague think s/he needs to improve? § What do you want to say? § How do you want to say it?

Summary for children's consent

§ When making decisions involving children, the welfare of the child is paramount § Treatment of children should proceed on the basis of consent wherever possible. § However, in an emergency where consent cannot be obtained, treatment can be given if it is in the child's best interests § A minor under 16 is presumed incompetent but may be Gillick competent. A minor over 16 is presumed competent. § A Gillick competent child can give consent to treatment, however a Gillick competent refusal can be overridden if the treatment is in the child's best interests

1) 14 month old boy with biliary atresia. Will die within 1-2 years without a liver transplant. Parents do not want T to have a transplant. Doctors place T on the transplant list. Parents move abroad and refuse to come back for transplant. *Should the doctors have put baby T on the transplant list against his parents wishes?* 2) Doctors took to court. Parents thought long and hard about it. Baby T had had surgery when a few weeks old. This had been unsuccessful and had resulted in considerable pain and distress for T. Parents did not want T to go through another major operation which would cause pain and distress with no guarantee of success.

§ Who should have the final say when doctors and parents disagree? o Generally, it is parents that make choices on behalf of their children. But Do parents have a right to decide what should be done to their child? OR Do parents have a responsibility to do what is best for their child? **The best interests argument: § Parents usually know their children better than anyone else. § Generally no one will love a child in the same way as a parent. § The welfare of the family will usually be highly relevant to the welfare of the child. § Therefore, parents are generally best placed to decide what is in their child's best interests. BUT § Parents may be so emotionally involved that they can not objectively weigh up the benefits and burdens of treatment. § The personal views or beliefs of parents may lead them to consider effective treatments as unacceptable. § There may be a clear conflict between what is best for the child and what is best for the other children in the family. **The Parental Rights Argument: § Individuals have a right to their own personal values and beliefs. § Therefore, we should respect the personal views and values of others. § It is desirable for parents to share their values and belief system with their children. § Therefore, we should not interfere with the decisions of parents provided they are motivated by the welfare of their child/children. BUT § Individuals do not have a right to impose their own personal values and beliefs on others. § Parents have a duty to enable their children to reach autonomous adulthood. § Therefore, parents should not be able to martyr their children to their values and belief system. 2) Baby T's parents thought that inevitable death was better than the pain and distress of a liver transplant even if this was the only prospect of long term survival.

Medical treatments that should go before the Court of Protection for a determination of best interests

§ Withholding or withdrawal of artificial nutrition from patients with persistent vegetative states § Organ donation or bone marrow transplants § Sterilisation for non therapeutic purposes, e.g. contraception § Some termination of pregnancy § Major decisions where there is doubt or dispute about best interests

B is a 51 year old machinist in a factory. In an unusual accident she has suffered severe crush injuries to both hands. The orthopaedic surgeon explains to B and her husband that she will require amputation of both hands with a view to further surgery to enable prostheses to be fitted. B asks what the operation will involve and whether some sort of artificial hand would be possible at a later stage. After a lengthy discussion with the surgeon and her husband, B agrees to the surgery. However she is unable to sign the consent form. Can the surgeon proceed on the basis of valid consent? § No, but surgery can proceed provided it is in her best interests. § Yes, provided a second healthcare professional witnesses the decision. § Yes, provided her decision is informed and voluntary. § No, but surgery can proceed if her husband signs the consent form. § No, consent for major procedures must be in writing and witnessed.

§ Yes, provided her decision is informed and voluntary. ** A signature is evidence but not proof of consent. Legally valid consent is the process of obtaining non-coerced permission from an informed, competent individual. Thus oral or written express consent is legally valid provided it meets these criteria. In this situation, where there is a major procedure being proposed, it would be wise (but not legally required) to have the oral consent process witnessed and signed for by a second individual as further evidence that valid consent was obtained.

Suicide act 1961

§ a person who aids, abets, counsels (advises) or procures the suicide of another, or an attempt by another to commit suicide shall be liable on conviction or indictment to imprisonment for a term not exceeding 14 years. § suicide was decriminalised in 1961

Johari Window Model

§ a tool which helps us to understand how we see ourselves, compared to how others see us. § model of self-disclosure that summarizes how self-awareness is influenced by self-disclosure and information about yourself from others § The Johari Window is a communication model that can be used to improve understanding between individuals within a team or in a group setting. Based on disclosure, self-disclosure and feedback, the Johari Window can also be used to improve a group's relationship with other groups. § Developed by Joseph Luft and Harry Ingham (the word "Johari" comes from Joseph Luft and Harry Ingham), there are two key ideas behind the tool: 1) That individuals can build trust with others by disclosing information about themselves. 2) That they can learn about themselves and come to terms with personal issues with the help of feedback from others.

What is in a social history?

§ alcohol § smoking § recreational drugs § diet § sexual history § occupation - Do you work? Are you in paid employment? § living situation - Is there anyone at home with you? § travel - Have you travelled outside the UK recently? § exercise - How physically active are you? § wider relationships - Who else is there that supports you? § stress - Is there much stress in your life at the moment?

Reflecting on communication

§ amending knowledge and understanding that we already possess § Experts often reflect-in-practice and adjust their behaviour or identify gaps in their knowledge very quickly. **reflection on experience: my thoughts, professional/disciplinary thoughts/ other people's thoughts § Reflective practice has been described as the "essence of professionalism" and so has obvious relevance to medical practice (Schon 1983)

73 y/o widow admitted following LHS stroke. Has no immediate family. Although she had multi-infact dementia, previously she was just about managing in her own home with carers three times a day. Since her stroke has made very little progress with rehabilitation. The PT and OT think she needs to go care home. Doctors disagree. What to do?

§ an independent mental capacity advocate MUST be involved. To investigate her PMx and take that into account. **two cases where must involve IMCA: § no family and where dealing with where someone goes to live. So even if doctors and PT and OT agree, still need IMCA, Cannot decide where someone lives without IMCA if they have no family. § when serious medical conditions **Stroke patient with no family. Little progress with rehab and PT's think she needs nursing home. Doctors think increase rehab. She doesn't have mental capacity - IMCA must be involved from the start. Someone to reflect patient's best interest. IMCA is friend when you don't have a friend.

Deprivation of liberty safeguards

§ as of 2020 has extended to people LIVING at home

Suturing procedure and communicating during procedure

§ assess wound size § local anaesthetic (e.g. lidocaine) § check patient has no allergies § use syringe to draw up local anaesthetic and needle to administer the local anaesthetic § keep everything in the sterile field except local anaesthetic as drawing that up § administer local anaesthetic near apex of wound, parallel to the wound, draw back and administer the LA as draw back the needle § give few mins for LA to work § use needle driver (in right hand), forceps § hold needle with needle driver at 2/3 distance from end at 90 degrees. § pull skin using toothed forceps. insert needle at 90 degrees to skin (out --> in, in --> out). draw suture through, leave about 3cm on the other side. do 2 loops around needle driver and pull instrument towards you and non-dominant hand away, then do this again but in opp direction and then a single loop. align know to one side of the wound. can then cut the suture at 5mm from the knot. § then safely disgard of sharps § then appropriate wound dressing and make sure wound is clean and dry.

Presenting most important info first?

§ can be counter productive, your view of what's most important may not match the patients § need to deliver info so that it can be recalled, understood and aligns with patient's concerns and information needs § this forms basis of informed consent which is necessary for informed decision making

GMC view on confidentiality

§ confidences must be respected § consent by patient is the primary exception to the principle of keeping confidential information secrete § but for public interest, disclosure advised. § patients should be told at the outset how information about them is used.

The ethical duty to maintain confidences can be defended on what grounds?

§ consequentialist, autonomy and duty grounds. § The different approaches can produce different answers. You need to decide which one is the most compelling. § As a doctor your legal and professional duty is to maintain confidentiality. The only exceptions to this are consent, where required by law, and in the public interest.

When uncertainty regarding mental capacity what to do?

§ continue life sustaining treatment (least restrictive) § court

Why is is important to define the precise moment of death?

§ enormous emotional, psychological and social significance

Non-verbal communication example

§ eye contact, body posture, gestures, facial expressions, touch etc. § Is continuous - it goes on for as long as the communicators are in each other's presence. Is the main channel for conveying attitudes, emotions and affect. Needs to be congruent - If there is discordance between the verbal and the non-verbal messages, the non-verbal communication will be more powerful and more likely to be believed. Can assist in demonstrating attentiveness to the patient and facilitate the formation of a helping relationship. Ineffective attending behaviour closes of the interaction and prohibits relationship building.

Possible criteria for death (ethically)

§ having a clear point at which we can say someone is no longer alive is essential. It is only at this point that we are permitted to harvest vital organs for transplantation. 1) Permanent loss of conscious awareness: This is more closely aligned to the morally important aspects of life - having a life that the individual can experience and value. 2) End of breathing and heart beat - Prior to the 1960s this was the accepted definition. With the advent of circulatory and ventilatory support however it became apparent that this was an inadequate definition, given that the heart and lungs could be kept artifically functiuoning beyond the stage where all brain activity has ceased. 3) Permanent loss of brain stem function: The brain stem plays a crucial role in integrating bodily functions. Once the brain stem can no longer function spontaneous breathing is impossible, and any residual cerebral activity is thought not to be compatible with consciousness. Even with ventilatory support organ necrosis will follow 4) Cessation of all cellular functions and processes: The body will have to have putrefied for this to have occurred. Such a definition would preclude organ harvesting. 5) Death as a process - This definition would allow for different things to be carried out at different stages - e.g organ retrieval or burial may require different end points 6) Desoulement- Some religions propose that death occurs when the soul leaves the body

Autonomy vs moral conscience

§ if have to respect patient's wishes to switch off her ventilator § if you were ITU doctor looking after Ms B for over a year, could you have sedated her and switched off her ventilator? o What if a doctor feels morally compelled to act paternalistically? o Having a personal sense of 'right' and 'wrong' is important. o Is it reasonable to require a doctor to go against his/her own moral instinct? Perhaps... o Perhaps, sometimes our sense of moral right and wrong is misguided. o Better communication may improve mutual understanding so that doctor and patient understand each other's perspective better. o This may also help the doctor accept the patient's decision.

Patient asks you about sending letter to Dignitas saying you support?

§ if patient asks about you sending a letter to Dignitas § so doctor should say is unable to discuss about this. Can provide patient with their medical records as this is their right, but not send to dignitas. **failure to stop someone from committing suicide and you could have --> medical negligence / manslaughter

Overall exceptions to consent

§ implied consent when in hospital § express consent § statutory requirement § assisting the police § wider public interest

Coco is a 6 year old girl who has been brought into hospital by her mother, L, following a fall on her bicycle. Coco is clammy and hypotensive with a tender abdomen. An urgent CT scan has confirmed that she has ruptured her spleen. Ms T is the on call paediatric surgeon and explains to L that Coco will need an urgent splenectomy and needs an immediate blood transfusion. L agrees to the splenectomy but says that their family are all Jehovah's Witnesses and that she cannot agree to Coco having a blood transfusion. Ms T explains that Coco has lost a significant amount of blood and her life is at risk without a blood transfusion. However, L maintains that a blood transfusion is unacceptable. What should Ms T do? § L's refusal is irrational and therefore Ms T can proceed without consent. § L has parental responsibility and therefore has an absolute right to refuse the treatment proposed. § This is a major procedure and therefore can only proceed with parental consent. Therefore Ms T should try to contact Coco's father to see if he can be persuaded to give consent. § in this situation, Ms I should proceed with the blood transfusion as it is in Coco's best interests. § In this situation, Ms T should speak to Coco alone and determine if she is Gillick competent.

§ in this situation, Ms I should proceed with the blood transfusion as it is in Coco's best interests. **Coco is 6 and severely unwell and will not be Gillick competent. The doctor has a legal duty to act in Coco's best interests. She may die without an immediate blood transfusion and therefore Ms T must override the refusal of Coco's mother and proceed on the basis of best interests. The Courts in England and Wales have made it clear that they will not allow parents to martyr their children on the basis of the parents' religious or cultural beliefs. The fact that a parent's refusal is irrational is not alone sufficient legal justification for overriding parental refusal. Overriding parental refusal will only be justified when it is in the child's best interests.

Example case for deprivation of liberty

§ is still deprivation of liberty as even though he does not have capacity § not letting him live a full life and putting restrictions on his life

How patient safety can be put at risk (human error)

§ is the framework for analysing risk and safety in clinical medicine, the LONDON PROTOCOL, Contributory Factors underlying an Adverse Event caused by Human Error. § The framework is derived from work by James Reason, Professor of Psychology at Manchester who published analyses of how error occurs based on work for the Aviation & Nuclear Medicine industries. 1. Third party characteristics - the patient communication problems: language, aphasia, edentulous, different expectations illness: confusion, pain, depression disability (e.g. deaf) inadequate self-care personality angry, sad, distrusting, obsessional unknown feature (e.g. thin skull) 2. Task -related: New, untested or difficult task Inadequate instructions Poor design 3. Individual factors (self): § Stretching beyond expertise § Lack of knowledge or skill e.g. poor interviewer § Attitude/ motivation § Tired/ under pressure § Problem with attitude/ motivation 4. Team factors § Poor teamwork § Inadequate supervision § Poor communication § Poor team morale 5. Environmental /situational factors § Defective equipment § Inadequate support services § Inadequate staffing § Out of usual environment § Distraction e.g. noise, relatives 6. Organisation/management/strategic § Inadequate leadership § Poor co-ordination of services § Poor management 7. Institutional: organisation itself is affected by the institutional context, including financial constraints external regulatory body the broader economic and political climate

Why is resource allocation important?

§ limited healthcare resources § simply digging deeper is not a long-term solution § For some interventions there is an absolute scarcity of resources e.g. organ transplants (demand> supply). § resources channelled into healthcare divert resources from other areas such as education or law enforcement.

Is there a moral distinction between withdrawing treatment or actively ending a patient's life if both will result in the patient's death?

§ morally different - in the case of treatment withdrawal it can be argued that the cause of the patient's death is the underlying medical condition, and that the doctor withdrawing treatment is not intending the patient's death - something that cannot be argued in the case of a lethal injection. In the case of withdrawal the patient is being returned to a situation that would have arisen had treatment not been given. There are of course counter-arguments to this position. § morally equivalent: This could be argued on the basis of both the act and the omission resulting in the same outcome. However in the case of treatment withdrawal it can be argued that the cause of the patient's death is the underlying medical condition, and that the doctor withdrawing treatment is not intending the patient's death - something that cannot be argued in the case of a lethal injection. In the case of withdrawal the patient is being returned to a situation that would have arisen had treatment not been given. There are of course counter-arguments to this position.

C is a 45 y/o man HIV positive in 1991. C stopped attending HIV clinic in 1993 and has not been on any treatment. He recently had a brain MRI which showed SOL which neurologists think may be related to his untreated HIV. Two days later C presents to A+E unconscious having had bleed from lesion. He requires ventilation. His partner accompanies him with a witnessed, signed Advance decision dated 23 april 1992. C has written this with his specialist specifically in relation to his concern about the complications of HIV infection such as tumours and HIV dementia. This stated that he declines all medical treatment if he loses mental capacity as a result of a serious intracerebral event or disease. What should the A&E doctor do?

§ option e- this is not an applicable advance decision and therefore C should be treated according to best interests. § because of this long amount of time and the change in treatment options from 30 years ago this is not applicable. Not option B as is unlikely to regain capacity. **-AD not valid as referring to complications and also AD taken very long ago (over 20 years). When decision between keeping man alive or letting him die and there is reasonable doubt, keep him alive.

Shared understanding and informed consent

§ patients levels of understanding are influenced by the extent to which doctors integrate the patient's ideas and concerns in the info delivery (Tuckett et all 1985) § highly effective in establishing patient understanding --> shared decision making § incorporating the patients ideas and concerns early on --> positively influence their evaluation of the info and can tailor info § failure could negatively impact on compliance and adherence and influence decision making --> may affect mutual decision making and partnership **overall: 1. We're trying to provide tailored information that is specific to patient needs (rather than 'all the info') and 2. Weave in their ICE when we deliver it?

What are the key issues in communication? Patient recall?

§ patients recall is generally v low (age is not a factor) § more info --> less likely to recall § providing all the info is least effective - avoid info overload. need to make sure address patient's specific info needs § a relationship between amount of info and level of recall § shared understanding --> shared decision-making § key objective is providing right amount of info for particular patient and their information needs

Ethical and legal basis for confidentiality

§ patients tell more if it remains a secret. § The client's right to privacy is guarded by this principle. Confidentiality assures the clients feelings, attitudes and statements expressed during intervention will not be misused. § there is no statute of confidentiality tho - it is a principle and has exceptions

Persistent Vegetative State (PVS)

§ periods of wakeful eye opening § but NO evidence of awareness § swallowing reflex may be preserved § record to survive is 37 years § cerebral cortex loses function + activity § patients retain brain stem function § able to breathe unassisted § normal sleep-wake cycles

one of the most positive and one of the most negative aspects of working in a multi-professional team.

§ positive - hear other people's ideas and utilise different skill sets § negative - conflicting ideas and difficult to get your point heard

Framework for giving information

§ prepare § intro § explore - what they know, info needs § deliver info § explore - patient understanding and thoughts § summarise

Describe two barriers to accessing healthcare might exist for an homeless patient with schizophrenia?

§ registering with a GP § unable to help themselves or self-refer

Tips when delivering info

§ relate to patient's perspective § clear and simple § explain new words, jargon § listen + respond to cutes § repeat key info § consider visual aids § summarise check understanding again

Characteristics of PVS (persistent vegetative state)

§ respiration - individual retains the ability to breathe unaided § waking/sleeping - periods of wakeful eye opening and sleeping which can occur cyclically § swallowing - swallowing reflex may be preserved allowing oral feeding. Patients in PVS would however normally be fed through a NG or PEG tube to reduce the risk of aspiration § Consciousness - thought to lack any awareness of their condition or their surroundings § Survival - with good clinical and nursing care an individual can survive for many years.

GDPR - Individual rights

§ right to erasure only if info no longer necessary or patient no longer consents to them using your info. BUT cannot just erase existence e.g. cannot make you destroy hospital notes as that's hospital property too.

Defining best interests - John Eekelar

§ should think about their basic interests, developmental interests and autonomy interests. **but what happens when these classes conflict with each other : § Basic, developmental and autonomy interests are the interests necessary to ensure current well being and development into an autonomous adult. § Respecting autonomous choices will usually be crucial to this development. § But if the choice will result in death or serious harm then the basic and developmental interests take precedence because they are necessary to reaching adulthood. **THUS eekelar proposed: § Best Interests versus Autonomy § Eekelaar proposed that the duty of society, parents and carers is to enable children to develop into autonomous adults. § As a child matures increasing weight should be given to their autonomous choices. § Balance respect for autonomy with need to protect child from 'bad decisions' to ensure that they reach autonomous adulthood. § Overriding autonomy may be consistent with acting in a child's overall best interests.

Ways to manage moral distress

§ speak up: recognise and name moral distress and insist on dialogue with other parties in the situation § be deliberate in decisions and accountable for actions § build support networks to empower colleagues and speak with one authoritative voice § use mentoring and institutional resources to address moral distress § actively participate in educational activities and discussions regarding the impact of moral distress

Aysha king

§ the five-year-old whose parents removed him from Southampton General Hospital because they wanted a different treatment for their son. he was being treated for a brain tumour, by his parents. At the time he could not swallow and had to be fed through his nose. The Kings took the decision to take Ashya to Prague to seek proton therapy. His doctors had recommended a course of radiotherapy and chemotherapy. But the Kings were concerned that was a danger to their son and wanted to try a different treatment abroad. The NHS trust involved had agreed to help with this, but the Kings would have to pay for it privately. After Ashya had left the UK and gone to Prague, in an unprecedented move, the NHS agreed to pay for his proton therapy, against the advice of its own independent experts. The clinicians at Southampton say that decision has left doctors across the country in a difficult position. **Parental autonomy: § parents are given a high degree of autonomy in relation to decision making for minor children -is consolidated under English Law in the Childrens' Act of 1989. § as given responsibility for making decisions that are in their childrens' best interests by virtue of their relationship with the child (will know childs best interests than any of us) § BUT lack of objectivness § parental autonomy may be restricted where parents appear to make decisions which appear not to be in the child's best interests - Overriding parents' wishes in this situation can be justified by reference to the 'harm principle' on the grounds that the parents' decision is likely to lead to an increased risk of serious harm. § This model of parental autonomy could be seen as 'constrained parental autonomy', where parents have a presumptive right to non-interference with their decisions, unless these decision fail to provide for the child's basic needs (Ross 1998). **Child's best interests: § On the one hand all the evidence points to the efficacy of the clinicians' proposed treatment plan, particularly in terms of long term survival, and on the other they are faced with seemingly caring parents who take a different view based on their own belief in a treatment plan (proton beam therapy without chemotherapy) with less evidence base, and potential for a lower chance of long term survival, but with fewer side effects. § may be different viewpoints because of a different value system (sanctity of life vs quality of life) § what if parents appear to have formed an opinion based on misinformation - may have underestimated the lower chance of survival in refusing chemotherapy for Ashya § The difficulty with using a best interests approach is that the child's best interests may depend very much on the underlying values that are being applied by the decision maker. § parents may have other competing considerations such as the welfare of other siblings, which might be quite legitimately taken into account § Rather than overriding parental decisions if they fail to meet a best interests standard, it has been proposed that the threshold for the state intervening should be one where parents make a decision that 'no reasonable parent would make under the same circumstances' (Pope 2011). Another standard that has been suggested is that parents may exercise choice within a 'range of medically reasonable alternatives' (McCullough 2010) - In the case of Ashya the question arises as to whether the parents' preferred treatment plan falls within this range. **NHS and society: § raised issues of equity/ fairness in provision § Following the media attention however the NHS made a decision to fund the treatment abroad. § the message that would send to other families with recently diagnosed medulloblastomas § now have to try to explain to families why one child is getting a form of treatment when they can't when they have the same kind of tumour and that is unfair. That is deeply unfair when the NHS is always supposed to be about equal health care for all **Ashya § 5 years old and therefore clearly too young to have meaningful involvement in the complex decisions that are being made § After the operation his cognitive state suffered further, and he was rendered unable to communicate § Generally however even young children will need to be involved in decisions with appropriate explanations given to gain their trust and cooperation § Even where it can be established that parents are making decisions that appear not to be in their best interests, there are serious repercussions that would result in overturning parental decisions. In enforcing a different treatment plan parents would still need to cooperate with attending appointments, supporting their child and complying with after care, all of which may be very challenging of they are fundamentally opposed to treatment. § The courts of course can decide to take the child into care, which could only be a very distressing experience at an already very difficult time in the child's life. In the case of Ashya King the parents were arrested and spent a brief time in custody while Ashya was admitted to a Spanish hospital without the presence and support of his parents. The psychological distress caused by separation of a child from his or her parents must weigh highly in any consideration of a child's welfare.

82 y/o been in hospital for 3 weeks following big stroke. Used to be fully independent. Now she is barely conscious and only responds to painful stimuli with little hope of improvement. Her NG tube feed has fallen out twice and her kids wants PEG inserted for long term care. Few months before she signed and witnessed saying she refuses all treatment if becomes dependent like this. Kids were unaware of this and insist on PEG. what to do?

§ this is a valid and applicable advance decision and therefore the PEG tube should not be inserted. **artificial feeding and hydration does not count as basic care

Overall principles of the Children

§ welfare of child is paramount § presumption of no order § The welfare principle in practice § parental responsibility § abuse of children

Children over 16 and confidentiality

§ • If the child is over 16 then he/she is presumed competent and disclosure should only be made with their consent. But confidentiality can still be lawfully breached if it is in the child's best interests up to the age of 18. § HOWEVER, it will generally not be in the best interests of a competent child to override their competent refusal

Doctor and advanced decisions liability

§A doctor would be liable if s/he provided treatment in the face of a valid and applicable advance decision. § If there are doubts over validity/applicability can treat in an emergency. § In a non-urgent situation can apply to the Court of Protection for a declaration. § A doctor would not be liable for providing treatment, unless he is satisfied that a valid and applicable advance decision exists § There is no legal duty to find out if an effective advance decision exists but the Act requires that health professional take reasonable steps to enquire if one exists (e.g. ask relatives/GP). Ultimately, the patient who made advanced decision should make sure it is accessible. § A doctor would not be liable for withholding treatment if he reasonably believed in good faith that a valid, applicable advance decision required this

Mental Capacity Act 2005

§The Mental Capacity Act 2005 provides a statutory framework to empower and protect vulnerable people who are not able to make their own decisions. It makes it clear who can take decisions, in which situations, and how they should go about this. It enables people to plan ahead for a time when they may lose capacity. § must be made in patients BEST INTEREST **The whole Act is underpinned by a set of five key principles stated at Section 1: 1) A presumption of capacity - every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless it is proved otherwise; 2) The right for individuals to be supported to make their own decisions - people must be given all appropriate help before anyone concludes that they cannot make their own decisions; 3) That individuals must retain the right to make what might be seen as eccentric or unwise decisions; 4) Best interests - anything done for or on behalf of people without capacity must be in their best interests; and 5) Least restrictive intervention - anything done for or on behalf of people without capacity should be the least restrictive of their basic rights and freedoms. **The Act deals with two situations where a designated decision-maker can act on behalf of someone who lacks capacity: 1) Lasting powers of attorney (LPAs) - The Act allows a person to appoint an attorney to act on their behalf if they should lose capacity in the future. This is like the current Enduring Power of Attorney (EPA), but the Act also allows people to let an attorney make health and welfare decisions. 2) Court appointed deputies - The Act provides for a system of court appointed deputies to replace the current system of receivership in the Court of Protection. Deputies will be able to take decisions on welfare, healthcare and financial matters as authorised by the Court but will NOT be able to refuse consent to life-sustaining treatment. They will only be appointed if the Court cannot make a one-off decision to resolve the issues.

You are doing a student placement in a hospice, and see Mr Davies, a 42 year old man with terminal cancer, on the ward round. The conversation mostly takes place between the patient's wife and the medical team, the patient remaining silent. His wife believes that further Oncology input is needed, to renew active treatment. Both the Palliative care team and previously hospital Oncology believe further intervention is unlikely to be beneficial. You later see Mr Davies on his own. He is very talkative, explaining that his wife cannot accept his condition, and that what he really wants is a few days with less medication, allowing him to think clearly and write the last chapter of his book. The next day you learn that the team has decided to involve Oncology again with a view to reconsidering active treatment. •How would you respond to this? •What are the advantages and disadvantages of this/ these responses •Make a judgement. What will you actually do?

• As a student: § Talk to the F1s /nurses/ someone i trust on the team and just tell them about my converstation with the patient § speak to patient again and see how he feels about the change in his care § Try to ensure that Mr Davies wishes are known and respected and that we have accurate information about what he wants **think about issues from: -patient(s), staff, self ** Some issues that this scenario raises •Communication (patient / wife / doctors / student) •Patient's wishes / consent •Goals of care •Realistic care •Student as 'healer' / responsibility of student •Moral distress?

Divisions of Law

• Common Law vs Statute Law ** Common Law • Based on tradition (local custom before 1066) • Heavy weight on judicial interpretation (cases) ** Statute Law • Laws passed in Parliaments • Effectively include executive powers by government agencies

How can we reduce barriers to communication?

•Check the communication the patient prefers •Always arrange interpreters for BSL users •Talk to the deaf person, not the interpreter •Environment •Lighting levels •Reduce background noise •Face the patient, avoid looking down or turning away •Context - signposting •Show, then tell. Be aware of divided attention. Use pictures, diagrams or gestures if necessary § Check understanding

Key principles of how to work with interpreters (Kai & Briddon, 1995)

•Check the interpreter and patient speak the same language and dialect •Allow time for pre-interview discussion with interpreter •Allow time for the interpreter to introduce themselves and check the patient is ok with the interpreter •Ask the interpreter to teach you how to pronounce the patient's name correctly •Always maintain eye contact with the patient and direct the questions to him or her •Use straight forward language •At the end check the patient's understanding with the interpreter •Have a post interview discussion with the interpreter

Importance of cultural awareness

•It is impossible to learn about all the different cultures you might encounter in medical practice. •Instead, we need to become culturally aware, and learn how to ask appropriate questions to obtain information on individual patient's culture. Cultural awareness means seeing a person as individual in their cultural context.

Mr D, a 42 year old Somalian, is admitted with pneumonia. Tests show that he also has diabetes. He does not speak any English. Inconsistencies in his story lead you to suspect that he is not a UK resident. Ethically should you inform your Trust's overseas administration officer that you suspect that this patient is not entitled to NHS care?

**use autonomy, consequence and duty approach 1) Consequence § yes - o Illegal immigrants have no entitlement to NHS treatment. o Illegal immigrants cause a drain on NHS resources. o This leaves less resources for those entitled to NHS care. o Reporting to the authorities may help reduce illegal immigrants using NHS resources § no: o It won't have any real impact on the financial state of the NHS. o If you tell the authorities then people who break the law will not seek medical help when they need it and will suffer as a result. o You may be wrong about the consequences - It won't have any real impact on illegal immigration or the NHS finances. o Permits doctors to breach confidentiality whenever - provided the patients don't find out! 2) Autonomy: §yes: Illegal immigrants using NHS resources cause serious harm to others therefore it is acceptable to override their autonomy. § no: o people without autonomy: o Infants and young children. o Adults with mental incapacity. o Dead patients. 3) Duty: § § no: o Your duty is to be a doctor not a policeman. o Ignores your duty to the patient: Your primary duty is to your patient not to the general public. o You have a duty to keep information confidential. § yes: o You are not permitted to disclose without permission. What about... - Serious crime. - Suspected child abuse. - Relatives of a dead patient. BUT the patient has a moral duty not to commit serious crime. If the patient commits a serious crime has he breached the terms of the promise

Fair Innings Argument

*Argument for: § People generally value their lives equally irrespective of age. § But at a certain age, say 70 years, one can be said to have had a fair share of life. § Any additional life over this 'fair innings' is a bonus and as such does not warrant public resources. **Argument against: o According to this argument we would never save or help those over 70 if there was anyone under 70 with unmet needs. o Who decides what would count as a fair innings? o Why is 70 years a fair innings but 69 years not? o According to the fair innings argument those over 70 would not be entitled to any form of nursing or basic medical care: A 30 year old with cancer and one month life expectancy would receive treatment rather than a 71 year old with appendicitis. o What if only scarce or expensive treatments were rationed on the basis of 'fair innings'? E.g. Organ transplants, ITU facilities. o Some healthy 70 year olds may have a life expectancy of 10-15 years or more. o Is it possible to have restricted ageism policy and not allow ageism to 'creep' in to other areas of healthcare. o Would even a restricted ageism policy inevitably lead to devaluing of the lives of older people?

Is paternalism ever justified?

1) 'Patients may become depressed if given bad news': § But empirical studies show most patients want to be told their diagnosis. § Many patients with a serious illness suspect their diagnosis before they are told. § Knowing the diagnosis and prognosis is important for making other important decisions. § Patients may not trust their doctor if they feel she/he is not being honest with them. § The way in which bad news is broken makes a big difference. **'Patients may put undue weight on potential risks and side effects'. § Risk and side effects are factual. § But the significance given to a specific risk or side effect is dependent on an individual's values. § What is an acceptable risk to you may be an unacceptable risk for me. § If patients seem excessively concerned about a possible side effect, perhaps the role of the doctor is to understand the patient's perspective and to ensure that patient has the correct information. **Does the doctor know best? § Doctors are often best placed to make decisions about best medical interests. § However best medical interests does not always equate with best overall interests. § Even spouses/close family members are often mistaken about each other's values and priorities.

The Six PCI Classifications

1) Allow patients to express their major concerns: **Korsch et al (1968) found that when doctors asked open-ended questions, patients reported greater satisfaction than the common practice of asking closed-ended question **Tuckett et al (1985) found that when patients who were able to get the doctor to listen to their ideas or concerns about the cause of the illness, those same patients were more likely to recall what the doctor told them and felt more committed to the doctor's view of the diagnosis and treatment. 2) Seek patients' specific requests: **Barry et al (2000) found that only 4 of 35 patients voiced all of their agendas in the consultation 3) Elicit patients' explanations of their illnesses 4) Facilitate patients' expressions of feelings 5) Give patients information: Van Zuuren et al (2006) - those who received brochure on gastroscopy felt less anxious and had greater satisfaction after 6) Involve patients in developing a treatment plan: increase compliance, clinical control of medication

Criteria for Gillick Competency

1) Ask the child if you can tell one or both of her parents.If she agrees then she can be treated like any other child - with her parent(s) permission.If she refuses then her confidentiality must be respected. 2) Assess how mature she is, in terms of the treatment: § Does she understand what is involved with the treatment and its complications? § If so she can be considered if: - 3) She is likely to suffer physical or mental harm without the treatment and it is in her bests interests to receive the treatment. **This has been extended to all forms of treatment for minors **Lower age limit: There is NO lower age limit to Gillick competence.... But clearly the younger the patient, the more the health care practitioner will have to justify how the assessment of maturity and best interests was made.

Why should doctors keep a patient's personal information confidential?

1) Consequentialist: Whether or not an action is morally acceptable is solely determined by its consequences. o Patients are generally happy to disclose personal information because they trust doctors to keep their information confidential. o It is essential that patients disclose personal information for doctors to treat them appropriately. o If doctors frequently breached confidentiality, patients would lose trust. As a consequence patients would be unwilling to disclose personal information. 2) Autonomy: Respecting autonomy should be seen as a fundamental principle in medical ethics. Therefore an action that does not respect autonomy is not morally acceptable whatever the outcome (unless there is a justifiable reason for limiting autonomy). Individuals consider it very important that they control who has access to their personal information. Therefore control over one's personal information is an expression of autonomy. Therefore respecting autonomy requires us to keep personal information confidential unless we are given permission to disclose However, it is permissible to override autonomy when there is serious and real harm to others. 3) Duty: § Certain actions are morally required and others are morally impermissible whatever the outcome i.e. we have certain moral duties. § When a doctor gains personal information about a patient there is an implied promise that this information will be kept confidential. § There is a moral duty not to break promises. § The duty is owed to ALL your patients. § Therefore it is wrong to breach confidentiality unless we are given permission to disclose.

Two characteristic components of the medical interview

1) Content elements ( substantive character of questions and responses, information being sought and delivered, discussion of treatment options, management plans etc.). Whilst these are relevant and important lines of inquiry, this still begs the question, HOW do you cover these topics in a way that will ensure you gathering information effectively and efficiently in a way that does not alienate the patient. This is where the process elements come in. (is PC, HPC, PMH, DH, FH, SH) 2) Process elements: the skills and techniques used which shape the process of the interview e.g. choice of question style (introducing yourself, establishing initial rapport, building rapport, expressing empathy, closing the interview) allow you to answer the HOW question. Content and Process CANNOT be viewed as mutually exclusive. §Uses open questions to encourage patient to talk and explore patient's perspective (may need to oscillate between open and closed) § Use transition statements/signposting, § Use of interim summaries § Summarise **The key is to ensuring effective integration of content and process is to pay close attention to the sequential organization of the interaction

Lauren is a medical student doing her clinical year rotation in neurology. She has never performed a lumbar puncture (LP), but a patient requires one for diagnosis. The SpR, Dr Adam, suggests that she attempt to perform one. Lauren is initially excited about this prospect, and Adam demonstrates to her the steps involved. When Dr Adam tells her, "It might cause some pain, but you have to make sure the patient is perfectly still," she begins to feel apprehensive. Lauren and Adam go to see the patient, Mrs. Jones, together. Dr Adam tells the patient that they will need to do an LP. The patient looks warily at Lauren and says, "Well, I don't want you practicing on me." Dr Adam responds, "Don't worry. You're in good hands." Lauren feels extremely conflicted. On the one hand, she feels as though she is practicing on the patient and could cause pain or a more serious consequence, since it is her first time ever performing the procedure. On the other, she knows that she needs to learn this important skill and that "practicing" in this manner is the only way to do so. She wonders whether to tell the Dr Adam that she doesn't want to do the LP on this patient, given his statement, but she is also concerned about upsetting him, as he will be evaluating her for the placement. •How might Lauren and Dr Adam approach this problem? •Script for: -Dr Adam, if he recognises / acknowledges the problem -Lauren, if Adam fails to recognise / acknowledge the problem **The questions and answer from Miller B. AMA Journal of Ethics 2017

1) Dr Adam: •Acknowledges Mrs Jones' concerns •And senses Lauren's discomfort •Diplomatically reframes the discussion to balance the patient's best interests, autonomy, and Lauren's need to learn... also shifting control back to Mrs Jones. 'Mrs Jones, Lauren is an excellent medical student who needs to learn how to perform lumbar punctures if she is going to provide the very best care to her own patients in the future. I have walked Lauren through the procedure and am confident that she will do a good job. However, there is a risk that with Lauren performing the procedure, you will experience more pain or that the initial attempt will be unsuccessful and I will need to undertake a second attempt. I will do everything possible to lessen these risks by directing her carefully and taking over if I feel she will cause you any harm, including excessive pain. In addition to the benefit you will gain from having this procedure, you will provide benefit to Lauren and her future patients. If you are uncomfortable with this plan, I will perform the procedure and Lauren will observe and assist.' 2) Lauren, medical student: •Adam doesn't recognise / acknowledge the problem •So she has two options: carry on despite her discomfort, or: a) Attempt to explain the situation to Mrs Jones herself: 'Mrs Jones, while I won't really be practicing on you, I am a medical student and need to learn how to do this procedure if I am to become a good doctor. Dr Adam is a great teacher and has already instructed me on all of the steps. He will guide me, and if at any time he thinks that you might be harmed or that you are experiencing unusual pain, he will take over. There might be an increase in your risk of pain or the need for a second attempt, but with my resident physician directing me, that risk will be reduced. If you agree, I will be very grateful for your contribution to my education.' b) Decline to proceed: 'Adam, I really appreciate your confidence in me, but with Mrs Jones seeming so reluctant, I'm much more comfortable watching you this time. Then maybe the next time an opportunity arises, I'll feel more confident and prepared.'

Exceptions to consent

1) Emergency - A medical emergency whereby obtaining consent would lead to damage to a patient and there is genuinely no time to ask the patient's permission. 2) Implied - Some patients imply permissions through their actions, such as lifting up a top when asked permission to examine. Usually we should rely on express consent - either oral or written permission, particularly for invasive treatment. 3) Waiver - Some patients waive consent. They don't want to know the details and just want the treatment to occur. Be careful who is attempting the waiver - fine if it's the patient. More often it's the relative who doesn't want the patient to know the details of their condition. WITHOUT GOOD REASON, the doctor must NOT put himself in the position of agreeing to such a waiver. Duty of care lies with patient, without good reason if don't get consent, then hinders patient treatment 4) Best interests - In certain situations it is not possible to obtain the permission of the patient. They may be unconscious or have severe dementia and thus not able to take part in a discussion about their treatment. In such situations, where the patient lacks the capacity to give consent (i.e. is not legally competent to give consent), the doctor must act in what he believes to be the patients best interests. For more information see the Mental Capacity Act e-module.

The Mental Capacity Act includes three further key provisions to protect vulnerable people

1) Independent Mental Capacity Advocate (IMCA): § An IMCA is someone appointed to support a person who lacks capacity but has no one to speak for them. § The IMCA makes representations about the person's wishes, feelings, beliefs and values, at the same time as bringing to the attention of the decision-maker all factors that are relevant to the decision. § The IMCA can challenge the decision-maker on behalf of the person lacking capacity if necessary. 2) Advance decisions to refuse treatment - Statutory rules with clear safeguards confirm that people may make a decision in advance to refuse treatment if they should lose capacity in the future. It is made clear in the Act that an advance decision will have no application to any treatment which a doctor considers necessary to sustain life unless strict formalities have been complied with. These formalities are that the decision must be in WRITING, SIGNED AND WITNESSED. In addition, there must be an express statement that the decision stands "EVEN IF LIFE IS AT RISK". 3) A criminal offence - The Bill introduces a new criminal offence of ill treatment or neglect of a person who lacks capacity. A person found guilty of such an offence may be liable to imprisonment for a term of up to five years.

Calgary Cambridge model for structuring a patient consultation

1) Initiating consultation: greeting the patient, introducing yourself, demonstrating interest, using open question etc. 2) Gathering info: explore patients problems and understand the patient's perspective. Make sure is structured 3) Physical examination: communicate during, let know what you're doing , pick up on non-verbal and verbal cues 4) Explanation and planning: give comprehensive and appropriate information responding to what the patient wants. Each patient must be assessed and the appropriate amount and level of information given. Doctors are obliged to provide some information to patients (e.g. purpose and risks of proposed surgery) even if patients do not want it. 5) Closing the session: Doctors are obliged to provide some information to patients (e.g. purpose and risks of proposed surgery) even if patients do not want it. A summary enables review of what has been learned as well as checking for any other information that you may have missed or that the patient wants to tell you. **Providing structure: By making organisation overt, both you and the patient will know where you are in the consultation. This can be achieved by summarising at the end of a line of enquiry, signposting the next section of the interview, structuring the interview in a logical way and attending to timing.

Calgary Cambridge model

1) Initiating session 2) Gathering info 3) Physical exam 4) Explanation and planning 5) Closing the session

All elements of preparing for interaction to closing

1) Preparing for interaction: § Attend to self-comfort § Minimise distraction § Focus attention on next interaction 2) Commencing the interaction: § Greet the patient (hello/ GM) § State your full name § Clarify your role § Obtain patient's name § Attend to patient's comfort (e.g. "You don't seem very comfortable on that chair...?") § Obtain the patient's consent + clarify confidentiality § State purpose of the interaction § Mention note taking § Clarify time available § Assess patient's ability to communicate § Demonstrate interest and respect § Empower patient to ask questions or seek clarification of anything that is unclear 3) Gathering information: § Use open questions initially § Allow patient to complete first sentence/s § Identify the patient's ideas, concerns and expectations: o Ideas - "Is there anything you think might be causing these symptoms?" "Patients often have ideas about possible treatments. Do you have any ideas?" o Concerns - "Do you have any concerns about your illness? "Are you worried about your symptoms?" "Patients ofen have worries about their symptoms. Do you?" o Expectations - "What are you hoping the doctor will do?" "What do you think your treatment will be like?" § Use active listening verbal (staying with patient's topic; using patient's words; reflection) non-verbal (eye contact; nodding) § Use other non-verbal behaviours (body posture; gestures; facial expressions, nodding) § Use open to closed-cone questions § Pick up verbal cues § Pick up non-verbal cues: "When you talk with the patient, you should listen, first for what he wants to tell, secondly for what he does not want to tell, thirdly for what he cannot tell" (Billings and Stoeckle 1999:25) § Probe sensitively § Survey for other problems § Set agenda § Clarify patient's terms § Make interim summaries: "Just so I can check that I have got this clear, the symptoms first started...". § Signpost or transition statements: "We have discussed why you have come into the hospital, what I would like to do now is ask you some questions about your health in the past." § Use silence appropriately § Avoid multiple questions § Avoid leading questions § Avoid unexplained jargon 4) Closing the interaction § Provide an end summary: "I'd like to summarise what we have discussed." § Discuss an action plan: "You will need to do the following things in preparation for your colonoscopy. First... second... etc. Is that clear? It can sound complicated but it is very important that you understand the preparation. Perhaps you can go over it with me again?" § Check for further information § Ask for questions § Check if the patient has any worries or concerns: "When we frst started talking you mentioned you were worried about the timing of the operation. Now that we have clarifed that, I was wondering if you had any other concerns **Relationship building: Throughout each stage, it is important to use relationship-building in order to establish and maintain your relationship with the patient § Use active listening § Make empathic statements § Show warmth § Pick up verbal and non-verbal cues § Use non-verbal behaviours (posture, gestures, facial expressions) § Identify patient's ideas, concerns and expectations § Avoid being judgmental

Overall abortion arguments

1) Status of fetus: a) human being approach b) person approach c) gradualist approach d) human relationships approach 2) Women's rights: a) Respect for autonomy 3) Thomson's violinist 4) Maternal duties 5) The legal status of the fetus and father **§ The ethical status of the fetus is central to most of the arguments concerning the ethical acceptability of termination. J J Thomson has argued that abortion may be ethically acceptable even if the fetus has a right to life. § However, even if termination is ethically acceptable this does not mean that it is ethically desirable. § Abortion is unlawful unless it falls within one of the grounds given in the Abortion Act and follows the procedures dictated in the Act. § Abortion on the grounds of fetal disability raises additional ethical issues.

Decision making (competence) - MCA test for capacity

1) Understand 2) retain 3) weigh up and Balance 4) Communicate back

Cultural issues in healthcare

1) Use of language: § Use of foreign language (i.e. patient and clinician must communicate in a language they are not fluent in) § Use of slang § Accent/dialect § Giving offence through over-familiarity 2) Use and interpretation of non-verbal communication: § Physical touch § Body language § Proximity - closeness/distance § Eye contact § Expression of afect/emotion 3) cultural beliefs and healthcare: § Interpretation of symptoms - what is considered normal and abnormal § Beliefs about causation § Beliefs about efcacy of treatment alternatives § Attitudes toward illness and disease § Use of complementary or alternative sources of healthcare § Gender and age expectations about roles and relationships § Role of doctor and social interactions related to power and ways of showing respect § Perceived responsibilities regarding adherence to medical recommendations § Family life events (e.g. rituals and beliefs with regard to arranged marriages, pregnancy and childbirth, older adult caregiving, treatment of elders, death) § Psychosocial issues (identifying common stressors, awareness of diversity in family/community supports) § Role of clinician in mental health 4) sensitive issues: § Sexuality - including sexual orientation, sexual practices and birth control § Uneasiness about some physical examinations § Use and abuse of alcohol and other substances § Domestic violence and abuse § Sharing bad news 5) HCP issues/barriers: § Extent of clinician-patient partnership, extent of family involvement, personal and family responsibility for healthcare and treatment § Ethical issues in care § Doctor's assumptions, stereotyping or prejudices § Concurrent consulting with a practitioner of complementary or alternative medicine

Supporting those who lack capacity

1) family: § Individuals making decisions on behalf of someone who lacks capacity must take all reasonable steps to maximise the involvement of the individual in the decision making process § Unless it is an emergency requiring an immediate decision, the family has a right to be consulted for all major decisions. 2) Under the MCA there is a statutory duty to appoint an IMCA, if a person lacking capacity has no one to support them and there are: a) Decisions relating to serious medical treatment, unless it is an urgent situation (within 24 or 48 hours and not enough time for IMCA to be appointed) b) Proposals to move a person into long term care in a hospital or care home (for more than 8 weeks) c) When a move to a different hospital or care home is proposed **the role of IMCA: § Representing and supporting the person who lacks capacity so that the person may participate as far as possible in the decision making § Obtaining and evaluating information § As far as possible ascertaining the person's wishes and feelings, beliefs and values § Ascertaining alternative courses of action eg different care or housing arrangements § Obtaining a further medical opinion if necessary § The IMCA is an independent advocate for those lacking capacity who have no one to represent their perspective § The IMCA cannot make decisions on behalf of the person lacking capacity § The IMCA can appeal to the Court of Protection if they believe that decision makers are not acting in the person's best interests

Exceptions to confidentiality

1) when patients care is managed as part of MDT. § Implied consent from patient by present. § But who is part of team? § Who is not part of team e.g. phlebotomist? § Identity and publications - as long as no identifiable patient info. 2) with patient consent. § must be express § most relatives don't have rights § how much information to be divulged? § to whom? 3) required by Statute (law) § notification of death (death certificate) § notification of termination (termination of pregnancy) § treatment of addict with specified drugs § notifiable infectious disease (e.g. malaria, plague, COVID-19, TB) 4) assisting the police. § general principle do not need to but there are exceptions. § exceptions: a) under a warrant from a circuit judge -b) in IDENTIFYING drivers suspected of offence c) to aid police in all matters with suspected terrorist patient 5) wider public interest § balance between duty to patient and duty to society § may be challenged § must justify action (or inaction)

What is the age of consent?

16. § Age of consent is 16: o Family Law (Reform) Act 1969 o Gillick Exception ** Those with Parental Responsibility § Parents (if married or on birth certificate) § Mother (if unmarried and no agreement) § Legally appointed guardian § Local Authority with a care or protection order

What is valid consent?

A COMPETENT person that understands the nature of the treatment based on information in "BROAD TERMS" WITHOUT COERCION who then gives permission. **Why is it broad terms: § If a doctor tells every possible side effect of a proposed treatment, then whilst the patient would be fully informed there is a danger that they will be overburdened by too much information and scared off from a potentially useful and safe treatment. § BUT If a doctor doesn't mention any of the known COMMON or SERIOUS risks of a procedure then he would have not told the patient enough. § The current legal position is that a doctor would be expected to provide the information that their specific patient would reasonably want to know. This underlies the importance of shared decision making, so that the doctor understands the impact of a proposed procedure or treatment on their patient. **Without coercion: § The agreement of the patient must be from the patient alone. § Sometimes a patient may agree to a treatment only under the pressure of a relative or friend. § It is fine to discuss one's concerns with friends and relatives, but when their advice turns into coercion then the patient must be removed from the coercive environment and the discussion repeated.

Abortion is a criminal offence

Abortion is a criminal offence § Offences Against the Person Act (1861). o Seeking to procure a miscarriage by administering a noxious substance to herself, or another giving it to her (S.58). o Supply or procurement of abortifacient (S.59). § Infant Life Preservation Act (1929): Where the fetus is capable of being born alive. **So abortion is a criminal offence UNLESS it falls within the terms of the Abortion Act

C is 24 y/o man, previously treated in hospital for schizophrenia. Made good recovery but stopped medication after. Following discharge he wrote an advance decision, witnessed, stating he refuses antipsychotic medication again if the doctors believe his life is at risk. Initially was well, then became isolated, lost weight. When psychiatrist visited him, he was talking about people coming out of the walls and scared and incoherent. How should psychiatrist proceed?

An advance decision does not apply to treatment under the mental health act. **can't refuse basic care or treatment under MHA in advance directive. **essentially yes - under the mental health act even if they are not a threat to society, they can be forced to have treatment against their will, under the mental capacity act. it is usually about degree and nature of the condition and gets a bit complicated but all you need to remember is that MHA will trump an advance decision with regards to psychiatric treatment

Maximising lives saved - primary prevention

Are saving 2 lives better than 1? § Imagine you are responsible for the local healthcare budget. You have been told: o Primary angioplasty is the first line treatment for an acute heart attack and costs between £15-20K. o The same money could be used in primary prevention to give cholesterol lowering treatment to 200 people and prevent 2 future heart attacks. o Primary prevention saves more lives therefore should more resources be directed here? **Think of flooded floor scenario: o If the floor is flooded, don't mop the floor, FIX THE TAP!! § But this assumes: o There is only one leaking tap. o That you can fix the tap. o That attempting to fix the tap won't cause new, unexpected problems. o What about the flooded floor? o Do you wait for the water to evaporate?

Child paternalist vs liberationist approach

CHILD PATERNALIST APPROACH: § adult decision makers should make decisions on behalf of children on the basis of best interests. § And it is ethically appropriate to override a child's autonomous decision if the decision is deemed not to be in that child's best interests. THE CHILD LIBERATIONST APPORACH: § Autonomous children have the same rights as autonomous adults. § Adults make bad decisions all the time. § The values, aspirations, priorities and beliefs of adults ALSO change over time. § Even as adults we often don't appreciate the implications of our decisions for our future lives.

In this NHS who has overall responsibility for patient confidentiality (information governance)?

Caldicott guardian. a senior person responsible for protecting the confidentiality of people's health and care information and making sure it is used properly. All NHS organisations and local authorities which provide social services must have a Caldicott Guardian. § In 1997, the Caldicott committee presented its report on patient confidentiality. § The impetus behind this were concerns about patientinformation and security. § For example, there had been reports in the press that patient hospital records could be freely accessed and that patient notes had ended up lying around in village streets for all to read

Thyroid symptoms

Hyperthyropidism: Prefers cold weather, sweaty, diarrhoea, oligomenorrhoea, weight loss, tremor, visual problems Hypothyroidism: depressed, slow, tired, thin hair, croaky voice, heavy periods, constipation, and dry skin

Implication if self-consciosness makes human life valuable (4/5)

Identifying the morally relevant features that give human life special moral value is central to healthcare decisions that we make at the beginning and end of life. But these features have wider implications for our approach to justice and healthcare in general, and our attitude to other life forms

Thomson's violinist

Imagine you woke up and found a concert violinist attached to you. He is relying on your kidneys and lungs to stay alive. In 9 months time, his body will have recovered sufficiently for him to be removed from your body. Do you have a moral duty to keep the violinist attached to you? § We have a duty not to kill deliberately. § It is generally a good thing to save those in need of rescue. § We may have a duty to save others in certain circumstances. § But we cannot have a duty to save everyone irrespective of the cost to ourselves. This was be too honorous and impossible to fill and impossible to save everyone in need of rescue. **Is pregnancy above the call of duty? § A fetus may have the same right to life as an adult. § But pregnancy is a significant physical burden and risk to the mother. § We do not have a moral duty to put our lives at risk or endure physical burdens to save others. § Therefore a woman does not have a moral duty to continue a pregnancy. **BUT What if the pregnancy was planned? § Does a woman have a duty to continue a pregnancy if it was planned? Well, it is almost impossible to imagine what it is like to be pregnant, and one person's experience of pregnancy can be different from others. so one could say one has not truly planned for a pregnancy. Would be nice to help violonist, but then realise it's more than you can cope with, you don't have a duty to keep him attached. § If I offer to donate a kidney to a friend, do I have a moral duty to donate even if I subsequently change my mind? Arguably would be nice to stick with offer but could not be said is morally bound to donate kidney

Basic legal principle of condifentiality

Information gleaned by a Health Care Professional should not be divulged to others. **Exceptions: § with consent § required by law § in the wider public interest

What does equal treatment mean? (justice and healthcare)

Justice requires equal treatment of equals. What does equal treatment mean? a) Equal resources? b) Equal rights? c) Equal respect? 1) Equal resources - most people agree that equal treatment means equal resources. That equal treatment means same number of material goods etc. 2) Equal rights: Rights can be thought of as moral entitlements. § Right to life. § Right to privacy. § Right to healthcare. § Right to children. **negative rights: what others may NOT do to us, e.g. kill, injure or steal from us. **positive rights: what others MUST provide for us - education, health care. **Who decides what counts as a moral right? § Right not to be killed. § Right not to be tortured. o Are these valid moral rights, or is it just that there is consensus that humans have the right to be protected from being killed or tortured? Or as discussed previously, is human life special and therefore requires rights to protect it? What about? § Right to housing. § Right to welfare. § Right to fertility treatment. § Do we have a duty to provide these things, or are they simply things that would be nice for a decent society to provide? **Recognising rights § Once we recognise a moral right, justice requires that equals should have an equal entitlement. § Rights imply duties on the State and society to ensure that the rights of individuals are protected. **Right to healthcare: § If we believe there is a right to healthcare then the State has a duty to provide and maintain this provision. § In this situation, to deny someone healthcare, for example on the grounds of mental disability, implies unjust treatment. § Or it implies that the lives of those with mental disability are of less value. 3) Equal respect: § Respect for persons requires us to respect autonomy. § What about people with defects in autonomy? For these people, maximising capacity for autonomous decisions now and in the future. Concern for welfare (best interests) when those people can't make an autonomous decision.

GDPR (General Data Protection Regulation)

New European Union law on data protection and privacy for individuals. (from may 2018). replaced data protection act

When interpreting, the interpreter is asked to:

Observe confdentiality at all times Conduct himself/herself professionally Respect the values and practices of the health professional's organisation Be attentive to the needs and wishes of the patient at all times, although the patient does not have the right to misuse the interpreter Respect the right of the patient to object to him or her as the interpreter. If this occurs the interpreter must inform the health-care professional Be aware that a female patient may be reluctant to share information with a male interpreter and vice versa but may not say this openly. An awareness of this possibility should prompt the interpreter to explore this appropriately Respect the rights of parents of children to be involved in care and decisions about the child as patient, but understand the rights of the child as paramount Interpret accurately and competently with sensitivity to the circumstances of the interaction Be competent in both languages, aware of emotional content, strength and force of words, the double meanings of specifc words and be consistent in translation of common words

J is an 84 year old man brought into A+E by his wife, L, with acute confusion and abdominal pain. Until 2 days ago he was fit and well and, according to his wife, could complete the Times crossword in 20 minutes. Now, he does not know where he is or what day it is. The on-call surgeon diagnoses acute appendicitis requiring emergency surgery and explains this to J and his wife. J thinks that he is in a German prisoner of war camp and tells the surgeon that he has rights under the Geneva convention. J says that he 'is not a traitor and will not agree to anything'. What should the surgeon do? a) Obtain L's consent and proceed with surgery/treatment. b) Proceed with surgery/treatment provided it is in J's best interests. c) Proceed, with the surgery/treatment, but only if a second senior doctor agrees. d) J clearly has a mental disorder/illness. Therefore obtain a section 3 order under the Mental Health Act and proceed with surgery / treatment. e) In an emergency, the doctor must always treat the patient.

Option B - Proceed with surgery/treatment provided it is in J's best interests. § From the information provided, J lacks capacity. § Therefore surgery is only lawful if it is in J's best interests. § Seeking a second opinion in this situation is good practice as it makes it more likely that you correctly ascertain best interests but does not of itself does provide legal grounds for surgery.

Mr X says that he does not wish to be given life sustaining treatment if he were to develop dementia such that he became dependent on others. Mr X develops dementia and is now in a nursing home. Mr X is dependent on others but seems quite happy. Mr X develops a kidney infection, treatable with antibiotics. Without antibiotics he is likely to develop septicaemia may die. § Should Mr X's kidney infection be treated? § Does respect for Mr X's previous decisions made when autonomous unjustly override his current right to life or our duty to show him equal respect?

Previously when made decision might not have fully anticipated him being happy now and living with dementia. His mind may have changed since that decision and if is determined to be competent today might make a different decision. In order to help decision, must discuss with Mr X and talk to those close with him. Without the antibiotics, Mr X is likely to die, hence if there is any doubt, the antibiotics should be given as is least restrictive option. Equal respect means that in this case, if he is not competent, we keep in mind his welfare and act in his best interests. is balancing between the autonomous decision made before and his right to life and duty to show him equal respect.

Principles of the Children Act 2

Principles of the Children Act 2: **Presumption of no order (s1.5): § The Act assumes that in most cases the courts will not force an order upon the parents or upon the Local Authority. § Court orders will therefore only be made where this will benefit the child. § There is a requirement for local authorities to work in partnership with parents for the welfare of the child.

Health a human right?

Promoting and protecting health and respecting, protecting and fulfilling human rights are inextricably linked (WHO)

Policy consensus and law regarding abortion

Public consensus supports abortion, at least in certain circumstances. So should law makers take into account public opinion and policy implications when considering the law governing abortion? **Yes: § Worldwide 80,000 women per year die as a result of illegal abortions. § Criminalising abortion in the UK would simply drive the practice underground. **No: If abortion is morally wrong then public opinion and consensus in favour of abortion does not make it morally acceptable. **Morality and law: § Should the law reflect morality or public opinion? § Are there absolute moral values or is morality shaped by culture and public opinion? § If there are absolute moral values, who decides what they are? § Can say, law is shaped by morality but not solely determined as takes in public opinion, regulation too. But ethics is necessary for the moral backbone of the law.

Lack of consent cases

R v dr flattery had consented to surgery but what happened in surgery wasn't what she agreed to

Respect all patients...

Respect all patients, colleagues and others regardless of their age, colour, culture, disability, ethnic or national origin, gender, lifestyle, marital or parental status, race, religion or beliefs, sex, sexual orientation, or social or economic status. Graduates will respect patients' right to hold religious or other beliefs, and take these into account when relevant to treatment options (GMC Tomorrows Doctors, 2015)

What is self compassion?

Self- kindness/ compassion: § Identifying and taming the inner critique § Taking responsibility but not 'beating yourself up' § Becoming your own best friend. § Not self -pity of self -indulgence

How might Zeno feel in a few years' time if the transplant goes ahead but Enya dies?

The limited psychological evidence that is available suggests that their can be a significant negative impact on child sibling donors. This is particularly likely when the sibling recipient dies or the transplant fails. In these situations sibling donors often describe feelings of guilt, anger and depression. Some have expressed a belief that their marrow was the cause of their sibling's death. Even when the transplant is successful sibling donors may feel guilt about transplant complications. Many siblings when interviewed said that whilst they believed it was the right thing to do they felt they had no choice or felt forced into agreeing to be donors. Perhaps not surprisingly the evidence suggest that negative feelings were more likely when donors and families did not feel adequately informed about the complications and prognosis. Many child donors felt health professionals did not make their parents aware of the emotional support they required.

B is a 44 year old mother of 3. She is 36 weeks pregnant with worsening pre-eclampsia. The obstetrician advises to have C-section within 24 hours to save her and childs life. She refuses and says her previous babies delivered natural delivery without complications. Husbands ays to have C-section. She insists on natural. Assuming hse is mentally competent what should the obstetrician do?

The obstetrician cannot perform the caesarean section unless he can persuade B to give consent. **father cannot provide consent ** death of unborn child is not relevant here as long as mother is competent.

Things to remember with interpreter

The pressure on the interpreter The responsibility for the interaction is yours as the healthcare professional Your power as a health-care professional - as perceived by the interpreter and the patient To show patience and compassion in a demanding situation To be aware of your own attitudes towards those who are different from you - including awareness of racism To be aware of your own shortcomings, for example not being able to speak the same language as the patient To show respect to the interpreter and his/her skills

Give examples of basic care

These cannot be refused in an advance directive

Institutional racism

This can occur by default, when the way things are done within a healthcare organisation does not take account of the needs of black and ethnic minority patients, for example by: providing services 1) in English only, not engaging local interpreting services. 2) applying equally to all rules and regulations that have the effect of excluding black and ethnic minority people. For example, nurse uniform regulations are often still based on traditional Western European dress and may be unacceptable to some Muslim women. 3) basing decisions on stereotypes or assumptions. For example, it may be assumed that black and ethnic minority elderly or disabled people do not need services because they prefer to look after their own". § Institutional racism has been defined in the landmark 1999 Macpherson Report following the racist murder of Stephen Lawrence: "...the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantages ethnic minority people..." (Source: Valuing Diversity, 2nd Edition 2003: A resource for health professional training to respond to cultural diversity. Edited by Joe Kai)

Philipa Foot's case study (difference between acts and omissions)

Two scenarios again: 1) I hear an appeal for funds to provide food for starving children in Africa. Funds will prevent child deaths. In fact if I were to send money I would prevent 100 children from dying. However I decide not to send the funds due to other priorities. 2) I decide to send a food parcel to the starving children but send bread that is laced with poison. This results in 100 children dying. **In this case it does not seem at all right to say that I am just as guilty of the childrens' deaths in omitting to donate to the fund as I would be if I were to have sent them poisoned food? We are able to say that failure to perform an act with foreseeable bad consequences is less bad than performing an act with similar bad consequences. There are a number of reasons behind this, that we will examine in the next slide.

S is 48 and has terminal melanoma, has cerebral metastases and is severely confused. He is bed bound and totally dependent on wife for all needs. You are GP and come to see him about pain relief. You find his doubly incontinent and in squalid conditions. His wife is clearly not able to cope with his heavy nursing needs. She refuses to allow S to be admitted to hospice or carers to assist. She says that competent S wanted to die at home and didn't want strangers looking after him. What to do?

Under the mental capacity act, an advance refusal of basic nursing care is not legally required. **Under mental capacity act advance refusal of basic nursing care is not legally valid. Always assess mental capacity first but in this case he is already severely confused. If has capacity he can refuse basic care. § IMCA not really required when they have a family member. So you need an imca if someone lacks capacity and has no family for serious medical treatment and where someone will live Not just family - anyone who can represent them, could even be close friend or neighbout

Tobacco use questions

Who to ask ? - everyone Do you smoke? Have you ever smoked? How many a day (or amount tobacco) do you smoke? Have you always smoked this amount? When did you begin smoking?

J is an 38 year old man brought into the A+E department by his sister, L, following a trampoline accident. Although J is medically stable, the on-call surgeon explains to J and his sister that he has a ruptured spleen and is bleeding internally. J will require a blood transfusion and emergency surgery. J says that he will consent to the operation but is totally opposed to receiving any blood products. He shows the surgeon a recently signed and witnessed advance decision that he always carries in his wallet, stating that he refuses any form of blood product even if it is a matter of life and death. The A+E charge nurse confirms that J is on the Jehovah's Witness register. The surgeon explains that there is a risk of major blood loss and that J may die if he is not given blood. J continues to refuse a blood transfusion. L is very distressed. She is not a Jehovah's witness. She takes the surgeon aside and suggests that the surgeon gives blood if necessary during the operation when J is under anaesthesia. Then J would never need to know he had been given blood. What should the surgeon do? a) Explain to L that this is a valid refusal and therefore J's wishes must be respected. b) Obtain L's consent as next of kin and proceed with the blood transfusion. c) Explain to L that although J has given a competent refusal, the blood transfusion can be given if J's life is at risk. d) Proceed with surgery/treatment provided it is in J's best interests. e) The refusal of life saving treatment shows that J lacks mental capacity. Therefore the blood transfusion can be given provided it is in ls best interests. In an emergency the doctor must treat the patient.

a) Explain to L that this is a valid refusal and therefore J's wishes must be respected.

S comes into A&E following a Road Traffic Accident. He is intoxicated with alcohol and admits to being the driver of a BMW that was seen to knock down a pensioner. The Police want to know his address and they want a blood alcohol sample. Can B. the A&E triage nurse give the police this information and the sample without permission from S? a) B may only give the address. b) B may only give the address if the police go to court and a judge asks her. c) B may not give the address or the blood sample. d( B may give the address and the blood if it has already been taken. e) B may give both the address and the blood alcohol sample.

a) Only the address. Under the 1988 Road Traffic Act there is a statutory requirement to provide information to assist the police in the identification of a person charged with a road traffic offence. There is no statutory requirement to given any other personal information under the Act and therefore the blood sample should not be given to the police officer without express consent from the patient. See section 4.

S is a 56 year old man with severe cognitive impairment following a subarachnoid haemorrhage 3 years previously. Although independently mobile, he is unable understand even simple questions or commands. His next of kin is his 31 year old daughter T. T lives on the other side of London but usually visits her father in his residential home 2 or 3 times each month. Whilst in hospital with complete heart block, S developed an ischaemic heel ulcer. He has had a pacemaker inserted without complications but now has dry gangrene of his heel. On the Monday morning he is seen by the consultant vascular surgeon who feels that conservative management has failed and asks his registrar to schedule S for a below knee amputation on his Thursday list. What should the registrar do? § The registrar must discuss the planned surgery with T first. § S should be scheduled for surgery as it is in his best interests. § S cannot be scheduled for surgery until T's consent is obtained unless his life is in immediate danger. § S has a life threatening condition and therefore any proposed intervention must be discussed with T first. § S cannot be scheduled for surgery until T's consent is obtained.

a) The registrar must discuss the planned surgery with T first. § Individuals making decisions on behalf of someone who lacks capacity must take all reasonable steps to maximise the involvement of the individual in the decision making process. § Unless it is an emergency requiring an immediate decision, the family has a right to be consulted for all major decisions.

Characteristics of human life

a) self consciousness b) memory c) moral reasoning - some would say is unique to humans d) enjoyment/fulfilment e) complex emotions - e.g. grief f) relationships g) communication through language h) personality **John Locke - a thinking intelligent being, that has reason and reflection, and can consider itself, the same thinking thing, in different times and places..." **John Harris - 'a person will be any being capable of valuing its own existence'

Sienna is a 14 year old girl who presents in casualty heavily pregnant (36+ weeks gestation) with vaginal bleeding. She is in complete denial about the pregnancy. There is clinical evidence of fetal distress and of a major placenta praevia. She requires urgent admission and a caesarean section. She is refusing to believe the seriousness of the situation and will not consent to the operation. She does not want her family to know (she will not give the parents' telephone number), saying 'They will kill me if they find out'. What should the clinicians do? a) A competent minor's right to confidentiality remains unchanged when life is at risk. b) In an emergency, clinicians can treat a minor without parental consent under the legal principle of necessity. c) A Gillick competent young person's refusal to medical treatment can be overridden in his / her best interests. d) Only the Court can override the refusal of a competent minor. e) Sienna is refusing treatment therefore you must obtain consent from one of her parents before proceeding with treatment. f) Sienna is 14 and therefore Gillick competent. Therefore her consent must be obtained before proceeding with the caesarean section.

b) In an emergency, clinicians can treat a minor without parental consent under the legal principle of necessity. § Sienna's state of denial about her pregnancy indicates that she is not Gillick competent. Therefore the decision is based on what is in Sienna's best interests. See 'The Gillick exception' In Section 8 of the Children e-module. § this is an emergency. § cannot obtain parental/law consent § can override child's confidentiality if it is in there best interests. § in gillick competence need to pass fraser test and make sure that they understand the condition. **Gillick competence can NOT refuse treatment.

W is uni lecturer with chronic pancreatitis and unpredictable hypoglycaemic unawareness. Doctor wants him to inform DVLA, patient not keen cos will lose job if can't drive. What to do? a) E should inform the DVLA on the phone on a "no names" basis. b) E is there to treat the W's diabetes and does not need to worry about the driving. c) E should write to the DVLA about the driving and at the same time write to the patient telling him what he has done. d) E should write to the DVLA to inform them that W has hypoglycaemic unawareness and chronic alcoholic pancreatitis. e) W's condition poses a real and serious risk to other road users so E should inform the DVLA and W's employer.

c) E should write to the DVLA about the driving and at the same time write to the patient telling him what he has done. § While there is no legal duty to inforrn in this situation, your professional guidance states that if you believe that your patient's continued driving poses a serious risk of significant harm to others & you have been unable to persuade the individual to disclose, then you have a professional responsibility to inform the DVLA and tell the patent what you are doing. Only necessary information should be disclosed i.e. Ws hypoglycaemic unawareness but not his diagnosis chronic alcoholic pancreatitis. Similarly while a breach of confidentiality is lawful in this situation, the breach should be the minimum necessary to prevent harm Therefore only the DVLA should be informed and not Ws employer.

Roxy is a 23 year old secretary who is 18 weeks pregnant. She has come to see her GP, with view to a termination of the pregnancy. She realises that she is making the decision very late but that she has had a terrible dilemma about what to do. She does not feel ready to have a baby. Her partner does not know she is pregnant. After a lengthy discussion the GP fills in the referral for a termination. Two days later her partner, Moby, goes to see the GP. He has found a hospital appointment letter in Roxy's handbag. When he confronted Roxy about this she broke down and admitted that she was pregnant and having a termination. Moby says that he will not allow his child to be murdered. What is the legal position? a) A woman has an absolute right under UK law to request a termination of pregnancy. b) The termination at this stage is lawful as it is necessary to prevent grave or serious injury to the mother. c) The biological father has no legal rights regarding the decision to proceed with a termination of pregnancy. d) It is not lawful to perform a termination without the father's consent. e) Provided a woman is less than 22 weeks pregnant, termination can be performed at the request of the woman. f) Where there is parental disagreement, a Court declaration must be sought before proceeding with a termination of pregnancy.

c) The biological father has no legal rights regarding the decision to proceed with a termination of pregnancy. § The biological father has no legal rights to veto or request an abortion at any stage of pregnancy. A woman does not have an automatic right to request an abortion. The abortion will only be lawful if falls with the grounds of the abortion act as agreed by two doctors acting in good faith.

C dies from cysticercosis (caught from pork). Patient's family are religious Jews and don't want mention of this on death certificate. What should doctor do. a) The duty of confidentiality to the patient continues after death and therefore the family's wishes should be respected b) As the family won't accept the death certificate it should be mentioned that the next step would be a coroners investigation with possible post mortem c) The matter should be discussed with the coroner. d) The duty of confidentiality to the patient continues after death and therefore no certificate can be issued. e) The requirement to fill out the death certificate accurately is absolute and therefore it must mention cysticercosis.

c) The matter should be discussed with the coroner. *coroner is legal expert. maybe can phrase on death certificate accurately but in way that not upset family e.g. brain infection. But coroner is legal expert so need his advice. But option e is true - The requirement to fill out the death certificate accurately is absolute **Medlearn feedback: Your professional duty of confidentiality continues after death. This duty is to the deceased person not their family although their wishes may be relevant when considering the best interests of the deceased. However, the completion of the death certificate is a statutory requirement and therefore must be completed. The coroner is always happy to advise when there is query, as in this case, as to the level of detail required. So when in doubt ask.

IMCA

§ IMCA came to visit to see what patient's wishes are § IMCA - independent mental capacity advocates

Coronavirus vaccine should be distributed globally according to need - A Healthcare Professional's Perspective

**Background: § SARS-CoV-2 (nicknamed COVID-19) is a novel infectious disease caused by a newly discovered coronavirus at the end of 2019 § In the absence of a vaccine providing long-lasting immunity, countries have been taking non-pharmaceutical interventions to slow the spread of COVID-19. § While rigorous testing, contact tracing and quarantine measures have helped to control the transmission of COVID-19, the best preventative measure is to have enough of the population to become immune to the virus so they cannot pass it on. § In order for chains of transmission to be broken, a percentage of the population must be immune to the disease, a concept described as herd immunity. § This can either be achieved by exposing a large proportion of the population to the pathogen, with the assumption that they will form a protective immune response to stop them from becoming reinfected, or by relying on a mass vaccination program to confer an artificial immunity. § In order for the transmission of COVID, it has been suggested by the UK government Chief Scientific Advisor that about 60% of the population would need to develop immunity before this could happen. § As of October 2020, estimates of finger-prick antibody testing suggest that only approximately 4.4% of UK citizens (non key-workers) could be immune to coronavirus infection, a decline from 6% reported in June. This decline was largest in people aged 75 and above compared to younger people. § Research into vaccines for COVID-19 has progressed very quickly compared to previous immunisation programs. § Recently several big pharmaceutical companies have announced vaccines against COVID-19 with high efficacy (Pfizer, AstraZeneca, Moderna) § Several ideas are being suggested for how to distribute the vaccine as the vaccine is a limited resource - here in the UK, the older and most vulnerable key workers are being prioritised for the vaccine. § It must first be decided what the primary aim of vaccination is; saving lives, improving quality of life, or controlling spread? 1) defining needs: § We need to decide who is most at need and which diseases are classed as most vulnerable and therefore require the vaccine first- could be based on evidence § Still requires some subjective evaluation of evidence § Conditions that have been researched more in relation to covid are more likely to receive attention § Need to consider whether protecting the healthcare system is a priority- and if we should therefore consider protecting healthcare workers as the most important factor 2) Age as a factor: § Elderly patients should receive the vaccine first as they are most at risk and have been contributing towards society their whole life But there are issues determining their social worth - who determines which people have contributed more to society? Also, studies have shown that elderly patients show a greater decline in antibody production compared to a younger patient § Elderly patients are less able to contribute to society now and have fewer years to live on average compared to a younger person - wouldn't it make more sense to prioritise those who could live longer? But there are issues with this as elderly patients are much more likely to die from COVID than a younger patient **Justice and healthcare: § The right to life could be said to be a fundamental right. § If everyone is equal then everyone has an equal right to life and therefore an equal right to be saved by the vaccine. § Choosing between people on the grounds of age would be an injustice. § People may choose to sacrifice their lives for others by forgoing the vaccine but society cannot impose that self-sacrifice on someone. **Overall arguments for: § As some people are more at risk of death from COVID (elderly, HCPs) Healthcare professionals are at a particularly high risk of contracting the virus, and at a high risk of further spreading the virus to vulnerable patients. § For less developed countries who have less HCPS and less resources → distribute here § Vaccine would offer a preventative measure, more cost effective than curative measures for COVID **Arguments against: § Who decides who's most at need? Disagreement between doctors, what to use to measure § Likely that rich countries will be deciding which needs are the most important Everyone has right to healthcare § Patients still value their lives equally § Counter argument for less developed countries → might not have the suitable conditions to store the vaccines (some require very cold temperatures e.g. -70 degrees) § Pharmaceutical companies have invested lots of money to develop these vaccines so they should see a return on investment **Conclusion: Taking all the aforementioned factors into account, we believe that the vaccine should be distributed based on need. In a situation such as this where there are a limited number of vaccines, stratifying individuals based on need allows for those most at-risk to be protected. When making any decision about the vaccine allocation, a transparent approach should be adopted to ensure that there is accountability and fairness.

What is lasting power of attorney

*planned before **can refuse treatment, when it comes to refusing life-sustaining treatment, the attorney must have been given permission to make these decisions when the LPA was made § decisions must be in patient's best interest § if patient doesn't have capacity, LPA makes decisions in best interest. § If LPA lacks capacity, doctor acts in best interests.

Criminal law?

-State punishes the wrongdoer -Police investigate -Crown Prosecution Service -Trial with Jury or Magistrate -Sentence or Release

Transformed clinical method way of structuring a consultation (Stewart et al, 2003)

1. Exploring both the disease and illness experience: In addition to assessing the disease process by taking a history and doing a physical examination, the doctor actively seeks to enter in the patient's world to understand his or her unique experience of illness. Specifically, the doctor explores the patient's feelings about being ill, their ideas about the illness, how the illness is impacting on their functioning and what they expect from the doctor. F = feelings I = ideas F = function E = expectations **FIFE** 2) Understanding the whole person: o integrate the concepts of disease and illness with an understanding of the whole person. This includes an awareness of all the aspects of the patient's life, such as personality, developmental history, life cycle issues, and the contexts in which they live 3) Finding common ground: To define the problem , To establish the goals of treatment &/or management, To identify the roles to be taken by patient and doctor 4) Incorporating prevention and health promotion: opportunity for prevention and health promotion. This may include helping to educate your patients. 5) Enhancing doctor-patient relationship: build on the relationship by including compassion, trust and a sharing of power. Self-awareness is essential as well as an appreciation of the unconscious aspects of the relationship such as transference and counter transference. 6) Being realistic: use all resources effectively to achieve the 5 components above This requires that the doctor is realistic about time, participates in team building and teamwork (either in the hospital or within their general practice) and recognises the importance of effective use of physical and other resources.

Fast Alcohol Screening Test (FAST)

1. MEN: How ofen do you have EIGHT or more drinks on one occasion? WOMEN: How ofen do you have SIX or more drinks on one occasion? 2. How ofen during the last year have you been unable to remember what happened the night before because you had been drinking? 3. How ofen during the last year have you failed to do what was normally expected of you because of drinking? 4. In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Choosing patients based on age - ageism. The argument for and against

Arguments for: § A 60 year old has ALREADY ENJOYED 40 more years life than a 20 year old. § A 60 year old only has a LIFE EXPECTANCY of 15 years whereas a 20 year old if saved can expect to live 55 more years. § A 60 year old if saved has relatively little time to CONTRIBUTE TO SOCIETY compared to a 20 year old. § Fair innings argument: o People generally value their lives equally irrespective of age. o But at a certain age, say 70 years, one can be said to have had a fair share of life. o Any additional life over this 'fair innings' is a bonus and as such does not warrant public resources. **Argument against: § A 60 year old will have been contributing to society for 40 more years than a 20 year old. § Allocation based on age would be arbitrary § The 60 year old and 20 year old both value their lives equally. § Argument against fair innings: o What if only scarce or expensive treatments were rationed on the basis of 'fair innings'? E.g. Organ transplants, ITU facilities. o Some healthy 70 year olds may have a life expectancy of 10-15 years or more. o Is it possible to have restricted ageism policy and not allow ageism to 'creep' in to other areas of healthcare. o Would even a restricted ageism policy inevitably lead to devaluing of the lives of older people?

Should artificial fluids + nutrition be considered medical treatment?

CANH = clinically-assisted artificial nutrtion/hydration. Yes: § artificial food supply is used to keep the patient alive- Just like a ventilator would be § In treatment for anorexia, nutrition is considered medical treatment that cannot be refused unlike food normally § since it needs to be prescribed by a Dr - it should be considered treatment *No: nutrition is a right that anyone with life could be argued to have **Is considered treatment: because they can no longer feed/breathe by themselves, they need medical assistance for adequate nutrition and ventilation. So, although it's a human right to food/air, in this case it's being delivered as a medical intervention and so can be withdrawn. It requires medical expertise to deliver. when we withdraw treatment we recognise that without the treatment they would have died anyway, this is different from actively killing someone. We cannot assist death. We may give morphine to ease pain but not to hasten death.

What is empathy?

Cole and Bird (2000;15) defined empathy as: "Indicating one person's appreciation, understanding and acceptance of someone else's emotional situation... A physician can best build rapport and respond to patients' emotions by communicating empathy". § To make an empathic statement, you need to RECOGNISE what the patient is feeling and COMMUNICATE this to the patient. § After the patient has expressed a feeling, an empathic statement can make a personal connection with the patient. "Yes, I can see you are in pain." "That must have been very difcult managing all those years" "I can tell from what you are saying that it was a distressing time for you." "I hear what you are saying about your depression. It can be extremely difficult." § Alternatively, patients can show their emotions non-verbally and it is helpful for you to note this and let the patient know too. "You still seem worried." "I can see that is hurting." "It is ok to be upset."

Who assesses capacity?

Criteria for capacity detailed by mental capacity act. e.g. locked-in-syndrome are not competent as although they can understand, retain and balance; they cannot communicate the decision back. **Who assesses capacity? § Any adult wishing to take action in connection with or on behalf of an individual thought to be lacking capacity. § Expert assessment of capacity will only be required for a serious decision and when there is doubt or dispute. § Families and carers are not expected to be experts. However, they need to have a reasonable belief in lack of capacity which, if challenged, is based on reasonable grounds.

Daughter need emergency splenectomy and blood transfusion. Father refuses blood transfusion as Jehovah's witnesses and refuses consent for blood transfusion but mother takes surgeon to one side and tells surgeon to do it before surgery. What should surgeon do?

Dr D should give the blood transfusion on the basis of parental consent from the mother. **could do it based on best interests but consent from mother is legally valid and can proceed on basis of consent. Is better to go with consent as is a defence in law against battery. Don't need both parents consent. If have emergency situation and can't get courts decision, continue based on best interests. **If mother didn't say, answer would be option 1 as cannot impose parents religious beliefs on children.

Relationship between ethics and law

Ethics v Law: § In liberal democracies, not everything that is (or widely considered) immoral is illegal. § Law makers must provide decisions which can be universally applied. § Law makers must provide decisions that are enforceable. § Law makers must decide whether the law is the best way to deal with a problem. **Law makers must consider... § Fairness. § Public consensus. § Policy implications. **In UK - 95% agree that abortion is mother's decision to do; 5% believe no even if mother's life is at risk

Implication if capacity for grief or joy makes human life valuable (4/5)

Identifying the morally relevant features that give human life special moral value is central to healthcare decisions that we make at the beginning and end of life. But these features have wider implications for our approach to justice and healthcare in general, and our attitude to other life forms

Children who lack autonomy -should promote their best interests. How to decide best interests?

Now autonomy interests not there. § What constitutes best interests is a question of value not fact. § The values of parents may be different to the values of the health professionals. § Who decides what is in a child's best interests?

B is a 56 year old woman with hypertension and schizophrenia. She is admitted into hospital with a life-threatening aortic aneurysm. The vascular surgeon has seen B and explained to her that she needs an operation. However, she refuses to consent to the operation. She says that she would rather die than have a graft. Her psychiatrist has reviewed her and says that she is mentally competent. Her husband tries unsuccessfully to persuade her to have surgery. Can the surgeon proceed? A) No, B has not given valid consent. B) Yes, since she may die without surgery. C) No but surgery can proceed if the Court agrees it is in B's best interest and gives proxy consent. D) Yes, since B's decision shows that she is not competent. E) Yes, provided surgery is in her best interests.

Option A. § A competent individual has an absolute right to refuse treatment even if that refusal may lead to severe and permanent harm or death. § The refusal may be based on a good reason, an unwise reason or no reason at all. § Provided the refusal is competent, informed and voluntary it MUST be respected. § Nobody, not even the Court, can give consent on behalf of a competent adult. § A person must not be judged to lack competence solely because they have made an unwise or unreasonable decision. **Treating the patient against their will would be an offence and so therefore their refusal of treatment must be respected.

Personal racism types

Personal Racism This occurs when individual attitudes lead a person to treat others less favourably on the basis of their colour or ethnic group. Such behaviours can be: 1) unconscious, when the behaviour is not deliberate but is based on stereotyping. 2) conscious, with deliberate acts of discrimination 3) overt, where it is clearly obvious that discrimination is taking place 4) covert, where discrimination is not easily apparent

What is resilience?

Resilience is about personal strength; it's about how well we can absorb and ignore the knocks and experiences of everyday life at home and work and maintain the energy and determination to drive through ideas and actions in the face of challenges. § The Resilience Quotient questionnaire is a general gauge of how resilient you may be. The higher your score, the more resilient you are. Don't worry if your resilience ratings weren't as high as you'd hoped or expected. It's not too late to § resilience is a skill that can be learnt and practised. Resilience can be considered as being about personal strength; it's about how well we can absorb and manage the knocks and experiences of everyday life at home and work and maintain the energy and determination to drive through ideas and actions in the face of challenges.

Advantages of PCI (patient centred interviewing) for patients

Stewart (2001) has identified factors that patients consider as signals of the doctor offering patient-centred care. In consultations that demonstrate PCI, the clinician: § Explores the patient's main reason for the visit, concerns and need for information § Seeks an integrated understanding of the patient's world - that is, seeing them as a whole person with emotional needs and facing real life issues § Finds common ground on what the problem is and mutually agrees on management § Enhances prevention and health promotion § Enhances the continuing relationship between the patient and the doctor

Advantages of PCI (patient centred interviewing) for clinicians

Stewart, (2001): § allowing basic medical tasks to be accomplished § informative, (providing both technical information and expertise and recommendations for behaviour in a way that is understandable and motivating) § facilitative, (in that all the patient's concerns are likely to be established) § responsive (to the patient's emotional needs and concerns); § participatory (so that patients have a responsible and authentic role in the decision making).

Lavina is a 41 year old shop assistant. She is pregnant and has gone two weeks past her due date. The baby is breech. The obstetrician advises her to have a caesarean section. Despite encouragement from her husband, she is very nervous about being awake while she is being operated on. After a lengthy discussion with the obstetrician and anaesthetist she gives consent for the elective caesarean section under general anaesthetic. A healthy baby boy is delivered without complications, but when the surgeon inspects the ovaries he finds a very suspicious tumour of the left ovary. The surgeon thinks it is clearly in her best interests to remove the affected ovary. What should the surgeon do?

Surgeon must close up and obtain consent from Lavina before removing the ovary. Best interests in this situation is irrelevant. Lavina will regain mental capacity when she recovers from the general anaesthetic. Her husband cannot consent on her behalf. There is non immediate necessity to remove the ovary. Therefore the surgeon must wait until she has regained competence and then seek consent. See section 4a, 'Legal Principles' of the autonomy, paternalism and consent e-module. **only understands that she's having a c-section. Even if wanted to do biopsy would have to ask afterwards.

Confidentiality after death

The GMC, BMA and DOH say that confidentiality must continue beyond death. Otherwise doctor could be found facing disciplinary action The following should be taken into account: § whether disclosure of information may cause distress to, or be of benefit to, the patient's partner of family, § whether disclosure about the deceased will in effect disclose information about the patient's family or other people, § whether the information is already in the public domain or can be anonymised § the purpose of the disclosure.

What can YOU do about racism?

The combined action of individuals make a difference. The following may be helpful: § Recognise that societal racism is unconsciously internalised by us all. This is not your fault. § Do not feel guilty and thus paralysed and unable to act. You can do something. § Develop greater awareness of your attitudes to difference and your behaviours. § Participate in and promote appropriate equality and diversity training. § Review your working practices-for example, consider and implement ways of improving quality of care for diverse communities. § Promote steps to achieve a representative workforce, and tackle racial harassment of staff and patients. Source; Kai J (2003) Learning to respond to diversity. In: Kai J (ed). Ethnicity, Health and Primary Care. Oxford, Oxford University Press.

Tom, dick and harry scenario

Tom Tom is 43 and a smoker. He is a single father of 2 young boys. He has respiratory failure secondary to a chickenpox pneumonia. He urgently requires an ITU bed. Dick Dick is 22 and carries the gene for Huntington's disease but has no symptoms of the disease at present. He has a life expectancy of 45 years. He fell asleep on the sofa whilst smoking. He was rescued from his burning flat but had suffered severe smoke inhalation injury. He urgently requires an ITU bed. Harry Harry is 63. He has acute respiratory failure from an adverse drug reaction during a phase 1 trial of a new drug for rheumatoid arthritis (his wife suffers from severe rheumatoid arthritis). He urgently requires an ITU bed. You have one ITU bed. Who do you save?

Taking alcohol history

Who to ask? - everyone •Do you drink alcohol? •How much would you say in an average week (or per day?) •Is that every week/day? •Suggest a range " Would that be 1-2 pints or 5-6?" •Ask separately about wine, beer and spirits **Classically 1 unit = a glass wine, half pint beer, one measure spirits

What is moral distress?

§ 'When one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action'- 1.Jameton A. Nursing Practice: The Ethical Issues. 1984 § Is not the same as an ethical dilemma where there are two or more justifiable solutions and you need to choose one § May involve an emotional response (anger / frustration / anxiety) but also guilt (as a medical professional I am doing something wrong)

What is alcohol limit?

§ 14 units/per week for men and women § should spread out § Up to 70% Emergency Department admissions related to alcohol

Advanced Decisions - changing your mind

§ The withdrawal may be oral § Can be withdrawn at any time as long as maker is COMPETENT § Once the maker loses competence it cannot be withdrawn

Best interests checklist

§ also considering views of family and carers

Mental capacity act

§ now more people under MCA due to living longer

Preparing for giving info

• Get your facts together, determine what information you wish to impart • Method - face to face / phonecall / videocall • Time - consider the time you have available and try and ensure you won't be interrupted • Patient - depending on the situation consider friend / relative / interpreter needed

Example of communication, ethical and PPD issue in scenario

• Giving information is a dynamic, interactive process • This is not simply a matter of information transfer • Ensuring recall does not ensure understanding • The delivery of information needs to attend to the situational variables and other contingencies to do with the patient's information needs

Communicating with telephone conversation with consultant

• Prepare what you want to say in advance • Identify yourself at the start of the call • Have relevant information at hand • Deliver the key relevant information • Speak clearly at all times • Offer to repeat information • Check that information is heard and understood • Clarify instructions by paraphrasing • DOCUMENT the call

English as a second language

•Check pronunciation of name •Use simple sentences •Deliver information in small chunks - avoid technical terms and abbreviations. •Check patient's understanding - How? •Pay even closer attention to picking up verbal and non-verbal cues •Pay even closer attention to signposting •Use diagrams if you need to •Google translate

How we students can support each other in moral distress

•Debrief helpful - form your own small group (3-5) students to discuss difficult cases / situations. Support each other if need for some kind of action •Schwartz round programme for students •D/w supervising clinicians, academic tutor, course leads

Family member or professional interpreter?

•From the patient's perspectives there may be a reluctance to discuss sensitive subjects in the presence of a family member •Mistranslation can add further difficulty •Using members of the family as interpreters may introduce difficulties due to family relationships, emotional involvement, maturity of the relative concerned if a child, and so on •Rosenberg et al (2011) found that in consultations with a professional interpreter there was increased likelihood of talk of emotions and follow up when compared with consultations using a family member •Lindholm (2012) identified a correlation between use of a professional interpreter and length of stay in hospital. Patients receiving interpretations services on admission or discharge on the whole stayed less time in hospital compared to patients who didn't receive interpretation services

Communicating with hearing loss

•It's easier when you know the context •It is essential to be looking at the person's face •Background noise or people talking together makes it worse •Shouting doesn't help •Many people will lipread without knowing they do it!

The importance of moral distress - what effects can it have on us?

•Why is it important to recognise / act on moral distress? •And why do some clinicians seem not to recognise / act on it? -E.g. case in the article? -Why does SpR seem oblivious? -Why do other students not do or say anything? **moral residue crescendo effect (epstein et al, 2009): § if repeatedly going through these situations which are not resolved, you get it lingering and builds up. § 'Moral residue' left over after morally distressing incident has taken place § Builds up over time - crescendo effect § 'That which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised.'

Effect of respecting autonomy in medical care

**Autonomy and Medical Care: § Respecting autonomy is likely to: § Help doctors give better advice. § Enable better decision making. § Improve mutual understanding. § Improve trust. § Improve adherence.

Women's rights for autonomy in abortion argument

**respect for autonomy § Autonomous choices should be respected. § As individuals we should be able to decide what does or does not happen to our bodies. § A woman can make an autonomous choice to have an abortion. § Therefore provided the choice is autonomous it is morally permissible for a woman to have an abortion. **But... § We can limit the autonomy of others if their autonomous choices harm others. § An abortion harms the fetus. § Therefore, it is an acceptable limit to autonomy to stop a woman having an abortion. **However... If a fetus isn't a person does killing a fetus constitute a legitimate harm in terms of limiting the autonomy of a woman?

Depending on the circumstances there are a range of people who may lawfully make decisions on behalf of someone lacking capacity under the mental capacity act

1) Carers 2) Health care professionals 3) Donee of LPA 4) Court appointed Deputy 4) Court

The result of moral residue crescendo

1) Compassion fatigue: -Numbing of moral sensitivity through recurrent exposure to morally distressing incidents 2) Burnout: -Unable to tolerate repeated episodes of moral distress

Disclosure after death exceptions

After death, can disclose when: § Assisting police or for Coroners inquiry § Under s251 of NHS Act 2006; for research, in public interest, education. § Death certificates § National audits § When a partner, close relative or friend asks for information about the circumstances of an adult's death, and you have no reason to believe that the patient would have objected to such a disclosure, § When a person has a right of access to records under the Access to Health Records Act 1990

AUDIT - C

Alcohol Use Disorders Identification Test -Consumption

W is a 51 year old woman with a history of schizophrenia who is currently stable on medication. During a medical consultation she says 9 years ago she smothered her baby who was thought to have died from SIDS. At the time she was not delusional or psychotic. W says she feels relieved by telling him. She said she did confession as she knows he can't say anything. what should GP do?

Confidentiality can be lawfully breached it is necessary for the prosecution of serious crime. Should report to police as serious crime has been committed. There is not a legal duty, so don't have to do but should report it as a professional duty - GMC may have issue with that.

Be aware of, and sensitive to, factors which vary among individuals and groups which may be relevant to health care, for example:

Health beliefs and attitudes to illness Negative experience or fear of health services Stigma attached to particular problems (e.g. mental health) Fear of death Particular problems encountered by refugees and recent immigrants Socio-economic problems Fear of attack, harassment and victimization and other stressful situations

Autonomy and acquired mental disability

If a person loses autonomy through acquired mental disability e.g. head injury, dementia, should their previous values, aspirations, likes and dislikes be considered when trying to work out what is in that person's best interests? **Advance decisions: § Dworkin and advance decisions § Ronald Dworkin has argued that autonomous individuals have an idea of how their lives should unfold and how their lives should end. § Respecting autonomy requires us to respect these values. § Therefore an individual's previously stated autonomous wishes should be DETERMINATIVE if autonomy is subsequently lost. **OVERALL, The lack of capacity, particularly in the case of mental disabilities, does not equate to lessened value of life

What is the basic principle of confidentiality

Information gleaned by a Health Care Professional should not be divulged to others. § even mentioned in hippocratic oath

Criminal law

Murder: a) defendant that caused the death of the patient b) the defendant intended to cause death or grievous body ham c) defendant cannot successfully raise a defence **Mercy killing is NOT a defence

Musculoskeletal symptoms

Pain, stifness, swelling of joints Diurnal variation in symptoms (i.e. With time of day) Functional defcit Muscle wasting Trauma

Case Study - St George's Healthcare Trust v S (1998)

S, was a competent woman, 36 weeks pregnant with pre-eclampsia. Her doctors advised her that a caesarean section was necessary to save the baby's life and her own. S refused. Ethically, should the caesarean section have been performed despite S's competent refusal to save the life of the unborn child? **The doctors sectioned S under the Mental Health Act and performed the caesarean section without her consent. A healthy baby was delivered S subsequently took the case to court. The Court found that the doctors had acted unlawfully. The fact that a woman is pregnant does not affect her legal rights in anyway. She can engage in (lawful) behaviour that is harmful to the fetus. She can refuse medical treatment including caesarean section even if it risks the life of the baby. If you want to consider autonomy and the ethical obligation of a pregnant woman go to the O+G case study in the autonomy e-module.

Neurological symptoms

Sight Hearing Smell / taste Seizures, faints, funny turns Headache Pins and needles (paraesthesiae) Weakness "Do your arms and legs work?" poor balance Speech problems Sphincter disturbance Higher mental function and psychiatric symptoms Diferences between right and left

Before getting started the interpreter is asked to obtain the following:

The name and role of the health-care professional Date and time and probable duration of the consultation/interaction The name, age and sex of the client The context in which the consultation will take place e.g. to obtain informed consent The exact language and dialect spoken by the patient Whether any reading or written information is required to be translated Whether the relative or carer or advocate will be present

Checking back should be done throughout the interaction (Mares et al, 1985)

Try not to ask "Do you understand?" or "Is that alright?" You are almost bound to get "yes" for an answer Try also to avoid questions to which the hopeful/desired answer is "yes" - Phrase the question diferently Ask the patient to explain back to you what s/he is going to do Do not take nods and other gestures or expressions at face value

Taking a sexual history

Who to ask? - NOT all your patients § This is a set formulaic history that you are unlikely to need at present § However don't ignore the possibility.... •Contraceptive pill and pregnancy are often implicated in disease •Abdominal pain in a woman •Urinary tract infection in men or women **Gender and sexuality: § It may be appropriate to ask a patient about their sexuality if it is relevant to the history e.g. " Do you mind me asking, is your partner a man or a woman?" § It may be appropriate to ask a patient, ...if they identify as the gender they were born with § ...or which pronouns they would like to be addressed by.

Recreational drug use questions

Who to ask? Consider everyone but especially- heavy drinkers, smokers, people who are stressed, tired or have mental health problems or unexplained symptoms •Use of the term "recreational" less judgemental than "illicit" or "street" and "taken" better than "used" e.g. "And do you mind me asking have you ever taken recreational drugs?

Alcohol- screening tools

Who to screen for problem drinking? - ideally routine (especially in a primary care and ED setting) Consider screening when: •Registering a new patient. •Screening for other conditions. •Managing a chronic disease (for example diabetes, hypertension, or chronic heart disease). •Carrying out a medication review. If screening everyone is not feasible or practical, focus on people who have an alcohol-related condition or who are at increased risk of harm from alcohol.

How to probe sensitively

e.g. death of family member, sexual history § acknowledge difficulty: "I can see this is difficult for you. Do you want to go on...? § normalising: "Many patients find it difficult to talk about resuming sex after this sort of surgery, is this dififcult for you?" § can also probe into other aspects of the patient's life - their sense of place in their community, their world view/religious beliefs and how these things relate to their illness experience. Many patients find great comfort in religion and this can be a very important factor helping them cope with illness. **Surveying for other problems: "So far you have mentioned that you have been experiencing headaches and neck pain, is there anything else?"

B is a 73 y/o retired history teacher. Admitted with life-threatening gangrene of left food. Is in significant pain, confused, don't know date/location. Wife says has been forgetful for years and doesn't recognise family sometimes. The vascular surgeon has seen B with his wife and says wife will need below leg amputation. It is clear that B doesn't understand what is being explained. B says whatever you think best doctor and wife offers to signs consent. Should proceed with surgery? a) yes since B's decision shows that he is not competent and therefore the decision is based on B's best interests. b) Yes, provided surgery is in B's best interest c) Yes provided the wife signs the consent form d) Yes, provided B signs the consent form e) Yes, since he may die without surgery

is b. **not a) as his answer doesn't indicate he doesn't have capacity, his background does c) his wife can't consent for him unless as LPA but that's not indicated her e) doesn't need to be dying to do surgery as long as in best interests

Raising concerns a medial students - legal or moral duty

medical students are not registered with the GMC and are not employees of their placement providers. This means that neither the GMC nor placement providers can legally require students to raise concerns. **HOWEVER, students do have a formal relationship with their medical school, which will expect them to raise concerns. Medical students also have a MORAL responsibility to raise concerns about patient safety, dignity and comfort. Professionalism is not about doing the minimum - it is about doing what is necessary to protect patients.

Showing active listening

o Lang et al (2000) made a call for Active Listening as a way to ensure that patients ICE provide us with clues about patient illnesses. § Use active listening verbal (staying with patient's topic; using patient's words; reflection) non-verbal (eye contact; nodding) § Use other non-verbal behaviours (body posture; gestures; facial expressions, nodding)

Maslow's Hierarchy of Needs

physiological, safety, love/belonging, esteem, self-actualization § Essentially the lower level needs must be addressed, although not necessarily fully, in order to move to the highest level of 'growth'.

What does GMC, BMA, MPS, Department of health, Royal colleges do?

§ GMC: The GMC is the regulator. It is an independent organisation with a statutory role to "protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine". Registration with the GMC is obligatory and it is at the discretion of the GMC whether or not a doctor is licensed to practise in the UK. The council itself is comprised of 24 individuals - half of whom are doctors and the other half of whom are lay members. Their functions can be divided into 4 main areas: o Registration - keeping an up-to-date register of qualified doctors. o Good Medical Practice - offering guidance to doctors and medical students on the fundamentals of being a good medical professional and keeping this guidance up-to-date. For example, the recent changes to the guidance on patient confidentiality. o Medical Education - setting the key aspects of the medical curriculum in the UK and regulating the medical schools offering this education. o Regulation of doctors - dealing "firmly and fairly with doctors whose fitness to practice is in doubt" § Dep of health - "health and social care policy, guidance and publications for NHS and social care professionals": The Department of Health is part of the civil service. Their ultimate aim is to "ensure better health and well-being, better care and better value for all". Their key roles are setting policy direction and priorities, and supporting delivery of healthcare policy for the current Government. They are accountable to Parliament and the public. They do not directly deliver healthcare but direct the NHS and other related organisations as to what they should be delivering to the public. § BMA - "looks after personal and professional needs...Represents doctors": The BMA is a trade union for doctors. It aims to "represent doctors from all branches of medicine all over the UK". Membership of the BMA is voluntary (and comes with the additional perk of a weekly copy of the BMJ!). Over two-thirds of doctors are members. The remit of the BMA is broad. It aims to voice the collective views of doctors on all relevant topics from public health and the state of the NHS, through to current ethical or scientific debates, as well as issues concerning contracts or training. § Medical defence organisations (MPS/MDU )-"professional indemnity and expert advice: such as the Medical Defence Union and the Medical Protection Society. They provide professional indemnity and advice to doctors (and medical students) facing legal or ethical problems (in return for an annual fee). § Royal colleges - supervise training, examinations, audits, guidelines, representation and promotion of specialty...: Different medical and surgical specialties has their own royal college. Examples include the Royal Colleges of: Surgeons, Physicians, Obstetricians and Gynaecologists, Psychiatrists and General Practitioners. Each Royal College aims to enable their members achieve a high standard of care for their patients. Membership requires qualification into that specialty by the passing of examinations and completion of a certain amount of clinical training. To this end the Royal Colleges have key roles in training, educating and assessing their prospective and current members. In addition to this role, they also aim to promote and support research and audit, provide advice for doctors, the public, the government and health trusts/ authorities alike.

Principle of Equal Consideration in MCA

§ Is there evidence of lack of capacity? § Decision should not be made solely based on an unwise decision. § Decision should not be based on:Appearance.Assumptions.Age.Race.Gender.

Examples of cultural beliefs and healthcare

§ Ramadan directly influences the control of diabetes § Pork-based synthetic insulins and beef insulins are not acceptable to devoted Muslims (Queshi, 2002) § Customs in Ramadan :Fasting from dawn to dusk ,Prayer and meditation Ifari, evening feast celebrated with family and friends, Spiritual activities (Taraveeh- night prayer) (Queshi, 2002)

Respecting patient autonomy in practice

§ should underpin every interaction in medical practice § Respecting autonomy does not simply mean handing over decision making **Autonomous choices: § Not all choices are autonomous. § Autonomous choices require ability to: a) Understand information. b) Form values. c) Make decisions based on values and understanding of information. d) also has to be a reasonable range of choices

Delivering information in informing a procedure

§ signpost - 'I'd like to talk to you about...' § organise the explanation - logical and sequential § for example - on the day this will happen, this procedure will involve § check understanding - 'Would you like me to repeat anything?' 'Can you summarise what I've told you?' 'Does what I've told you make sense?'

Two stage test of capacity

§ some examples of impairment - dementia, alzheimer's, head injuries, intoxication, learning difficulties, PVS, psychosis, delirium, withdrawal

Responsibilities as a medical student

§ taking action if aware of addiction issues personally or affecting colleagues § whistle-blowing, especially if a patient's safety is at risk

Remaining AUDIT C questions

§ young people are drinking less alcohol

What is compassion?

§ "A sensitivity to the suffering of self and others, with a deep commitment to relieve it" (Dalai Lama) § "A deep awareness of the suffering of another coupled with the wish to relieve it" (Chochinov, 2007) Fear, stress activates the Threat System and shuts down the affiliative system. People 'hunker down' for survival. In a high stress, high threat environment, a person may respond with increased aggression, reduced compassion, reduced ability to self-soothe, and reduced motivation and creativity.

The Case of Tony Bland

§ A landmark legal case § An avid Liverpool supporter, aged 18 he was severely injured during the 1989 Hillsborough stadium disaster. § He suffered a hypoxic brain injury causing 'catastrophic and irreversible brain damage'. § He entered into a Persistent Vegetative State (PVS) and was fed through a nasogastric tube. § He had an indwelling catheter and suffered frequent infections treated with antibiotics. § After 4 months parents requested treatment be discontinued as they felt his life was not worth living in his current state. **What factors would you need to determine about continuing CANH in Tony Bland's best interests? § Although this case was heard before the Mental Capacity Act was enacted, the following legal principles in determining best interests would now apply: a) Has he made an advance decision (in which case, if valid and applicable this will determine the treatment) b) Has he appointed any one to be consulted (by creating a Lasting Power of Attorney)? c) What is the likelihood of recovery? d) Is he likely to regain capacity? e) Is it possible to ascertain his previous views/ wishes and if so what are they? f) What are the views of people close to him - in particular his parents? g) Is there any indication of his beliefs or values that could help determine what his wishes would have been? h) The decision must not be motivated by a desire to bring about his death.

The Mental capacity Act creates two new public bodies to support the statutory framework, both of which will be designed around the needs of those who lack capacity

§ A new Court of Protection - The new Court will have jurisdiction relating to the whole Act and will be the final arbiter for capacity matters. It will have its own procedures and nominated judges. § A new Public Guardian - The Public Guardian and his/her staff will be the registering authority for LPAs and deputies. They will supervise deputies appointed by the Court and provide information to help the Court make decisions. They will also work together with other agencies, such as the police and social services, to respond to any concerns raised about the way in which an attorney or deputy is operating. A Public Guardian Board will be appointed to scrutinise and review the way in which the Public Guardian discharges his/her functions. The Public Guardian will be required to produce an Annual Report about the discharge of his/her functions.

Adam is a 27 year old man with a history of paranoid schizophrenia. Two years ago he was detained under section 3 of the Mental Health Act for treatment of his schizophrenia. He is currently well but unhappy with his treatment. He feels that his anti-psychotic medication is numbing his mind and has turned him into an overweight diabetic. He has decided to stop his medication. Before doing so he writes an advance decision stating that he refuses all anti-psychotic medication even if his schizophrenia necessitates admission into hospital. Nine months later, Adam is having auditory hallucinations and paranoid delusions. § What are the side effects of anti-psychotic medications? § Ethically, assuming that Adam's schizophrenia is not posing a risk to others, should his advance decision be respected? § What is the legal position regarding advanced decisions to refuse antipsychotic medication?

§ Adam is an adult with paranoid schizophrenia, a serious mental health condition, which carries a significant risk of self-harm. § He has previously been compulsorily detained and treated under the Mental Health Act for his schizophrenia. § We are told that he responded well to treatment and remained well for 2 years on anti-psychotic medication. § But although well he is unhappy with the side effects caused by his medication and draws up an advance decision saying that he refuses anti-psychotics in the future even if he becomes unwell. § Anti-psychotics have a wide range of side effects and data from randomised controlled trials shows a very high discontinuation rate amongst trial participants due to side effects. § Often doctors seem to focus on the physical side effects but for many patients it is the psychological side effects: emotional and mental numbing that lead then to discontinue the medication. § It appears that Adam has made a competent refusal regarding anti-psychotics in the future. § Legally this is not binding if he is sectioned again under the Mental Health Act because Advance decisions cannot be made to refuse treatment given under the Mental Health Act. § This seems at odds with the increasing pre-eminence given to autonomy in both law and ethics. § For any other form of illness, a competent adult has an absolute right to refuse treatment even if that refusal will result in severe harm to the individual or even their death. § The right to refuse treatment even if that treatment is in your best interests is enshrined in the Mental Capacity Act. § The Act specifically identifies Advance decisions as the one situation in which best interests do not apply when making treatment decisions for a patient who lacks mental capacity. § Why should the situation be different for mental illness? § One argument in defence of this position is that patients with severe psychiatric illness may pose a risk to others and it is generally agreed that serious harm to others counts as a legitimate reason for limiting the autonomy of an individual. § However, this defence only holds water if Adam is genuinely posing a serious risk of harm to others. § Another argument is that Adam's refusal is not really a competent decision. Arguably, it is unlikely that he was mentally competent at the time he was sectioned under the Mental Health Act. Therefore can he really understand the consequences of his refusal of treatment? § Legally and ethically, the difficulty with this second argument is that it sets a very high threshold for competence and arguably a much higher threshold than we would set for refusal in other forms of illness. § Thus in the case of Ms B, the quadrapelegic who refused to continue to be ventilated, the Court found that the fact that she had not tried a period of rehab in a spinal injuries unit (as recommended by her doctors) did not constitute sufficient grounds to say that she did not really appreciate the consequences of her decision. § To take a more everyday scenario, lots of people with diabetes miss insulin doses or do not monitor their blood sugars resulting in poor glycaemic control and a high risk of serious complications such as dialysis or blindness. The fact that they have never experienced blindness or renal dialysis does not constitute grounds for saying that these individuals do not fully understand the implications of their actions and are therefore incompetent. § Instead, we accept that this is their autonomous choice. § Nonetheless, the position remains that if it is deemed necessary to section Adam under the Mental Health Act then his Advance Decision is not legally binding. § However if he is not sectioned then his Advance Decision is binding and he cannot be treated with anti-psychotic medication. § The Mental Capacity Act is still in its infancy and few people have drawn up advance decisions. It remains to be seen whether the current position of the Mental Capacity Act with regards to Advance Decisions and the Mental Health Act would withstand a legal challenge (e.g. as contravening Adam's human rights under the Human rights Act).

Consent presumptions

§ Adults (from age 16 onwards) - Are assumed to have mental capacity to make a decision regarding treatment - Unless there is contrary evidence § Children (less that 16) - Are assumed to NOT have mental capacity to make a decision regarding treatment - Unless there is contrary evidence (gillick competence) **The legal situation regarding individuals aged under 18 but 16 or older is slightly more complicated, particularly regarding refusal of treatment.

IT and confidentiality

§ Advances in IT can greatly improve information sharing but also increase the risk of breaching confidentiality. § Data storage devices allow large amounts of person patient information to be stored facilitating audit, research and administration but if lost or stolen may result in breaches of confidentiality on a massive scale § There is therefore a delicate balance between ensuring adequate protection of personal information and efficient legitimate access to such information.

Alcohol and health

§ Alcohol is a causal factor in more than 60 medical conditions, including: mouth, throat, stomach, liver and breast cancers; high blood pressure, cirrhosis of the liver; and depression § Affects anti-social behaviour; also drink driving and road traffic collisions, domestic violence

when do best interests not apply

§ All adults are presumed competent unless shown to lack capacity. § Mental capacity is decision specific. § Any decision made on behalf of an individual lacking mental capacity must be in the best interests of the individual. § Advance decisions are the only situation where best interests do not apply.

When is an advanced decision inapplicable

§ An advance decision will be invalid if: The maker has competently withdrawn the advance decision The maker has created and LPA after the advance decision AND given the LPA the power to make the decision in questions The maker has acted in a way inconsistent with the advance decision **An advance decision may be inapplicable if: There has been a significant change in circumstances not addressed in the advance decision eg pregnancy There has been a significant change in the prognosis/ treatment of a condition since the advance decision was made

Case of Baby Charlotte Wyatt

§ An important moral question is when ought doctors to strive to keep patients alive and when ought they to allow them to die? o To illustrate the different perspectives in this decision making we will use the real case of Baby Charlotte Wyatt § born Premature - 26 weeks gestation § Chronic Lung disease on ventilatory support § Blind § Deaf § showed signs of brain damage § Incapable of voluntary movement § Thought to be in pain § Her parents and the doctors were unable to reach a consensus. The case was taken to the High Court for a decision. ** Although the original judgment concurred with the doctors' decision not to provide further ventilatory support, Charlotte continued to survive. Her case was revisited over the proceeding 3 years but she made some improvement and was eventually discharged from hospital aged 3. It was last reported in 2009 that, although she continued to require oxygen, she could now stand and walk with a frame and appeared to enjoy listening to nursery rhymes. **Sanctity of Life vs Quality of Life: In the previous case of baby Charlotte two key arguments that were presented in court were arguments relating to the sanctity of life and the quality of her life. In deciding what to do in this case we may have to make a judgement as to whether their quality of life is so poor as to not be worth preserving?

An individual who lacks mental competence ___ give consent ?

§ An individual who lacks mental competence CANNOT give consent § Mental competence is task specific § Under common law no one can consent on behalf of an adult who lacks mental capacity **Treatment of an adult who lacks capacity is lawful under common law if it is necessary. Treatment is necessary if: § it cannot wait until such a time that capacity was regained, if this was a possibility AND § It is in the patient's best interests **Problems with the common law: § How is best interests defined? § Who determines best interests? § What is the role of previously expressed competent wishes in determining best interests? § How do we ensure the rights of those lacking capacity are protected?

What do advanced decisions apply to?

§ Apply only to refusals of treatment § Must be: Informed Competent Voluntary § Need not be written, can be a witnessed oral statement § Maker must understand consequences of their decision **NOT covered by the Mental Capacity Act: § An advance decision cannot refuse: Basic nursing care Hydration and nutrition that is given orally, artificial means are considered medical treatment

Principles of the Children Act 5

**Abuse of Children: § Largely outside the scope of this module. Non accidental injury will be considered in more detail in your year 5 teaching. § The Act provided details of the types of situations whereby the Local authority is obligated to intervene. § Categories that exist are: o physical o sexual o neglect o emotional § Each local authority is required to keep a list of those who are considered "at risk".

Unit of alcohol

**Classically 1 unit = a glass wine, half pint beer, one measure spirits Units = alcohol by volume (ABV) x volume in ml. 1000 A 1L bottle of 40% spirits = 40 X 1000 1000 = 40 units

Should coronavirus vaccine be distributed by free market?

**For: § justice - access for everyone § autonomy - people can choose to buy § competitive market - free marker --> based on demand, maximise choice and cheaper § healthcare can be viewed as commodity **Against: § ageism § QALYs not maximised § need vs ability to access § effectiveness and complications of vaccine § as high demand vs supply --> drive price up and then many cannot afford it **should not be by free market: most vulnerable can be saved and saving lives maximised

Growth vs. Fixed Mindset

*Fixed:* has to prove smartness, smart people do not make mistakes, effort is unneccesary, success is natural, good score= smart *Growth:* learning and stretching ones mind is achieving, wants to make progress/accepts challenges, effort is neccessary/you get what you give, good score= hard work

Choosing between diseases using evidence based medicine

*NICE uses this. § Use clinical evidence to determine what interventions should be provided. § Biased towards medical perspective as to what counts as health benefit. How do we determine effectiveness, is still a value-based judgement (based on threshold you set (e.g. increased LE by 1 month or 3months is effective BUT also how we measure effectiveness. Medical perspective focuses on number of months gained in cancer patients, but for patients this might be to be free from side effects. § Interventions where little research is done are likely to be de-prioritised (as less evidence) § Interventions where there is a lot of research likely to be prioritised. § Potential for industry bias. (major funder of clinical research, more likely to fund pharmacological over non-pharmacological treatments)

What are some possible definitions of death?

1) loss of conscious awareness (lack of cerebral cortex function) 2) When heart and lungs stop 3) Permanent loss of brainstem functions (can no longer have integrated functioning of body as a whole) 4) When all cellular functions and processes stop 5) Desoulement (when soul leaves the body)

Substituted judgement or best interests?

UK system is based on best interests - more objective. § issues with SJ - people can change their opinions, values and beliefs over time; whose judgement - is it acc richards or just ours? § issues with BI - how to weight up the different factors

Example SBA: Britney is 9 y/o american girl at boarding school in england. At school, she sustains serious head injury. brought into hospital by teacher Mr B. Surgeon says she needs urgent surgical drainage. Needs it or will die. Calls parents but neither available at the moment. What should she do? a) Britney is likely to be gillick competent and therefore her consent should be sough b) In an emergency the doctor can sign the consent form as is it on Britney's best interests c) Ms C should operate under the basis fo necessity as is it is britney's best interest d) As britney is at school, Mr B can act in loco parentis and sign the consent form e) This is a major operation and therefore verbal consent must be obtained before proceeding

c) Ms C should operate under the basis fo necessity as is it is britney's best interest *doctor cannot sign consent form, only keyholders (parents/guardians etc) *Gillick competence not apply as big head injury § This is an emergency and cannot wait until the consent of one of her parents is obtained. Only someone with parental responsibility can give consent for the operation. Neither Mr B nor the doctor has parental responsibility in the legal sense. However, surgery is clearly in Britney's best interests and therefore can be performed under the legal principle of necessity. Britney is 9 and critically ill and will not be Gillick competent.

P comes into A&E following a RTA smelling of alcohol. Thinks he's knocked over a statue. A passerby took by P's number plate. Receptionist confirmed that he in A&E. Police want his address and confirmation if he's been drinking. What to do? a) B may only give the address if the police go to court and a judge asks her b) B may give both address and report any suspicions regarding P's alcohol intake c) Under the road traffic act, B must provide the police both the address and evidence to suggest that P was driving under alcohol influence d) B may not disclose an personal information without consent e) B may only give the address

e) B may only give the address. **only name and address § Under the 1988 Road Traffic Act there is a statutory requirement to provide information to assist the police in the identification of a person charged with a road traffic offence. However, under the Act there is no statutory requirement to given any other personal information or to provide evidence unless you are directed to by the Court In Confidentiality: NHS Code of Practice 2003 the Department of health stabs that 'theft, fraud and damage to property' would not usually provide reasonable justification for breaching confidentiality.

enhanced autonomy model (Quill et al, 1996)

encourages patients and physicians to actively exchange ideas, explicitly negotiate differences, and share power and influence to serve the patient's best interests. Recommendations are offered that promote an intense collaboration between patient and physician so that patients can autonomously make choices that are informed by both the medical facts and the physician's experience

Healthcare and global justice

§ Globally there are huge inequalities in healthcare and mortality. § Is there a global right to a decent level of healthcare? § Do we have an obligation to ensure everyone has access to decent healthcare?

Medical best interests v best interests

§ Medical best interests do not necessarily equate with overall best interests § Health care professionals may often not be in the best position to determine overall best interests § Views of carers, close family are likely to be important § What about people with no close family or care

Choosing between diseases rather than patients

§ Rather than choosing between people should we choose between diseases? § We could decide that a right to health care applies to everyone. § But that certain physical problems do not fall within that right e.g.Cosmetic surgery.Fertility treatment. **this way not saying some lives more important than others but saying that some conditions don't fall under the branch of necessary healthcare.

patient with sepsis --> delirium. refuses IV Abx. what to do?

§ the MDT made consensual decision to treat her § this required IV Abx, which required restraint and mild sedation. There are local policies and NICE guidelines to guide you. § By day 5, patient improving **N.b. - section = detained under mental health act. don't worry too much about this - mental capacity act is what need to focus on.

Communication challenges when communicating with a patient whilst performing a procedure on them

• Performing the procedure whilst talking to the patient • Picking up non-verbal cues • Distractions • Giving instructions - patient could be under the influence of alcohol • Cognitive load