CDM- Knowledge, Decsion Making and Law, Ethics And Professional Issues Flashcards
1
Q
What are the components of a good decision?
A
- subjective
- justifiable after the fact
- based on probabilities
- may conflict with values
- safe care
- not always equal to doing something
2
Q
Why can how good a decision is be subjective?
A
Harm vs benefit is subjective
3
Q
What’s professional (nursing) knowledge
A
-The specific knowledge (justified true beliefs) held by nurses that means they’re not physios or drs etc.
- Has to be based off best available evidence (justifying belief)
-Philosophy of nursing and nursing theory say what is nursing and not
-Can include skills
-Holistic (bio-psycho-social model)
-Multi disciplinary
-May know some things certainly but need ability to look up rest if unsure
-Relates to duty and standards of care
4
Q
Why is critical thinking required?
A
- needed to apply professional knowledge (to make decisions)
- needed to justify decisions about what you do, have done and are going to do
5
Q
Why is knowledge important?
A
- give reasons for why doing something
- help make decisions
6
Q
What is knowledge?
A
A belief which is justified and true
7
Q
What is truth in the context of knowledge?
A
- what there is wether or not it’s believed or what can be learnt about it
- something is still true even if people don’t believe it and can justify why they don’t
- doesn’t strictly need to be provable
- not the same as faith (part of values)
- in healthcare based on probabilities not absolute so research focuses on this)
8
Q
What is belief in the context of knowledge?
A
- cannot know something unless you believe it
9
Q
Can beliefs be justifiable?
A
- yes, can be confident in them due to a high probability or likelihood
- but a belief can be justified but not true (e.g if results justification came from we’re due to chance of luck)
10
Q
What is justification in the context of knowledge?
A
- why you believe something (nurses need to know why they believe something or do something)
- might believe something that’s true but hold that belief by luck so then don’t know it
- justification can be evidence (quality of evidence is then important)
- some situations require stronger justification
11
Q
What are Carpers ways of clinical knowing (4)
A
- Personal
- Empirical
- Ethical
- Aesthetic
12
Q
What’s personal knowledge (Carper)
A
- knowledge used in practise based on past experiences, beliefs, attitudes and biases
- needed to engage in authentic interpersonal relationships
13
Q
What is empirical knowledge (carper)
A
- Knowledge derived from scientific systemic inquiry
14
Q
What is ethical knowledge (carper)
A
- based on standards, values, moral reasoning and ethical frameworks
- what to do and not do
15
Q
What is aesthetic knowledge (carper)
A
- Clinical practise based on art, subtle craft of practise in action
- how you do something
- based on perception and empathy
16
Q
What’s makes a profession a profession?
A
- lots of debate
- used to be autonomous over working conditions
- extended learning
- specialist (professional) knowledge
- serving public via essential public good
- oversight/registration- professional body
17
Q
What makes up professional issues
A
- An amalgam of law and ethics (distinct disciplines) but with different implications
18
Q
What are the crucial considerations when making any clinical decision?
A
Law ethics and professional issues
19
Q
What’s the necessity of clinical decision making?
A
- status as professionals
- patients need for care
- legal duty of care
- moral
- NMC- need evidence and experience formed decisions, critical thinking when applying evidence and base decisions on people’s needs and preferences and consider what influences their decisions
20
Q
What are reasons when making decisions and why are they needed?
A
- justification
- require critical thinking
- justify what you do, have done or will do
- need to apply to the situation
- can be a cause (not association)
- makes actions intelligible (understandable)
- something that’s counts in favour of
- can be what would happen if an action didn’t happen
21
Q
What’s practical reasoning?
A
- can justify things after the fact but nurses also need to decide what to do in a situation when an action has not already been done
- can think of reasons that apply to help decide what to do and to justify why going to do something
- reasons can come apart
- can be done with little conscious thought using intuition or may require more focus (as repeated may become more intuitive)
22
Q
What are the two different types of reflection?
A
- Reflection on action (explanation or justification after the fact)
- Reflection in action (reflecting during the event is taking place)
23
Q
What are the problems with reflection on action?
A
- Impacted by rationalisation, confabulation and other bias
- Afterwards may seem better than it was at the time- or try to make it seem that way
- Ok when nothing rests on it but a problem when things depend on it e.g, qualitative research
24
Q
What’s the difference between task based and situation based?
A
- situations influence a decision (and require one)
- task based is step by step following rules so may not need many or any decisions
- anyone can be taught be a skill but harder to apply relevant knowledge (to results maybe) or make it situation based
25
What are Dreyfus’ stages of skill acquisition (5)
- Novice
- Advanced Beginner
- Competent
- Proficient
- Expert
26
Features of novice skills acquisition?
- rule bound
- focus on non situational features that can be recognised without skill
- poor application to real practise
27
Features of advanced beginner skill acquisition?
- starts to recognise some situation specific features
- emphasis on rule following (not bound)
28
Features of competent skill acquisition?
- realises rules no good alone
- individual facts and learning events appreciated become overwhelming so begins learning how to focus on importance
29
Features of proficient skill acquisition?
- no longer emotionless rule based process
- still has to decide what to do
- needs to develop emotions
30
Features and problems of expert squill acquisition?
- assesses what needs to be achieved based on lots of previous exposure and recognition of situations
- can see immediately (intuitively) how to achieve goal
- problems- might be unable to change views or practise, can be harder to justify actions after fact if done intuitively
31
What’s the spectrum of decision making speed? And what can change position of same decision on spectrum?
- Decisions can be fast or slow along a spectrum
- a certain decision may at first be a slow/complex decision but with repetition become faster/ more intuitive
- same decision with different decision maker may be at different place on spectrum
- same decision in a different situation/context may be at different place on spectrum
- different types of decisions used in combination in practise
Things with higher probability of risk or more serious risks need to use less intuitive decision making and more analytical that can be made explicit (justified)
32
Features of slow thinking/decisions
- complex tasks
- high uncertainty
- low volume
- analytical and evidence based decision making
33
Features of fast thinking/decision making
- simple tasks
- low uncertainty
- expert level skill acquisition
- high volume
- intuitive and heuristic decision making
34
Types of decision making definitions, heuristic, analytical, evidence based and intuitive
- analytical = structured and systematic, gathering and analysing (pros, cons, weighting/priorities) data (about situation or evidence) to guide decision
- evidence based = using best available (up to date + high quality) evidence to guide decision
- intuitive = gut feeling, intrinsic knowledge, know it without reasoning or proof
- heuristic = mental shortcuts (ignoring some info) to quickly reach reach decisions and form judgments
35
What is dual process theory?
Idea that thoughts can arise in two different ways/through two different ways. Conscious and unconscious process.
36
What’s the difference between implicit and explicit knowledge
Implicit
- intuitive
- fast thinking /decisions
- knowledge how
- tacit
- subconscious (doesn’t require effort and time critically analysing)
- skill based
- rule based
Explicit
- analytical (justification/evidence)
- knowledge that
- conscious (slow decision making/thinking)
- propositional (needs to be applied)
- influenced by other factors eg values and emotions
37
What’s Benners expert nurse theory and it’s criticism?
- intuition
- implicit knowledge
- skills (inc CDM) as automatic dispositions (part of you)
- able to cut through background and focus on task
- CRITICISM- clinicians need implicit and explicit knowledge (need to know how and why)
38
Different models of decision making (3)
- information processing = as you learn new facts and values these can be recalled when necessary. Superficial learning might mean unable to recall meaningfully
- intuitive = subconscious recognition of problem and what to do, see patterns and know how that connects to next steps intuitively, efficient- filters everything out
- cognitive continuum = range based on other two models
39
Advantages and disadvantages of fast decision making
Advantages-
High volume
Efficient
Disadvantages (if used on own)-
More easily impacted by bias
Maybe hard to justify after bad outcome
If things don’t follow expected process next steps hard as can’t use intuition
Not always adaptable to be patient or situation specific
40
Advantages and disadvantages of slow decision making
Advantages:
Evidence based
Adapted carefully to situation
Disadvantages:
Might not be applicable research available then what?
If based on incorrect research only then maybe wrong decision
Can’t make all decisions like this- decision fatigue would take too long
41
What is CDM a balance of?
Experience, awareness (emotional intelligence and empathy), knowledge, appreciation of law ethics and professional issues, information gathering, colleagues, the best available evidence to guide the decision
Evidence based not feeling based
42
That’s the CDM process
- if not an intuitive decision
- systematic information gathering (facts and values)
- judge information (relevance to situation, quality of information)
- make decision (shared decision making)
- evaluate outcome (did it work? How well)
43
What is critical thinking?
Ability to remove unhelpful and irrelevant emotions from reasoning, being skeptical, with the ability to clarify goals, examine assumptions, be open-minded, recognise personal attitudes and bias (and remove it) and able to evaluate evidence
44
Can emotion be removed from critical thinking?
- can disregard unhelpful and irrelevant information
- can’t remove it entirely as emotion and reasoning aren’t distinct
- emotions can be reasons
- should we remove all emotion? (Can form important reasoning) shouldn’t remove patients emotions- important to consider
45
What are the skills required for CDM?
- learning from experience (reflection)
- communication (especially for SDM and consent)
- using and appraising evidence (especially research)
- teamwork (no one person can care for a patient alone in most settings)
- critical thinking
46
What are facts gathered for CDM and how?
- facts are what’s contingently the case (can change)
- facts can be discovered
- nurses discover facts empirically (through the senses), through observation
- facts discovered or shown in evidence such as area specific policies and values, research or from experts
47
What’s the relationship between reasons and values
- the reason to do something can be the outcome of doing it
- if one doesn’t want the outcome then the reasons change
- wether or not a reason exists or how a decision is made then depends on what is wanted/values
48
What are values in CDM?
- decisions in CDM can be influenced by patient or decision maker values
- value can be subjective (valuable for me but not for you)
- value can be objective (valuable for all- its value does not depend on anyone else) e.g moral value.
- what people see as having objective value may differ e.g religious values
49
How are values in CDM discovered?
- might be assumed based on our own values
- asking the pt
- asking the family where appropriate
- may be explicitly told someone’s values or they can be assumed based on their actions (may not always match)
50
How are values judged in CDM?
- can we?
- if competent have to respect decision even if don’t agree with values used to make decision
- against criteria e.g morals/ethics of religion
- against our own values
51
How are facts judged in CDM?
- quality of evidence?
- have consider research quality
- “best available evidence”
- factors such as peer-reviewed, up to date, RCT as gold standard
52
By what criteria are outcomes judged?
- can be objective e.g numerical, wound size subjective
- can be subjective (what’s success for everyone can vary- like values) criteria’s may not match
- can evaluate if in line with or influenced by pt values
53
Role of patients in decision making
- primary decision maker (if they want to be)
- final arbitrator
- give consent (to legally protect HCPs when doing harm)
54
What can influence decision making?
- economics
- pt values
- HCP values
55
What’s the role of HCPs in decision making?
- guide the patient
- pass on all (even negative) expert knowledge in a way that can be understood (necessary for consent)
- responsible professionally and legally for decisions made
56
What’s shared decision making?
- a collaborative process that involves person and HCP working together to reach joint decision about care
- respects the extent to which a person may wish to be involved in their care
- choosing tests and and treatments (or option to have no treatment) based on both evidence and patients preferences beliefs and values
- can be impacted by HCPs preferences beliefs and values
- empowers people to make decisions about care that is right for them at that time (appreciating can change so need to re- evaluate especially if life and death)
- person needs to understand risks, benefits and possible consequences of different options through discussion and information sharing (maybe patient decision making aids)
- relates to consent and autonomy
57
What decisions can be made using SDM?
- all
- to not receive treatment
- between different treatments
- about tests
- for decisions straightaway
- for decisions about care in the future (e.g, advance care planning)
58
What are the reasons for shared decision making?
- moral/ethical (relate to consent and autonomy)
- clinical (better compliance with decisions)
- legal (relate to consent and autonomy) (relates to duty of care) health and social care act involved commitment to patient experience and duty to include patients in decisions about their own care
- professional (supported by NMC) (supported by evidence so have duty to use- NICE)
59
What’s the role of pts family in SDM?
- pt may not want family involved at all
- can be helpful for information gathering
- can’t share info without consent
- family and pt values can differ
- family may not know pts wishes
- family may not have pt best interests at heart
- families are impacted by the outcome of decisions
- changes based on capacity/age
Can help to, actively engage in discussion, help pt explain what matters to them, help them make decisions about their care, help them remember info they’ve been given during discussion
60
Pts values in SDM (not making assumptions)
What’s most important for one person may not be most important for someone else
Subjective value and priorities
Pts wishes may change with time
Need to be known to make SDM
Evidence based decisions (empirical facts) might not be what matters most (is valued most) to pt
HCP values not the same as pt values but can bias them through info sharing
61
Is SDM working? Evidence around improving SDM.
Must be barriers to SDM as it’s not consistently happening in practice
Cochrane unable to find evidence to support interventions to improve SDM
NICE committee had insufficient evidence to recommend interventions to improve engagement in SDM
No robust quantitative data but used qualitative data which comitee agreed was accurate representation and showed facilitators to SDM and barriers including difference between ‘what a person knows’ and ‘how a person acts’ for both healthcare service users and practitioners
62
What’s the NICE guideline on SDM?
Covers how to make SDM part of everyday care in variety of settings
Promotes ways for HCPs and pts to work together to make decisions about treatment and care
Includes recommendations on training, communicating risk, using decision aids and joe to embed SDM in organisational cultures and practises
Tailor methods used to context of decision e.g phone vs face to face
Ask if pt wants family involved
Ask to what extent pt wants to be involved in decision making
Offer interventions before during and after discussions so people are fully involved throughout care
63
What’s the Cochrane evidence of patient decision making aids (leaflets to provide info on different options for a decision- available on NICE for some)
High Quality evidence- when used people improve their knowledge of options, feel better informed and more clear about what matters most to them
Moderate Quality Evidence- have more accurate expectations of benefits and harms of options, participate more in decision making
May help achieve decisions more consistent with pts informed values
64
What’s the law? (In relation to profession and morals)
- some think it’s just whatever the legal system says it is
- other think if it’s immoral then it’s not a law (law is to reflect morality)
- something can be the law but still open to question (or have problems) morally and ethically
- distinct discipline
- normative (what one should do)
- restricted to territory it covers e.g England
65
What’s morals/ethics (in relation to law and profession)
- ideas about what should and shouldn’t be done (good/bad or right/wrong)
- often used to criticise the law
- idea of professional morality is contested
- distinct discipline
- normative (what one should do) but also at times how one should be (traits and values)
66
What’s the profession (in relation to law and ethics)
- professional code and decisions are within the law
- sometimes supererogatory to it (expects more than the law demands)
- code is probably (and tries to be) moral but it’s statements are open to ethical assessment
- amalgamation of law and ethics/morals with different implications
- normative (what one ought to do) but also how one should be (traits and virtues)
- restricted in scope to how one should be and what one should do as a nurse
67
Key points for law ethics and professional issues
- all crucial considerations for CDM
- discussed as a nurse (what is reasonable for a nurse to know)
- legal professional and ethical and clinical decisions can be contested (on legal, professional or ethical grounds)
- emphasis on idea of autonomy and how it’s supported in law
- emphasis on standard of care (and what evidence used to set the standards)
- they can be the same/relate on some points
- they have different purposes
68
How is autonomy protected in law?
- law of consent (also protects HCPs legally when doing harm)
- criminal assault if care done without consent (case precedent schloendorff 1914)
- human rights act 1988 (right to control decisions)
- capacity act (protects autonomy by ensuring fair process when deciding who can be autonomous)
69
Key points when considering the law
- need to get processes right
- be up to date
- use English law (Scotland, wales and NI can be different)
70
What’s professionalism?
- characterised by the autonomous evidence-based decision making by members of an occupation who share the same values and education and who provide an essential good for human well-being
71
What are professional standards
- standards members of profession meet (often supererogatory to law) not the same as legal standards and duty of care but will meet legal standards
- NMC set professional nursing standards (code and proficiencies)
72
What’s confidentiality?
- keeping information private and respecting wishes around information sharing and doing so responsibly
- isn’t secrecy (sometimes legally and professionally required to break it- with justification)
- combines law ethics and professional issues
- based on trust in nurse patient relationship (essential for healthcare institutions to function)
73
How does confidentiality relate to professional and ethical issues?
- right to privacy is a human right
- confidentiality is included in professional standards (in line with law)
- sharing information without consent is in breach of ethical principle of autonomy
- professional duty for training (Caldicott everyone aware of responsibilities- gdpr training)
74
How is confidentiality related to the law?
- common law contains duty of confidentiality
- common law requires lawful basis for disclosure of personal information
- data protection act (statute) and gdpr control how personal information is used by organisations/businesses or government (higher legal protection for more sensitive information)
- Caldicott principles (trust Caldicott guardian) are eight principles to ensure information is kept confidential and used appropriately
75
What are the Caldicott principles?
- justify purposes for using ci
- use ci only when necessary
- use minimum necessary ci
- access to to ci on strict need-to-know basis
- everyone with access to ci should be aware of their responsibilities
- comply with the law
- the duty to share information for individual care is as important as the duty to protect patient confidentiality
- inform patients and service users how their ci is used
76
What’s the legal, professional, and ethical basis for confidentiality not meaning secrecy?
- common law says needs lawful basis for use or disclosure of personal information e.g in overriding public interest, statutory basis or legal duty to disclose
- Caldicott principle “duty to share information can be as important as duty to protect patient confidentiality”
- ethical- sharing information may prevent harm being caused to patient or others
- professional duty to report in some cases (in line with law) e.g, child abuse
77
What are the principles involved in the delegation of work?
- still professionally and legally accountable for the tasks (your responsibility to follow up)
- only delegate to those trained and competent to carry out the task
- decision to do so must be made in patients best interests not to save time (ethical principle of beneficence)
78
What are the key points around delegation in social care?
- scope is expanding and people are doing more than before
- social care has been delivering delegated healthcare interventions for some years and is increasing
- seen clear benefits for people who draw on services
- recognition of value, skills and complexity of care across health and social care settings
- 2023 will see standards of delegation for healthcare work for people working in social care
79
Key points around justification in ethical decision making
- justification for moral beliefs and actions are difficult and contested
- in part as nature and knowledge of morality and itself is contested
- student nurses must know their own moral code
- duty to help other people stronger than other components of practical decision making
80
Key points from Bickoff moral courage of student nurses
- student nurses must know their own moral code
- moral courage comes from instinctive reaction
- intuitively knowing the right action to take
- feeling in your gut where you know somethings right or wrong
- combined with slow thinning as have to be thoughtful as if haven’t thought about it probably unwilling to sacrifice for it
- moral courage = courage to take action for moral reasons despite the risk of adverse consequences
81
How do human rights relate to ethics and law
- enshrined in law (human rights act)
- based off ethics/morals
82
What are the Beauchamp and Childress principles of biomedical ethics?
- autonomy
- justice (as fairness)
- non- maleficence
- beneficence
83
What’s the legal explanation of autonomy?
- freedom of self choice/self determination
- person can do what they want (within the law)
84
What’s the moral explanation of autonomy ? Kant + Mill
Millsian- adult can do what they want providing it does not harm others
Kantian- autonomous will to comply with the moral law (stronger ethically)
85
How does the professional explanation of autonomy relate to the moral and legal ones?
- matches the legal explanation whilst encouraging more moral choices
86
Can adults refuse care?
- because of autonomy adults can refuse any treatment at all inc pregnant women (autonomy stronger than life of foetus)
- still have to care for them as profession has to adhere to the law
87
What’s beneficence?
To actively do good
(For patient- good is subjective)
88
What’s nonmaleficence?
- To not do bad/ to not do harm
- through an act or an omission
- to not do so intentionally/ deliberately/recklessly/ negligently
89
How is autonomy protected in professional standards?
- protected in law and professional standards have to be within the law so professional duty to preserve autonomy
90
How are beneficence and non maleficence legally and professionally protected?
- law of negligence
- duty of care
- allowed mistakes but not if negligent or reckless (no reasons for why/ justification)
- profession has to be within law but also stronger professional duty to not harm patients or public or put them at risk of harm
91
What’s justice?
- fairness
- clinical need can help manage this
- can involve economic issues
- need to be consistent across people (patient and decision maker) and region to be fair
92
Equality vs Equity
- equality= treat all people the same no matter what (not everyone may want to be treated the same)
- equity= recognises people may needed to treated differently to reach the same/equal outcome
93
Key points around quality of life and best interests
- courts final arbitrator of best interests
- judgements on the hole subjective
- have tools to measure quality of life
- dr and nurses may have expertise on probability of treatment working but not necessarily if it should be given (values and norms) and the two aren’t always directly related
- when assessing best interests need to look at welfare in broadest sense- look beyond medical factors to incorporate social and psychological factors
- crucial part of judgement includes discussion with those close to individual (family, friends and individuals may also involve lasting power of attorney or people previously nominated by pt) when appropriate acknowledging legal duty of confidentiality
94
Professional ethical and legal considerations around best interests
- NMC code: balance need to act in best interests of people at all times with requirement to respect a persons right to accept or refuse treatment
- still have to follow law and respects moral and legal ideas around autonomy and consent
95
What are professional ethics?
- ethics focussed on what nurses should and should not morally do
- debate on how can exist- some think either morality encompasses professionals or doesn’t and some think nature of profession entails a distinct morality
- code can be considered to be about professional ethics (professional values that should be moral and are within the law)
96
What’s conscientious objection and when does it apply?
- allows nurses in England to legally and professionally to refuse to participate in care in two scenarios if they have a conscientious objection
- technological procedures to achieve conception and pregnancy
- treatment which results in termination of a pregnancy except where it’s necessary to save the life or prevent grave permanent injury to physical or mental health of a pregnant woman
97
What changed when swapping from beneficence model to autonomous model?
- stopped being just that dr knew best and acted in best interests
- change from paternalistic to individualistic
- increased need for specialism (not just one dr for everything)
- increased research (use to just be dr trying to make individual pt better)
- society change (saw harm being done in interest of best interest medical decisions)
- new treatments and research become moral question as much as medical
98
What is consent and what does it need to be to be valid
- consent is legal term
- has to be voluntary (inc from unintentional coercion from position of power of HCPs)
- made by someone with capacity (assumption is adults have capacity to consent or refuse decisions until proven otherwise)
- informed (informed of everything inc bad, not just what the dr thinks they’ll want to know- legal right to know Montgomery 2015)
99
What about consent and children?
- 16-17 have same decision making power and also assumed to have capacity to make decisions until proven otherwise but can be overruled by court in circumstances
- Under 16s can be shown to have competence to consent to treatment if Gillick competent but harder to refuse treatment
100
What’s Gillick competence?
- law protecting of autonomy of under 16s who have capacity to make decision to consent to treatment
- used to decide if child can consent to care without need for parental permission or knowledge
- contains Fraser guidelines which are specific to sexual health
101
Can children under 16 refuse treatment?
- harder to refuse treatment than to consent to it
- if child is competent and refuses then person with parental responsibility told and this should usually be respected but not always (and doesn’t always have to be)
- court of protection can override a child’s refusal of consent
102
Key points about parental responsibility and who holds it?
- never assume
- it is changeable
Who holds it :
- automatically at birth child’s mother
- child’s father if married to mother or on birth certificate (can apply for pr from mother or court)
- legally appointed guardian
- person with a residence order concerning the child
- local authority designated to care for child
- local authority or person with emergency protection order for the child
103
What’s the court of protection responsible for?
- deciding if someone has capacity to make decisions for themselves
- appointing deputies to make ongoing decisions for people who lack mental capacity
- giving people permission to make one off decisions on behalf of someone who lacks capacity
- handling urgent and emergency applications where decision must be made on behalf of someone without capacity without delay
- making decisions about a lasting power of attorney or enduring power of attorney and considering any objections to their registration
- considering applications to make statutory wills or gifts
- making decisions about when someone can be deprived of their liberty under the mental capacity act
104
How can consent be given?
- implied (not suitable for big decisions)
- orally (witnessed for bug decisions)
- in writing (best for big decisions e.g consent form for surgery- easier to defend legally)
105
What’s capacity
Ability to:
- understand information
- weigh up/use information
- retain information
(To make a decision)
- communicate the decision (using any means necessary)
At the time the decision (or action) needs to be made
106
Key points around lacking capacity
- if unable to do any of 4 parts of capacity test is failed and they do not have relevant capacity
- decided on a decision by decision basis
- if mind is impaired or disturbed in some way
- can pack capacity temporarily or permanently
- if someone lacks it temporarily can only take measures to repair physical damage to save life before they regain capacity
- if temporary impairment and decision can be put off till they’re likely to regain capacity then it should be
107
Key points of mental capacity act
- supports autonomy in law by providing fair process when deciding who can and can’t be autonomous
- legal framework for making decisions on behalf of an over 16 who lacks capacity to make decisions themselves
- clarifies who can make decisions, including decisions about medical care and treatment, for people who can’t decide themselves and how those decisions should be made
- everything possible should be done to support people to make their own decisions (supports autonomy)
- protects adults with capacity’s right to make decisions that seem unwise or irrational (supports autonomy) as capacity is about ability to make decision not the outcome
- any action taken on their behalf must be in their best interests
108
What’s lasting power of attorney?
A person who can make only financial and healthcare decisions on behalf of a person who lacks capacity in their best interests
Cannot make decisions about treatment for patients sectioned under mental health act
109
Exceptions to best interests and capacity
- enrolment in research related to condition
- where patient has valid (carried out when they had capacity) and clear advanced decision to refuse treatment
110
Key points of mental health act
- people with learning disabilities generally excluded
- people who have capacity can be treated without their consent if they are at serious risk of harming themselves or others (not just refusing)
- community treatment orders allow for this in the community
- ECT cannot be given under act if person has capacity and refuses
111
Consent case precedents
- undue influence by other invalidates refusal of consent to blood transfusion of adult pt
- capacity impaired but understood reasons and risks arrived at clear decision so able to refuse life saving treatment
- refusal of C-section due to needle phobia overruled
- adult competent pt can refuse treatment even if it results in death
- lacked capacity to refuse life saving treatments because of previous beliefs and wishes when they had capacity, allowed to refuse through best interest decision
112
Standard to meet for consent
- reasonable belief is standard to meet
- need to know factual things and the patient and get consent
- reasonable belief the patient lacks capacity and that the action is in their best interests
- reasonable= BOLUM would a reasonable practitioner do the the same as you
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What are the key points of of Montgomery 2015
- protects patients legal right to know
- relates to autonomy, consent and shared decision making as all require full information sharing
- prudent patient test not prudent doctor test (wether risk is material depends on views of reasonable person in patients position not reasonable body of medical men)
- HCPs have to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of an reasonable alternative or variant treatment (need to consent to treatment and know about alternatives to be valid)
- determination of material risk is subjective and needs to be considered on individual basis (not generalised like patient decision aid)
- it’s the standard of care for consent/duty of disclosure for informed consent/duty to inform
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What is negligence?
- a legal term
- hard to prove
- have to prove that there was a duty of care that was breached and harm occurred as a result of it directly
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What’s the duty of candour?
Legal requirement to admit if errors are made/standard of care not met or saying why a certain treatment is available e.g finances or age
Legally protected- apology under this doesn’t count as a legal admission of negligence
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How does duty and standard of care relate to clinical decision making?
If making a clinical decision about someone then have a duty of care to them. Required decision to do no harm to them and must meet a reasonable standard of care. Needs to be justifiable (e.g evidence based- could use guideline but needs to be adapted to situation and then guideline may not apply but still needs to be justifiable)
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The difference between moral professional and legal standards of care.
They may be different or the same.
Legal is the lowest expected standard of care within legal limits. Professional standards will align with this but may also require more- can meet legal standard of care to not be negligent but may not meet professional standards. Ethical may be the highest standard of care required.
Can meet legal standard of care to not be legally negligent but patient still be harmed which would be okay legally but maybe not professionally or ethically.
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What minimum standard of care must be met?
Bolum 1957
- reasonable care
- meet the standard of a responsible body of medical people who’s opinion is logically given
- what would a reasonable/average nurse do in the same situation (even if you’re below average/newly qualified)
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Legal ethical and professional basis for breaking confidentiality
Sometimes legally and professionally required to do so and not doing so would fail to meet reasonable standard of care. Also may fail to meet ethical principle of doing no harm.
Public health act and health protection regulations act can share information even with refusal (and detain but not treat) for control of diseases
Road traffic act requires disclosure of some conditions that affect driving to DVLA
Terrorism act requires disclosure of info such as bomb plans
Statutory reporting of things such as child abuse.
Abortion regulations
RIDDOR (reporting dangerous and hazardous events)
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Risk and certainty
- healthcare decisions made around probability- not premised on certainty
- patients and staff generally poor at interpreting risk
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Legal precedents around standard of care
- breach in care found but doesn’t always mean it caused the harm/death (Met legal standard for not being negligent but not professional)
- standard of care owed by junior doctor same as any member of staff in that post on specialised unit
- expected avoiding not giving misinformation is reasonable
- no breach of duty as tacit acceptance of rules and consent given so no high degree of recklessness or carelessness
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Key points around prescription orders
- pharmacists and nurses can refuse to administer or dispense prescribed drugs
- need good reason
- requires communication with prescriber and patient
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Key points around refusal to care
- almost always not legally or professionally appropriate
- not including conscientious objection
- definitely not appropriate if due to competency , safety concerns or mismatch in values.
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Role of law ethics and morals for nurses
- understanding law and morals (as well as anatomy and physiology) help nurse be aware of situations and recognise cues or patterns.
- cues help understand formal guidance
- this will then help with critical thinking (and in turn decision making)
- consider filtering out irrelevant info as too much info can cause cognitive overload stopping any decision being made and too little info may cause the wrong decision to me made
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What’s the difference between research quality improvement and audit?
- research is generalisable (results not specific to a place and time) and discovers new knowledge about a problem
- audit is finding out how well a specific already existing standard is being met at a specific time and specific place
- quality improvement often follows an audit and aims to improve/maintain practice within current standards in a specific place
Research is generalisable beyond study unlike audit and QI and aims to make new knowledge/a new standard.
Research has a greater risk to patients than audit as something new is being tried unlike in audit where that’s just monitoring what’s going on already with no change.
Research has more external scrutiny (e.g research ethics) but audit and qi can still have external scrutiny e.g, CQC
Quality improvement bring change faster than research but only to that specific place
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Key features of service improvement
- primary focus on changing behaviour
- ultimate aim of improving patient care (need to consult patients as patient experience can be different to intended)
- need to involve relevant staff- staff it affects and senior staff to agree support and help implement project
- must be doable and have measurable outcome
- start small as people are more likely to trial small changes, easier to adopt and build on small changes in behaviour, starting small inspires confidence and can build rapid momentum
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NICE requirements for evidence used in SDM and examples
- reliable
- high quality
- taken into account accessibility (need to meet NHS accessible information standard)
Examples
NICE accredited info
Links to NHS website
Info from appropriate patient organisations
Relevant NICE guidelines
Quality assured patient decision aids
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What’s the role of the court in decision making
- final arbitrator
- ultimate decision maker
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Role of relative/parent/guardian as a decision maker?
- if patient lacks capacity
- can only make decisions in their best interests
