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4th Year > CEL > Flashcards

CEL Flashcards

1
Q

What is priniciplism?

A

The four (five) principles of:

  • Respect for autonomy
  • Confidentiality
  • Beneficence (best interests)
  • Non maleficence (balance of harms vs risks)
  • Justice
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2
Q

General description of the four principles in principlism?

A

Autonomy:
- Doctors should make every effort to do things as a patient wishes, within reason, even if they lack capacity

Confidentiality
- Everyone has some right to the keeping of their information (this can be superseded however)

Best interests:
- Moral obligation to do good to a patient, underlined by the legal duty. A doctor must act in the patients best wishes when they lack autonomy.

Non-maleficence:
- A doctor must try to avoid harm, although some harm may potentially arise, this may be appropriate if the anticipated benefits outweigh this risk.

Justice:
- General principle that services and treatment should be allocated fairly within a society.

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3
Q

What is consequentialism?

A

Consequentialist theory states that the morally correct course of action is that which results in the best overall outcome, irrespective of the means used to achieve those consequences.

One example is utilitarianism.

The principle of utility provides that the morally correct course of action is that which promotes the greatest happiness of the greatest number. So the right thing to do is determined by the action that will result in the greatest overall happiness.

Problems:

  • However, must be impartial to apply it.
  • It also is very demanding as have to weigh up a lot, and not a lot of moral breathing space.
  • It may overlook the means, as is so focused with the result.
  • DIFFICULT to apply to real life scenarios - as we cannot see into the future
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4
Q

What is deontological theory?

A

Focuses on duties and rules as opposed to consequences, i.e. some acts are intrinsically wrong irrespective of their gains (e.g. torture).

Problems:

  • hard to apply one rule to all situations without weighing up the benefits and risks.
  • Does not provide a definitive list of duties, and does not say what should be done if duties are in conflict.
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5
Q

What is virtue ethics?

A

An idea founded by Aristotle, suggesting that a virtuous person can rationally identify and then incorporate virtues (such as honesty, compassion, benevolence and justice) into a decision-making process.

For example:

‘Tasha, a 15-year-old girl, was born with a congenital heart defect that was repaired at birth. She now needs a heart transplant to enable her to live an active life. She is, however, adamant that she does not want to live ‘with someone else’s heart beating inside me’. The prognosis of recovery after the heart transplant is good. Her parents are prepared to accept whatever deci- sion she makes as they believe she will have to live with the consequences.’

When applied to medicine, benevolence means to act in a way that best serves the interests of the patient

Tasha, has a good chance of leading a normal life. It would not be in her best interests to die.

A discerning doctor would weigh complex emotional issues and understand the reasoning behind the patient’s decision.

He/She would perhaps understand that Tasha does not want to die but that she has fears surrounding the operation and the consequences of having a transplant.

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6
Q

What is casuistry?

A

A method of applying theories. it is ‘case-based’. Ypu take a clear-cut case a ‘paradigm’, and then compare other more complicated cases to it. If a case is similar then a similar action should be taken, if not then it should be different.

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7
Q

Guidelines on care for extremely premature babies?

A

25 weeks and above:
- Intensive care and neonatal unit unless known complication incompatible with any significant period of survival

24 weeks - 24+6 weeks
- Intensive care and neonatal unit unless docs and parents agree it is not in best interests

23 weeks - 23+6 weeks
- Hard to predict outcomes, precedence given to parents choice, however if treatment will be futile clinicians do not have to treat.

22 - 22+6 weeks

  • Standard practice to not resuscitate
  • Can be if parents really want to and clinicians think it is in best interests

<22 weeks
- Experimental research only with ethics and parental approval.

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8
Q

What factors are used in the epicure study on the long term outcomes of premature babies?

A

Lung function
Retinopathy
Physical disability
Others

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9
Q

In what three circumstances can life sustaining treatment be withdrawn in children?

A

Life is limited in quantity and treatment will not necessarily prolong life and it is in best interests of child

Life is limited in quantity - treatment may be able to prolong life but not alleviate the burdens associated with the condition itself.

Informed consent for the withdrawal of treatment - Older children when they repeatedly express this and are supported by the clinical team and their parents.

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10
Q

Apart from the interests of the baby (which is paramount) what other interests may you take into account when making decisions regarding the treatment of babies?

A

All potentially other affected parties - usually the interests of other family members (old or young) who will live with the child or who depend on the family.

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11
Q

What questions should you consider when thinking about withdrawing or initiating life sustaining treatment after the birth of a child?

A

What degree of pain, suffering and mental distress will the treatment inflict on the child?

What benefits will the future child get from the treatment, for example, will the child be able to survive ?

Independently of life support, will the child be capable of establishing relationships with other people, and be able to experience pleasure of any kind?

What kind of support is likely to be available to provide the optimum care for the child?

What are the views and feelings of the parents as to the interests of the baby?

For how much longer is it likely that the baby will survive if life-sustaining treatment is continued?

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12
Q

With regards to children if you are not given consent to share information, can you still decide to do so?

A

Yes, if:

  • It is in the interests of the welfare of the child
  • It protects the child from significant harm
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13
Q

Issues regarding consent in children?

A

You should involve children and young people as much as possible in discussions about their care, even if they are not able to make decisions on their own.

A young person under 16 may have capacity to make decisions, depending on their maturity and ability to understand what is involved

At 16 a young person can be presumed to have capacity to make most decisions about their treatment and care.

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14
Q

Can you assess capacity in all situations, even if the person seems absolutely sound of mind?

A

Need to have some doubt to do a capacity assessment.

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15
Q

If you are presented with an emergency life or death situation what should you do with regards to ethics and law?

A

Should always just act on the need to safeguard life, without delay, so just get on with saving their lives until you are presented with uncontradictory evidence that that is the wrong thing to do.

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16
Q

What is the current legal rules regarding life preserving decision making in minimally conscious or persistent vegetative state patients?

A

Has to go to the courts

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17
Q

What age do you have to be to write an advance decision to refuse treatment?

A

18 at least.

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18
Q

When did lasting power of attorney for health and welfare come into force? If someone says they have LPA from before this date what should you do?

A

2007 - If they have one from before this date it cannot be valid for health and welfare

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19
Q

Does a lasting power of attorney always extend to decisions regarding life-sustaining treatment?

A

It has to explicitly say this.

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20
Q

If a person sectioned under the MHA has capacity and wants to refuse a treatment for a physical health condition can they do this?

A

Yes, if they are not related to their mental health condition. Unless it is anorexia.

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21
Q

Who can do a capacity assessment?

A

F2 and above

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22
Q

Acid test for DoLs (when you might need to do a DoLs)?

A
  1. Is the person under continuous control or supervision?

2. Is the person free to leave

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23
Q

In terms of vaccines and screening tests, do doctors have the right to enforce kids to have it if the parents object? What if the parents disagree?

A

Doctors do NOT have the right to enforce it if both parents refuse to consent (kids are normally too young to consent themselves)

If parents disagree you have the right/responsibility to act in the child’s best interests and can give the vaccine in this case - although would be better to sit and talk it through with both parents first, as you at risk of damaging your relationship with one of the parents.

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24
Q

5 questions to work through to answer ethical issues?

A
  1. What are the key problems? List them?
  2. What ethical and legal principles (of the 5)?
  3. What are the different perspectives to be considered?
  4. What options are available? What are the issues with each option?
  5. What are you going to do, why, how will you justify it?
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25
Q

Different sections and their 1. Reasons, 2. Duration and 3. who can detain?

A

Section 2:

  • For assessment
  • Lasts 28 days
  • Section 12 Doctor (has to be approved: GP or psychiatrist)

Section 3:

  • For treatment
  • For 6 months
  • Section 12 doctor

Section 5(2):

  • For detention on a ward
  • For 72 hours
  • Full GMC doctor

Section 136:

  • Emergency police section
  • 72 hours
  • Police
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26
Q

What part of human rights legislation allows for the lawful detention of someone of unsound mind?

A

Article 5 of the European convention on human rights

27
Q

Rules surrounding ECT?

A

ECT requires the consent of the patient (if they have capacity) even if they are sectioned

If the patient does not have capacity then a second medical opinion is needed

The patient can make an advanced decision but it has to say specifically ‘even if life at risk’

28
Q

How would you assess whether consent is valid?

A

Do they have capacity

Have they been given the information they need?

Do they understand the procedure?

Three questions:
1. Is the patient aware of any risks relevant to his or her decision regarding the proposed treatment?

  1. Is the patient aware of any reasonable alternatives and their associated risks and benefits?
  2. Have I taken all reasonable measures to ensure that I have presented this information in a form the patient understands?

In minor procedures you may take implied (e..g bp) consent or verbal consent.

If the procedure is more risky you need to obtain written consent:

  1. If the procedure is complex or involves more risk
  2. Significant consequences on pts personal, social or employment
  3. Providing clinical care is not the primary purpose
  4. Research
29
Q

What is the significance of the montgomery ruling?

A

A case of shoulder dystocia in a woman with diabetes.

Doctors now have a legal responsibility to inform patients of risks of interventions, doctors must:

‘take reasonable care to ensure that the patient is aware of any material risks involved in any treatment, and of any reasonable alternative or variant treatments’

A ‘material risk’ is one in which ‘a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it’.

30
Q

What are the reasons to assess capacity, what three things need to be considered before you do?

A
  1. Reasonable grounds to suspect they may lack capacity
  2. Can the decision be put off until they regain capacity?
  3. Do they have an impairment to the mind that would affect their ability to make this decision? (if not then you would not assess capacity)
31
Q

How do you assess capacity?

A

If any of the 4 questions is a no then you make a best interests decision on their behalf.

  1. Can they understand the information necessary to make the decision?
  2. Can they retain the information long enough to make this decision?
  3. Can the person use or weigh up the information needed to convey the decision
32
Q

What factors need to be considered in a best interests assessment?

A
  1. Encourage the person to take part as far as possible
  2. Identify what the person would have taken into account if they were making the decision
  3. Find out the person’s prior views, wishes and beliefs
    consult others, where appropriate about the person’s views, wishes and beliefs
  4. Make an objective assessment of what would be in their ‘best interests’.
33
Q

Who can make an advance decision?

A

> 18

Must have capacity (when they make the decision)

Must be valid and applicable

34
Q

Rules for advanced decisions in life-sustaining treatments?

A
  • Must be in writing
  • Must be signed and witnessed
  • Must state ‘even if life is at risk’
  • Can refuse artificial nutrition and hydration but not basic care
35
Q

What makes an advance decision valid and applicable?

A

Has the person said anything that clearly goes against their advance decision

Have they withdrawn their decision (can be verbal)

Subsequently deferred power to make that decision to a LPA

Did they have capacity when they made that decision?

Would the decision have been different if they had known something that is now evident, but was not back then?

36
Q

What is a DoLs?

A

Deprivation of liberty safeguarding

It is legal protection for vulnerable people who are or may become deprived of their liberty

37
Q

Eligibility for a DoLs?

A

> 18 y/o

Suffering from a mental disorder

Lacks capacity for decision in a hospital or care home

No valid or applicable advanced decision/LPA

No MHA section

Needs to be deprived of liberty in their best interests

Proportionate least restrictive course of actions.

38
Q

What obligations do people with LPAs have?

A

Must adhere to the MCA 2005 code of practice

Must act in agreement with a joint LPA

Must be registered with the office of the public guardian

39
Q

Why is confidentiality important?

A

Maintain trust in the doctor-patient relationship.

One of the key principles of the medical profession, patients have an ethical and legal right to protection of their information.

40
Q

Under what circumstances should personal information be shared?

A

In order for safe and effective direct care some patient information must be shared within health professionals. You can also argue that for research on a wider perspective it is important for data to be shared

It is legal (but not required) - not breaching confidentiality if:

  1. The patient consents
  2. For the overall benefit of the patient who lacks consent
  3. Required by law
  4. In the public interest

If patients lack the capacity to consent and it is in the best interests to disclose information you may do so
- If they ask you not to you should still try and persuade them otherwise and must tell them before you do.

41
Q

When would you do a DNACPR, who would you discuss it with?

A

CPR is not going to be successful
- Decide if it is appropriate to discuss with pt, seek approval to inform NOK.

CPR may be successful but:

  • Wider implications such as need for ICU and support, need to weigh up benefits against burdens and risks
  • Pt may still wish to receive CPR with only a small chance of success, need to fully inform the pt and make sure they understand why you think this may not be appropriate (if you don’t), should try to reach an agreement e.g. minimal resus, ultimately it is the clinicians decision.

Need to involve pt’s unless gonna cause significant distress.
- If pt lacks capacity need to discuss with relatives

42
Q

What does gillick competence mean?

A

Children under 16 that can consent, as they are mature enough to make decisions for themselves. Originating from a court case. Need to assess:

Maturity
- Takes account of the child’s experiences and the child’s ability to manage influences on their decision making such as information, peer pressure, family pressure, fear and misgivings.

Intelligence
- Takes account of the child’s understanding, ability to weigh risk and benefit, consideration of longer term factors such as effect on family life and on such things as schooling.

43
Q

Who has parental responsibility?

How can Dad have parental responsibility?

A

Mother automatically

Dad, if:

  • Married to child’s mother
  • Listed on birth certificate

If unmarried (and not on certificate):

  • Jointly registering the birth of the child
  • Getting a parental responsibility agreement with the mother
  • Getting a parental responsibility with the court
44
Q

Rules regarding surrogacy and parental responsibility?

A

The woman who gives birth to the child is always the mother until they transfer it, whether they are genetically related or not.

  • illegal to pay a surrogate (apart from expenses)

The surrogates legal partner is automatically the child’s second parent.

45
Q

If parents and doctors disagree about what is in the best interests of the child what steps should be taken?

A

Has to go to the courts

46
Q

Circumstances where it is legal to have an abortion under 24 weeks?

A

If it reduces the risk to a woman’s life; or

If it reduces the risk to her physical or mental health; or

If it reduces the risk to physical or mental health of her existing children; or

If the baby is at substantial risk of being seriously mentally or physically handicapped.

Two doctors must certify in good faith that one of these apply.

47
Q

When is it legal to get an abortion >24 weeks?

A

Risk to the mother’s life.

Risk of grave, permanent injury to the mother’s physical/mental health (allowing for reasonably foreseeable circumstances).

Substantial risk that, if the child were born, it would have such physical or mental abnormalities as to be seriously handicapped. Such terminations must be conducted in an NHS hospital.

48
Q

Is abortion on the grounds of gender alone legal?

A

No - unless it is at risk of a significant X-linked disorder

49
Q

Principles regarding abortion in the under 16?

A

The girl understands all aspects of the advice and its implications.

You cannot persuade her to tell her parents or to allow you to tell them.

Their physical or mental health is likely to suffer unless they receive such advice or treatment.

It is in the best interests of the young person to receive the advice and treatment without parental knowledge or consent.

50
Q

Rights of doctors conscientiously objecting to doing an abortion/

A

Right to conscientiously object to performing one, unless it is an emergency situation where the woman’s life is in danger?

51
Q

Four principles for prudent healthcare?

A

Public and professionals are equal partners through co-production (citizens involved in the delivery of the service)

Care for those with the greatest health needs first

Do only what is needed and do no harm

Reduce inappropriate variation through evidence based approaches

52
Q

What is the legal position in the UK for assisted suicide and voluntary euthanasia? What do doctors need to consider?

A

Voluntary euthanasia is illegal, as well as assisted dying.

It is also illegal for a doctor (or anyone) to encourage or assist someone in committing suicide.

As a doctor you can do all you can to address anyone’s palliative care needs including sedation.

53
Q

Arguments for and against abortion?

A

For
- Women have a right to choose what happens to their body and a fetus has not got an automatic right to the use of a womans body

  • A fetus is not a person - does not have the moral characteristics of a person e.g. rationality, self-awareness, consciousness, emotional capability.
  • There is a history of dangerous practice when abortion is not provided and you would be putting people at risk of harm if you did not offer it.

Against
- The fetus is basically the same as a child and it is wrong to kill a child, so it follows it is wrong to kill a fetus

  • Fetus is a potential human being and it is wrong to kill a potential human being. (might agree that a fetus is a potential human being but not that it is wrong to kill one, are egg and sperm potential human beings?)
54
Q

Types of child abuse?

A

physical
sexual
emotional abuse
neglect

55
Q

What should doctors do with regards to confidentiality and child abuse?

A

Obviously have a responsibility to report abuse

No promises about confidentiality

Should try to discuss with the child first of all, however not if that would expose them to greater harm

If it is not considered to be in their best interests to disclose, then should confidentially discuss this with an experienced senior colleague. Record these discussions.

56
Q

When should doctors be able to conscientiously object to providing an intervention?

A

BMA:

  • Should have a right to in abortion, fertility or withdrawal of life-saving treatment if another doctor is willing to take over.
  • Should never on the basis of a particular group of patients for whatever reason.
57
Q

Considerations of restraint in young people?

A

Restraint should be used only when it is necessary to give essential treatment or to prevent a child from significantly injuring himself or herself or others.

The effect should be to provide an overall benefit to the child and in some cases the harms associated with the use of restraint may outweigh the benefits expected from treatment.

Restraint is an act of care and control, not punishment, and should be administered with due respect.
Unless life prolonging or other crucial treatment is immediately necessary, legal advice should be sought when treatment involves restraint or detention to override the views of a competent young person, even if the law allows doctors to proceed on the basis of parental consent.

All steps should be taken to anticipate the need for restraint and to prepare the child, his or her family, and staff.

Wherever possible, the members of the health care team involved should have an established relationship with the child and should explain what is being done and why.
Treatment plans should include safeguards to ensure that restraint is the minimum necessary, that it is for the minimum period necessary to achieve the clinical aim, and that both the child and the parents have been informed what will happen and why restraint is necessary.

Restraint should usually be used only in the presence of other staff, who can act as assistants and witnesses.
Any use of restraint should be recorded in the medical records. These issues are an appropriate subject for clinical audit.

58
Q

Considerations regarding genetic testing in children?

A

May lead to better management of the condition if they already have one, and this generally should be offered

If it is about future conditions then you should delay until a child can make their own decision regarding this
- Although need to make decisions in the childs best interests

59
Q

When is consent valid?

A

Consent is only valid if it is autonomous, with capacity, is

informed and free of pressure.

60
Q

Current law on organ donation?

A

Have to opt in to donate, if you have, and had capacity then the family have no lawful reason to object, however may still object and may not take organs in that situation

Family of deceased can also consent for organs to be donated if you had told them that’s what you would have wanted

61
Q

NICE guidance on IVF?

A

The latest NICE guidance recommends that infertility treatment should be offered to individuals or couples who have a medical cause of infertility or those who have unexplained infertility after trying to conceive for 2 year

Women under 40 who have been trying for more than 2 years should be offered three full cycles of IVF

Women aged 40 to 42 should be offered one cycle of IVF provided they have had no previous IVF cycles, they have no evidence of low ovarian reserve and they are made aware of the increased risks arising from pregnancy at this age

Treatment is only recommended if the woman has a BMI of between 19 and 30

62
Q

Arguments regarding the rights of a fetus?

A

When a woman wishes to terminate a pregnancy, her reproductive autonomy is in direct conflict with the interests of the foetus.

Although a foetus has no legal rights, it could be argued that it has a moral claim to a right to life, which trumps the woman’s right to procreative autonomy

63
Q

Factors to consider when doing a best interests for a neonates withdrawal of treatment?

A

Pain, suffering, mental distress and capacity for independent survival, pleasure and relationships with others.

Don’t take into account parents religious views

64
Q

When can doctors give contraception?

A

Can’t under 13 legally consent to a sexual relationship

• The young person understands the health professional’s advice

• The health professional cannot persuade the young person to inform his or her parents or allow the doctor to inform the parents that he or she is seeking contra-
ceptive advice

  • The young person is very likely to begin or continue having intercourse with or without contraceptive treatment
  • Unless he or she receives contraceptive advice or treatment, the young person’s physical or mental health or both are likely to suffer
  • The young person’s best interests require the health professional to give contraceptive advice, treatment or both without parental consent

4th Year (15 decks)

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