1 to 1- Consent and capacity Flashcards
Whilst you are undertaking the x-ray, the patient tells you that he is not very happy as his daughter, who is his main carer, is mistreating him. The two of them share a house together and whilst she has never hit him, she is verbally abusive to him daily and keeps him locked in his room. He is only allowed out of his room for doctors and hospital appointments.
The patient is insistent that he does not want anyone else to know as he does not want to get his daughter into trouble; he just wanted to tell someone today.
For 7 marks: describe how you would manage this situation
Reassure patient – required for full marks
Ask questions to clarify detail
Check that he lives alone with his daughter – required for full marks
Whilst talking to the patient, assess his capacity to give consent to withhold this information
Explain that it would be best if adult safeguarding were informed
However, if the patient appears to have capacity, you must not breach his confidence (required for full marks)
If the patient has capacity, inform adult safeguarding of what you have been told without naming the patient
Contact adult safeguarding
If you decide the patient has capacity – explain the situation without naming the patient. Ask for advice
If you decide the patient does not have capacity – explain the situation without naming the patient initially, explain why you think he does not have capacity.
Inform the patient of your actions, explaining your rationale – required for full marks
Do not confront the daughter.
Make a note of the conversation and your rationale for decisions made as per local protocol – required for full answer
If the patient has capacity – and only you can make this decision as you have been told this information in confidence – you must NOT breach this confidence.
You can, however, contact adult safeguarding for advice without revealing specific patient details
i.e. – I have an 84 year old male who tells me he is being abused by his daughter. He does not want me to tell anyone else. He lives alone with his daughter, so no-one else is at risk. I believe he has capacity to make this decision.
For 3 marks, describe three radiographic appearances which would lead you to refer the image directly to a reporter for review or for hot reporting prior to discharging the patient from the department.
Any 3 of:
Pneumothorax – description of lucent thorax distally with clear edge
Significant infection – description of patchy opacity in lung field
Pleural effusion – description of homogenous opacity starting in costophrenic angle
Tumour/mass – description of isolated opacity
Widespread patchy opacity
Any other reasonable answer
Note the questions asks for “radiographic appearances” rather than name three pathologies; you need to describe this rather than just naming a pathology. This demonstrates that you know what you are looking for on a CXR.
For infection – a minor infection possibly doesn’t need urgent reporting, but could ask the patient if they have started antibiotics; if yes, probably no need for hot reporting
For 5 marks which policies, guidance and/or legislation would you use to guide your decision making process in this situation?
Local safeguarding policy – required for full marks
HCPC Standards of Conduct, Performance and Ethics
Society of Radiographers Consent Guidance
Society of Radiographers Guidance on mental capacity decisions in diagnostic imaging and radiotherapy
The Care Act 2014
The Mental Capacity Act
NHS Safeguarding guidance
This is a GP request – there are different protocols for before, during and after imaging for different referral sources
The patient’s name – this is probably a male patient
DOB – patient is 88 years old. Consider what this may mean in terms of room prep, communication, technique. However, do not make assumptions
Address – the patient lives locally; this appears to be a private address, not a care home
Request states walking. However, GP requests often not accurate for this
Chest x-ray – is this appropriate for the room you are in? Is any room and/or patient prep needed?
Clinical history – does this match the examination requested? What do any abbreviations mean? Could an alternative examination not using ionising radiation be undertaken? What pathology are we looking for (differential diagnoses)?
Signed – there are no “trick” questions in the OSCE but this must always be checked.
Based on this, is the request justified – you should be considering this for every request, even if you are not asked it.
This is a GP request – there are different protocols for before, during and after imaging for different referral sources
The patient’s name – this is probably a male patient
DOB – patient is 88 years old. Consider what this may mean in terms of room prep, communication, technique. However, do not make assumptions
Address – the patient lives locally; this appears to be a private address, not a care home
Request states walking. However, GP requests often not accurate for this
Chest x-ray – is this appropriate for the room you are in? Is any room and/or patient prep needed?
Clinical history – does this match the examination requested? What do any abbreviations mean? Could an alternative examination not using ionising radiation be undertaken? What pathology are we looking for (differential diagnoses)?
Signed – there are no “trick” questions in the OSCE but this must always be checked.
Based on this, is the request justified – you should be considering this for every request, even if you are not asked it.
A&E request – probably urgent. ?different protocols from OP/GP imaging
Mobile – does this increase urgency? What does this tell you about the patient?
Name – probably a female. Remember not to assume any language spoken from the name
DOB – Young patient. Is this patient probably fit and well other than what has brought her to A&E? Are there potential LMP issues?
Pelvis x-ray requested – is this usual for a mobile request? What would justify this as a mobile rather than coming to department? Must consider LMP
Clinical history – matches request. Known dislocation indicates recent imaging, make sure previous images are checked prior to continuing. Post reduction demonstrates treatment has been undertaken in A/E; does this help to justify a mobile?
LMP – overridden by IR(ME)R practitioner. Remember this is the only role that can override LMP; the referrer can not
Request is signed but note the signature is different to the named consultant. Is this acceptable?
A&E request – probably urgent. ?different protocols from OP/GP imaging
Mobile – does this increase urgency? What does this tell you about the patient?
Name – probably a female. Remember not to assume any language spoken from the name
DOB – Young patient. Is this patient probably fit and well other than what has brought her to A&E? Are there potential LMP issues?
Pelvis x-ray requested – is this usual for a mobile request? What would justify this as a mobile rather than coming to department? Must consider LMP
Clinical history – matches request. Known dislocation indicates recent imaging, make sure previous images are checked prior to continuing. Post reduction demonstrates treatment has been undertaken in A/E; does this help to justify a mobile?
LMP – overridden by IR(ME)R practitioner. Remember this is the only role that can override LMP; the referrer can not
Request is signed but note the signature is different to the named consultant. Is this acceptable?
You are working with another band 5 radiographer and an imaging department assistant on a Friday evening. The other radiographer has been called to theatre.
You call A&E to determine if a mobile examination is justified. You are told that the patient is unconscious and unstable following the reduction. She is unable to be moved from the resus area. The patient had a full body CT scan prior to the reduction being undertaken
For 2 marks: Describe how you can use the CT scan images to help plan this examination; explain your answer
Viewing the images will help to determine patient size
This will help to plan exposure factors and determine if a grid is required
Any other reasonable answer
As you walk into resus you are approached by a man who states he is the husband of your patient. He is really upset and explains that he thinks his wife is in the early stages of pregnancy as they have just finished their second course of IVF treatment.
He tells you that he knows his wife would not consent to further imaging due to the risk of radiation. He explicitly tells you that he does not give consent for you to irradiate her and their unborn child.
For 8 marks: What action do you now take; fully explain your answers?
For 5 marks which policies, guidance and/or legislation would you use to guide your decision-making process in this situation?
What- Calmly explain that you cannot discuss the patient with anyone else and ask the man to wait by the doors to resus while you talk to the team
Why- Must not breach patient confidentiality
What- Discuss the situation with the referring clinician, confirming the relationship of the man to the patient
Why- Again, this ensures confidentiality is maintained.
What- Without breaching confidentiality explain to the man that the dose of radiation is minimal and will be kept as low as reasonably practicable
Why- This may provide some reassurances whilst still maintaining patient confidentiality
What- Ensure consent is discussed with the medical team and that the examination is in the best interests of the patient, even without consent from the patient herself
Why- The medical team will give consent for the examination whilst the patient is incapacitated; legally the patient’s next of kin cannot withhold consent.
What- Fully document in patient notes/RIS
Why- To ensure that medico-legal requirements are met and that the patient is aware of actions taken whilst she is incapacitated
Local consent policy – required for full marks
HCPC Standards of Conduct, Performance and Ethics
Society of Radiographers Consent Guidance
IR(ME)R 2017
Society of Radiographers Guidance on mental capacity decisions in diagnostic imaging and radiotherapy
The Care Act 2014
The Mental Capacity Act
A 45 year old male presents from A/E on a trolley for a wrist x-ray ?#
There is an obvious deformity on his wrist
The patient is very drunk and barely awake
When you talk to him, he tells you to go away and leave him to sleep
He pushes your hand away if you try to touch him.
This patient does not have the capacity to consent or refuse treatment.
This is most likely temporary and due to his alcohol intake.
Will he come to significant harm if he does not have the x-ray now? The answer is probably no.
He will regain capacity in a couple of hours when he has sobered up.
He possible wrist fracture can be managed conservatively until this time.
He will also be more cooperative when he is sober (probably) so you will get better quality images.
Consent not given and should not be given by anyone else.
A 32 year old female presents from A/E for a full body CT, post RTA.
She is unconscious on a trolley but no other injuries have been noted on the request
Her presents tells you that they are currently going through IVF and he is very worried about the consequences of the radiation
He does not want her abdomen exposed to radiation
Partner or next of kin cannot give/refuse consent. No person may give valid consent on behalf of an adult lacking capacity.
Mental capacity act gives protection against liability in battery
Need to act in the best interests of the person lacking capacity pending recovery of capacity
In this case, the CT will enable clinical decisions to be made that are potentially life-saving
10 day rule would be over-ridden in this case by an IRMER practitioner
Medical ethics prioritises the life of the mother over that of the unborn child
Therefore the scan can be undertaken, even without the partner’s consent
Everything must be documented
An 85 year old male inpatient is referred for an abdomen x-ray
Clinical history “distention ?ileus”
He is sent to the department in a wheelchair and does not have a nurse with him
You note that he suffers from dementia and it is obvious that he doesnt understand where he is or what he is having done
In line with new Trust policy, he is dressed in clothes rather than pyjamas
He has to be transferred form his bed to the table and you will have to get him changed into a gown
n.b. Many hospitals are now getting patients dressed during the day to reduce what is colloquially called “pyjama induced paralysis”
Talk to the patient and see if you can assess his capacity to consent
He must consent to both the x-ray and getting changed into a gown
Ring the ward and ask for someone who is familiar with the patient to come down to the department
Ring the referrer and discuss if this x-ray is really in the patient’s best interests – what impact will the x-ray have on the patient’s management
If the x-ray is in the patient’s best interests and the referrer agrees with this, you may proceed
If it becomes apparent that the x-ray isn’t in the patient’s best interests at that time, the x-ray should not be undertaken
Ensure everything is documented either in case notes or the CRIS system
A 3 year old child presents to the x-ray department for a chest x-ray
Clinical history “New diagnosis CF”
He is accompanied by his mother
The child is very distressed, uncooperative and screaming
His mum tells you to “just get on with it”
The child does not have capacity as he is only 3. In this scenario, the mother has to consent for the examination.
The mother has given you consent to undertake the examination, despite the child’s obvious distress.
There is no indication that the mother lacks capacity, however with an upset child and the distress of a new diagnosis, it could be argued that she is perhaps not at full capacity.
Though you have consent and could continue, this x-ray is not urgent and could be carried out at another time.
A better quality x-ray will be produced if the child is calmer. This child will need multiple chest x-rays over his life and it is important to create a calm environment so that future x-rays will not automatically cause distress due to remembering one bad experience.
It may be best to offer the mother an appointment to come back for the x-ray on a different day. If she does not want to do that, may be let them go off for a walk and let both the mother and child calm down. Arrange for them not to have to wait when they return.
A 15 year old boy presents from ODP for a chest x-ray
Clinical history “AML; infection follow up”
When called for the examination, the boy tells you he doesnt want an x-ray as he has had lots already and doesnt want to glow in the dark
His mum insists you proceed and as he is under 16 you have to listen to her, not him.
You need to speak to the mother and child away from other members of the public.
Ask him if he understands what examination he has been sent for and what the consequences of not having it could be.
Explain the very low risk from a chest x-ray exposure and the risk from not having the x-ray.
From his response try to determine his level of capacity. Does he have “sufficient understanding and intelligence to enable him to understand fully what is proposed”.
However, under Gillick competency a parent can consent to the procedure even if a competence child refuses.
Try to manage carefully without upsetting child but in this case, the parent can give consent.
