Block 11 Flashcards
3 factors to be taken into account in reproductive ethics =
- Parents
- Future or existing children
- Third parties (e.g. the state)
What autonomy to parents have?
Procreative autonomy
Procreative autonomy =
Parent’s wishes regarding reproductive choices should be resepected with minimal interference from the state.
What can override procreative autonomy?
Interests of future children
ART =
Assisted reproduction technologies.
Definition of ART =
Any treatment involving in vitro handling of human oocytes or embryos for the achievement of human pregnancy
Arguments for ART
- Procreative autonomy
- Psychological health of parents
- Welfare interests
Arguments against ART
- Involves destruction of embryos
- Harmful to parents: disappointment, risk of multiples
What are the restrictions to reduce the number of multiple pregnancies with ART?
<40 - 2 embryos
> 40 - 3 embryos
What do we mean by ‘interests of future children’
If, as a result of being concieved, a child is likely to suffer serious physical or mental harm, then it would be hard to justify ART in child’s best interests
What Act includes ‘welfare cirterion’
Human fertilisation and embryology act
What is a welfare criterion:
A woman shall not be provided with ART unless account of future childs welfare has been taken
Criticisms of welfare criterion:
- Fertile couples don’t have to meet this
- Research shows father isn’t needed - ammended
Fertile couples don’t have to meet the welfare criterion, what is the counter argument to this?
- Maybe they should
- Difference to between positive and negative rights. Don’t have the +ve right to conceive without state if state is helping.
What argument is used against selection of embryos with disabilities?
Right to an open future
Right to an open future =
Choices should be make to ensure child will have maximally open future.
3rd party interests in ART =
- ART is expensive
- Child may place high burden on state
What does NICE recommended for women between 23-39:
Up to 3 IVF cycles funded on NHS
PGD =
Pre-implantation genetic diagnosis
Less contentious use of PGD:
Screen for genetic abnormalities like CF
More controversial use of PGD:
Sex-selection
Desirable traits
Survivor sibilings
MRT =
Mitochondrial replacement techniques
Positives of MRT
Health benefits to child
Benefits to parents
What act allows termination of pregnancy?
The abortion act (1967) - 1990
Abortion is legal if:
- 2 docotrs
- <24 weeks
- Risk to mothers life
- Risk to mother physical or psychological wellbeing
- Risk of child suffering from serious physical or psychological handicap
GMC on conscious objection:
Respected, provisions need to be made. Refer, don’t obstruct. Must in an emergency situation
York IV criteria:
- 28-42
- 2 yr stable relationship
- 2 yr unprotected sex
- BMI 19-29
- No smoking for 6 months prior
- No other children
Why are young people particular vulnerable?
- Vulnerable to harm
- Rely on others for care
- Communication issues
- difficulty accessing services
What does the GMC say about young people
They are individuals with rights that should be respected. Should listen and take into account what they have to say. Respect their decisions and confidentiality.
Making treatment decisions: children <16
- If child is Gillick competent, can consent
- If child isn’t competent, someone with parental authority can consent
- If parent won’t consent to childs best interests, court or treat in an emergency
Those with parental responsibility have a legal obligation to:
Act in child’s best interest
Gillick competence refers to what age
Children under 16
Gillick competence:
The parental right yield to the child’s right to make his own decisions when he reaches a sufficient understanding and intelligence to be capable of making up his own mind on the matter requiring decision
Fraser guidelines refer to
Contraception/STIs/Sexual health
What are the Fraser guidelines:
- Understand all aspects of advice and implications
- Cannot be persuaded to tell parents
- There is risk of physical or mental harm without
- In patients best interest to recieve advice without parental knowlege
- Likely child will have sex with/without advice
Young people aged 16-17 consent:
- Assumed competent to consent to treatment
If someone under the age of 18 refuses treatment =
Allows treatment is consent from parents or court
Why are parents generally allowed to make treatment decisions for children?
Parental autonomy
Parental autonomy =
Assumption that parents know children the best (best interests) and will be motivated to act in best interests
Can parental autonomy be overruled?
Yes - e.g. Charlie Guard
Arguments for compulsory immunisation:
- Harm principle
- Bring about public good
Arguments against compulsory immunisation:
- Parental autonomy
- Risk harm (side effects)
Who described the harm principle?
Mill
The harm principle (Mill) =
The harm principle holds that the actions of individuals should only be limited to prevent harm to other individuals.
How does the harm principle relate to childhood immunisations?
- Prevents harm to others
- Prevents more harm than it will cause
What does, as present, the BMA recommend in regards to compulsory immunisation?
Inform and educate patients
Confidentiality and children =
Doctors owe children obligation of confidentiality. This isn’t absolute
When should you share info in regards to child’s sexual health?
- Young person too young/immature to understand
- Disparity in age/power
- Position of trust - teacher, healthcare worker
- Threat, force, pressure
- Drugs or alcohol
- Partner known to police/child protection
Medicalisation =
Process by which human conditions and problems come to be defined and treated as medical condition
Childbirth is becoming increasingly
Medicalised
Tokophobia =
Psychological condition characterised by extreme fear of childbirth or pregnancy
Are all vaginal deliveries natural?
No
‘Normal’ labour occurs with
- Spontaneous onset and vaginal delivery
- Low obstetric risk
- Sequential nature
- Progressive cervical dilation and effacement
- Progressive urterine contractions which are regular
‘Normal’ labour occurs without
Induction
Instrumental assistance
Surgical assistance
Epidural/spinal/general anaesthesia
Social model of birth =
Aim for increased choice and greater control of own labout.
Birth rate/trends
Declining
Older mothers
More single parents
More mothers in work
C-section rate
25% of births
Name a mode for the active management of labour:
O’Driscoll’s model
O’Driscolls model for active management of labour:
- Diagnosis at 2cm
- ARM (artificial rupture of membranes)
- 2 hrly vaginal exam
- Syntocinon if slower than 1cm/hr
- Personal nurse
What did O’discolls model do?
Increased rate of spontaneous vaginal births
What was the most important factor in O’Driscolls model?
Personal nurse
What influences a woman’s ‘choice’ in birth?
- Media
- Stories from family/friends
- Fear of unknown
- Fear for safety of body or baby
- Perception of the birth process
Examples of high risk pregnancies =
Psychiatric disorders Multiple pregnancies Prev PPH Borderline DMI HIV/AIDS Groups B Strep Blood disorders: sickle cell, thalassemia High Bp Lupus Maternal age >35, teenage Thyroid disease Diabetes (type 1, 2 and gestational) Alcohol/smoking/substance abuse
Fergurson reflex =
Fetal ejection reflex. Neuroendocrine reflex comprising the self-sustaining cycle of uterine contractions
Fergurson reflex is initiated by
Pressure at the cervix or vaginal wall
3 things highlighted in Maternity matters (2007) -
- Continuity of care
- More choice
- Improve access to care
How many infants, children and adolescents die every year in England and Wales?
> 5000
What group of children have the highest mortality?
Infants, before the 1st year
What group of children have the 2nd highest mortality?
Adolescents (15-19)
What kind of conditions dominate in infancy?
Perinatal conditions
Congenital
> 50% of deaths in adolscents occur because of
External causes
External causes of adolescent deaths =
Trauma
Accidents
Suicide
Deaths in infancy most likely related to
Preterm births
Injury in boys is what % more likely than females?
> 70%
What % of external deaths in adolescents does road traffic accidents account for?
50%
Non-intentional causes of child death:
Drowning
Falls
Fire related
Suffocation, strangulation
Examples of ‘intentional’ causes of child deaths:
Homicide
Physical assaults (shaking)
Abuse, neglect
Patterns of suicide and deliberate self harm in children =
Rare in <10s
Higher in older boys
Ligature, jumping, poisioning
How many deaths a year does suicide count for in older adolescent boys?
> 60
Examples of injuries in childhood:
Falls Head injuries Road traffic collisions (pedestrians, unrestrained children) Drowning Swallowed foreign body
50% of poisioning occurs in
<5s
Almost all posionings occur
In child home
Types of posioning =
Non-medicinal: cosmetics, cleaning
Medicinal = analgestics, cough medicine, antibiotics, vitamins
Common illnesses in children =
Congenital: chromosomal, cardio Infection Respiratory Trauma Malignancy Neurological
Which malignancies account for 2/3rds of all childhood cancers?
Leukemia
Brain
Lymphoma
CNS disease in childhood =
- Result of perinatal asphyxia
- Epilepst
- Cerebral palsey
- Neurodevelomental disorders
Examples of chronic illness in children:
CF Diabetes Epilepsy Psychiatic Neurodisability IBD Obestiry Asthma
Most common chronic illness in children
Asthma
Implications of childhood chronic illness:
- Childs physical, mental and social health
- Development
- Missed school
- Siblings
- Parents
- Finances
- Lifelong
In the UK, how many babies died before 1
> 3,000
In the UK, how many children died >1
> 2,000
After infancy, what is the most frequent cause of child death
Accidents
Prevalence of childhood asthma in UK
1 in 11
Most common type of meningitis
Viral
Most common cause of bacterial meningitis
Strep.pneumoniae
Common causes of childhood death in low income countries
Infection Diarrhoae Pneumonia Malaria HIV/AIDS
Common causes of childhood death in high income contries =
Congential Preterm birth Accidents Posioning CNS disorders, cancer
Talking to vs talking with children =
Talking to = implies as exclusive approach, child feels left out. Less likely to comply, conveys message child doesn’t own their body and makes them less likely to own their problems in later life.
With = inclusive approach which implies discussion. Encourages responsibility, compliance and ownership of problem in later life. Values child
When talking with children you should talk at a level appropriate for their
Stage of development
What can be used to assess very young children?
Behaviour and play
Things that may affect communication with children
Hearing problems
Sight issues
Speech
Comprehension
Why might a child be anxious?
New school Domestic situation New home Recent illness Bereavement Being told off etc.
Good listening and clear talking can be summed up with:
- Is language appropriate?
- What is body language conveying
- Eye contact, turn-taking, listening, validating child, talking TO child
What questions should be used when talking with children?
Open
What kind of questions should be avoided with children?
Why questions
WHO definition of adolescence =
10-19
Children’s Act (1989)
States that children must be kept informed about what happens to them and participate in decisions about their future
Adverse event/patient safety event =
Unintended event resulting from clinical care than causes patient harm
Near-miss =
Situation in which events or omissions arise during clinical care and don’t go any further, resulting in no harm to patients
% of hospital admissions which experience a AE
10%
Examples of AEs
Wrong site surgery Med error Side effects Failure to treat Wrong diagnosis Falls Pressure sores Nosocomial infections
Most common adverse event in hospital =
Falls
Most common NEs in hospitals =
Wrong site surgery, retained foreign objects
Serious incidents =
Events where potential for learning so great, or consequences so significant that resources should be spent to investigate and act
Never events =
Subset of serious incidents that should never occur if the proper guidance and safety recommendations are put into place
How many adverse events occur each year in NHS hospitals?
850,000
How many patients lodged a new clinical negligence claim last year?
11,000
NHS England paid out how much in clinical negligence?
£1.6 billion
How do people assess ‘safety of hospital’
Mortality data
Safety event data: AEs, SIs
Monitoring and inspections
Who inspects hospitals?
CQC
NHS improvement
Why can’t we just compare 2 hospitals?
Different age
Different complexity of cases
Different location etc.
SMR stands for
Standardised mortality ratio
Standardised mortality ratio -
Ratio between observed number of deaths in a study population and number of deaths that would be expected based on age/sex-specific rates in standard population and population size. High SMR = high number of excess deaths.
Why are HSMRs not fit for purpose =
- People die in hospital
- Not a measure of avoidable deaths
- Doesn’t relate to quality of care
- Depends on hospice/when hospital discharges patients etc.
What % of hospital deaths are avoidable?
3%
Name a model for why there is harm
Swiss cheese model
What is the swiss cheese model?
Need a lot of things to go wrong for things to actually go wrong! Lots of layers where things have helped to make adverse event occur
Active failure =
Unsafe acts committed by people in direct contact with patient.
2 types of active failure and their subsets
- Error: knowledge, rules, skills
- Violations: routine, situational, reasoned, malicious
What is very important for causing error (more important than active failures?)
Latent conditions
Latent errors develop
Over time and combine with active failures
2 types of bad culture for patient safety
- Blame culture
- Normalisation of deviance
Elements of a safety culture:
Leadership Teamwork EBDM Communication Learning Patient centered
What was long recognised in the aviation industry but is now only being acknowledge in health care?
Human factors/the inevitability of human error
What should we do with human error?
Design it out
Situations associated with increased risk of error =
- Unfamiliarity with the task
- Inexperience
- Shortage of time
- Inadequate checking
- Poor procedures
- Poor human equipment interface
Duty of candour
Need to tell patient about wrror
NHS resolution is a
National safety and learning service
What should be avoided to reduce human error?
Reliance on memory
Reliance on vigilence
What should be done to reduce human error?
Make things visible
Streamline, standardise, simplify
Checklists
Ex of designing error out
Surgical checklists
What to do if adverse event occurs =
Report Assess seriousness Root cause analysis Apologise and explain to patient Learn from event
Examples of ‘dangerous healthcare’
- Mid-staffordshire
- Bristol royal infirmity
- Individual doctors: Rodney Ledward, Richard Neale
Mid-Stafforshire =
Between 400-1,200 patients died as a result of poor care between 2005-2009 at Stafford Hospital
What report came our of the Mid-Staffordshire case?
Francis report
Bristol royal infirmity =
High death rates in paediatric cardiac surgery due to:
- Old boys culutre
- Lack of leadership
- Lax approach to safety
- Secrecy amongst doctors
What % of hospital deaths are avoidable
3%
When is a patient’s death judged to be ‘avoidable’
Problem with care which contributed to death
Avoidable deaths can be due to acts of
Omission
Commission
Complications
Omission =
Failure to treat according to the evidence
Commission =
Incorrect treatment or management
Complication =
Unintended harm due to care
What % of hospital admissions are avoidable death?
<0.1%
Examples of scheme to improve patient safety:
TArgeted efforts to reduce MRSA and C.diff infection: reporting, fines.
Introduction of never events
Why might increased number or errors be good?
Means there is increased reporting - can learn
PROMs =
Patient-reported outcome measures: QoL before and after procedure
What is a patient’s responsibility in healthcare?
Informed, make a decision.
Medical practice has 3 deficiencies internationally which effect quality of care:
- Medical practice has a weak evidence base
- Large variations in training and practice
- Difficult to measure outcomes
The basis of healthcare reform what be at what level?
Organisational/structural
SHMI =
Summary hospital-level mortality indicatior
Summary hospital-level mortality indicatior
Actual mortality rates within 30 days of discharge compared to expected mortality given hospitals characteristics
SHMI in york?
100 deaths per month (small)
HES =
Hospital episode statistics
What are hospital episode statistics, what do they include?
Detailed dataset including diagnoses, consultant responsible, referring GP, procedures given, duration of stay and discharge/death
CQC =
Care quality commission
What does the CQC do?
Regulated all health and social care providers.
Licences
Unannounced visits
Name some agencies involved in consumer protections:
CQC NHS improvement Public health england GMC Royal collages NICE Department of health and NHS England
