CHAPTER 16: ETHICS AND MISCELLANEOUS Flashcards

Question

How do you assess capacity?

Answer 1

Lack of capacity requires demonstration of both: • Impairment of or disturbance in functioning of mind or brain (e.g. cognitive impairment, mental disorder, delirium, or intoxication) • Inability to do any of the following: - Understand information relevant to decision - Retain relevant information for long enough to use it for the decision - Use or weigh information - Communicate decision

Answer 2

Any intervention in the care of an incapacitated adult, either by healthcare professionals or by their welfare attorney or guardian, must: - Benefit the patient - Take account of the patient’s wishes - Take into account the views of others involved in the care of the patient - Allow the patient to retain as much of their independence as possible.

Answer 3

- if a welfare attorney or guardian has been appointed, you must seek his or her consent on behalf of the patient where possible. - if no welfare attorney or guardian, a certificate of incapacity with a specified validity period is issued. - if there is any disagreement - seek Mental Welfare Commission for a specialist 2nd opinion - in an emergency, you can treat an adult with incapacity if your actions will either save a life or avoid deterioration of the patient’s condition.

Answer 4

Advance decisions can be drawn up by anybody to specify treatments they would not want if they lost capacity. They cannot demand treatments. Provided advance decisions are made when the person had capacity, and they are sufficiently specific to cover the patient’s current predicament, clinicians must respect them. They can be made verbally and can be reversed by the individual if they regain capacity. Advance decisions that refuse life sustaining treatments (such as ventilation) have to be written, signed, and witnessed to be valid. It is incumbent on clinicians to find out if an advance decision exists and assess whether it is valid.

Answer 5

Decide on what treatment (if any) is in patient’s best interests • Try to establish what the patient would have wanted if he or she had capacity. Research known opinions and values. Consult, but do not necessarily follow (unless a lasting power of attorney covers the decision), the opinions of family and friends • Consider involving the IMCA (independent mental capacity advocates) service if the patient has no family or friends • Beware of assuming that "best interests" is what the clinical team feels should happen; remember principle 3 of the Mental Capacity Act (the right to make unwise decisions)

Answer 6

- to support and represent a person who lacks capacity in making a specific decision, and who has no-one (other than paid carers) to support them. The service comprises the independent organisations that assign someone to support and represent “unbefriended” people who lack capacity. Their recommendations do not need to be adhered to by clinicians, although they should be taken into account as part of the decision making process. Each local authority (borough) has appointed its own IMCA service. When to instruct an IMCA. - for care reviews or adult protection cases - when serious medical treatment is being proposed (such as ventilation, major surgery, chemotherapy, and discontinuation of artificial nutrition or hydration) - when accommodation for more than 28 days in hospital or 8 weeks in a care home is being arranged or changed

Answer 7

A person could appoint a named person (the “donee”) with the authority to make decisions on their behalf if they lost capacity. Previously this only applied to property and affairs. The Mental Capacity Act widens this authority to decisions about personal welfare, including health care and social affairs. It includes all decisions except those about the withdrawal of life saving treatment, unless explicitly authorised in the agreement. Property and affairs lasting power of attorney agreements can start before a person has lost capacity, but personal welfare ones cannot. Clinicians treating people without capacity must follow the decision of a donee, unless they are thought not to be acting in the person’s best interests or to be abusing the person lacking capacity, in which case you should follow the guidance of the code of practice. In serious cases you may need to seek a decision from the court of protection. When making a lasting power of attorney agreement, the limits of the powers granted are specified—this is known as the “nature and effect.” Decisions about life sustaining treatment must be specified in the lasting power of attorney, and a signed statement from the attorney and a certificate completed by an independent third party are required. A parallel system exists where the court of protection can appoint a deputy for someone who already lacks capacity. The deputy is likely to be a family member or director of social services. The deputy can consent on the person’s behalf but can never consent to decisions that will shorten the person’s life.

Answer 8

Previously it was involved in the adjudication of the financial matters of people without capacity, but its role has widened to include health and welfare decisions. It will be more accessible and available to arbitrate on disputes and is now able to “establish precedent” with the same powers as the High Court.

Answer 9

Age 16 = adult with capacity to decide < 16 = may have capacity depending on ability to understand (Gillick competence = Fraser ruling) Where a competent child refuses Ix & Rx the following parties can authorise it if in their best interest - Person with parental responsibility - Court (If parents want GC child to have an Ix & Rx but child (< 16) doesn’t want to then you can proceed despite their refusal – i.e. minors can consent but can’t refuse) Under 16 - a person with parental responsibility may authorise or refuse Ix & Rx but if deemed not in their best interest then can apply to court

Answer 10

A - good evidence to support the use of the procedure B - fair "" C - poor "" D - fair evidence to support the rejection of the use of the procedure E - good ""

Answer 11

Aims to resolve claims without going to court Timescale - if pt / lawyer requests pt's health records, request must be acknowledged within 14 days and records supplied within 40 days - pts must then send the dr a 'letter of claim' (their version of events, alleged injury and compensation sought) - dr must respond within 4mths, outline what you did, reasoning behind decision you made, what your notes say

Answer 12

- Not all parents have parental responsibility Both do if - Married at time of conception - Married at some point after child’s birth - Neither lose responsibility on divorce - Unmarried fathers of children born after 1/12/2003 in England and Wales, provided his name is on birth certificate - Adoptive parents (biological parents lose rights after adoption) - If never married, mother only has responsibility but father can apply to courts - A legal guardian can be appointed by courts - If child is under local authority care, parents share responsibility with LA (who can restrict parental resp)

Answer 13

1a: Systematic reviews (with homogeneity) of RCTs. 1b: Individual RCTs (with narrow confidence interval) 1c: All or none RCTs 2a: Systematic reviews (with homogeneity) of cohort studies 2b: Individual cohort study or low quality RCTs (e.g.

Answer 14

A demand for financial compensation for alleged harm caused by substandard clinical care For claim to be successful, pt has to prove: - BREACH OF DUTY - that the treatment was such that no reasonable practitioner would have delivered that care. - CAUSATION - that the breach of duty / negligence caused or contributed to the injury, loss or damage suffered, and the pt wound not have suffered that injury w/o the breach.

Answer 15

- 3 mths from date of injury, or when pt knew | - can be longer if child, mentally ill or interval before pt knew of injury

Answer 16

- CDs kept in metal cupboard - CD register, separate pg for each drug, stock balance - 2 members of staff to check in/out CDs, sign register - Check expiry dates, expired drugs are destroyed by registered person

Answer 17

Inhibits platelets - Vit E, garlic, ginger (large doses), gingko biloba, ginseng, feverfew may react with adr - ephedra

Answer 18

- A summary of the concern - A description of the investigations carried out - Copies of any expert opinions received during the investigation (however, do not include correspondence or advice received from MPS) - Copies of relevant medical records - An explanation of what happened and why in relation to each issue - An apology, where appropriate - What action will be taken, if any - Details of the right to notify the Ombudsman - An offer to discuss the response with the responsible officer - Signature of the responsible officer (or their delegate).

Answer 19

Aspirin - Irreversibly blocks TXA2 - discontinue 10d Clopidogrel - irreversibly blocks ADP receptor on platelet cell membranes - platelet tx Warfarin - competitively inhibits Vit K-2-3-epoxide reductase - FFP, vit K Heparin - inhibits factor Xa - protamine sulphate NSAIDs - inhibits COX pathway and PG synthesis

Answer 20

Class, Risk of infection ``` I Clean (1-4%) - non-contaminated skin, aseptic technique ``` II Clean-contaminated (5-15%) - GI, resp, GU w/o gross contamination - minor breaks in aseptic technique III Contaminated (6-25%) - GI, resp, GU with gross contamination - major breaks in aseptic technique IV Dirty +/or infected (>25%) - FB contamination, acute bacterial inf, pus

Answer 21

At high risk of endocarditis - prev inf endocarditis - prosthetic cardiac valve - congential heart disease unrepaired / repaired < DM, malignancy Antibiotic (30-60mins before procedure) - amoxicillin 2g po - cephalexin, clindamycin, azithromycin/clarithromycin

Answer 22

supraorbital nerve - notch, mid-pupillary line infraorbital nerve - notch, midpupillary line - intraoral: b/t 1st & 2nd premolars at labial sulcus mental nerve - notch on chin, lateral to midline

Answer 23

radial nerve - 3 fingerbreadths proximal to distal wrist crease, just beside cephalic vein median nerve - 3 fingerbreadths prox to distal wrist crease, under PL ulnar nerve - cubital tunnel b/t olecranon and med epicondyle of humerus

Answer 24

The Review Committee gathered evidence from those working in the cosmetic procedures sector, the public, academics and international policymakers Recommendations made Change needed in: 1. High quality care 2. An informed and empowered public 3. Accessible resolution and 'redress' in case things go wrong

Answer 25

Current legislation Cosmetic surgery is not defined as a surgical speciality with a common qualification or an organisation responsible for setting standards. There are no restrictions on who can carry out non-surgical procedures. Only some of the products implanted or injected into the body are regulated as medical devices. There is little reliable data to help people consider the risks and effectiveness of different cosmetic treatments, and consent procedures are poor. People are often offered time-limited discounts for surgery – for example, they are given a discount if they sign a binding contract at the end of a first consultation.

Answer 26

The main actions that the review group says would contribute to a successful and safe cosmetic surgery industry include: - making all dermal fillers PRESCRIPTION only - ensuring all practitioners are properly QUALIFIED for all the procedures they offer, from cosmetic surgeons offering breast enlargement to people offering ‘injectables’, such as dermal fillers or Botox - an OMBUDSMAN to oversee all private health care including cosmetic procedures to help those who have been treated poorly Other recommendations - surgical providers should provide a RECORD of implants and operations to both the person undergoing a procedure and their GP - a REGISTRY should be established for breast implants and other devices – this should alert the authorities to any signs of concerns at an early stage, and will provide critical intelligence in the event of product failure or recall - providers are obliged to ensure that people are aware of the IMPLICATIONS and RISKS of procedure and that they have adequate time to consider this information before agreeing to surgery - an ADVERTISING code of conduct should be developed and compliance should be mandatory for all practitioners insurance products should be developed to protect patients in the event of product failure, or provider insolvency

Answer 27

PIP expert group final report (2012) - Keogh DoH Poly Implant Prothèse (PIP) Company PIP contains non-medical grade silicone, containing higher levels of siloxane and platinum. No other impurities detected. * rigorous analyses have not shown any evidence of significant risk to human health * PIP implants are 2-6x more likely to rupture or leak than other implants, detectable within 5 years of implantation * rupture leads to local reactions and clinical signs * PIP implants are substandard although no evidence of significant increased risk of clinical problems in absence of rupture. In the light of these conclusions we advise that: • all providers should contact patients and offer specialist consultation and investigation to determine if implants are still intact (if not, GP should refer to specialist) • if any sign of rupture, offer explantation • if the implants intact, discuss with specialist the best way forward • if she wishes to have implants removed, healthcare provider should carry out this surgery. Where original provider is unable or unwilling to help, NHS will remove but not normally replace the implant • if a patient decides not to seek early explantation, she should be offered annual follow up • Any signs of tenderness or pain, swollen lymph glands around breasts or armpits, may indicate a rupture. Contact specialist and offer removal.

Answer 28

PIP: 6-12% at 5 years, 15-30% at 10 years Allergan: 10% at 10 years Mentor: 14% at 8 years (Mentor now has lifetime guarantee on their implants for rupture if it is due to implant failure. Rep will come to collect implant).

Answer 29

Subjective - Patient questionnaires - Vancouver scar scale (med) Objective - Tenometers

Answer 30

Belongs to person who took photo. In private practice: it's you. In NHS: it belongs to the Trust, as the photographer is employed by them.

Answer 31

Under the DPA, if you handle and store information about identifiable living people, you are legally obliged to protect that information. You must: - only collect information that you need for a specific purpose. - keep it secure. - ensure it is relevant and UTD. - only hold as much as you need, and only for as long as you need it. - allow the subject of the information to see it on request.

Answer 32

It is the UK's independent authority set up to uphold information rights in the public interest, promoting openness by public bodies an data privacy for individuals.

Answer 33

Doctors who are in private practice will need to register with then Information Commissioner as a data controller, the annual fee is 35 pounds.

Answer 34

Neglect Physical abuse Emotional Sexual Wales 34 per 10000 England 23 Scotland 18

Answer 35

- Regularly review data protection policy, type of data held, who has access, how it is kept secure. - All electronically held data should be encrypted, and can be remotely wiped if lost or stolen. - Paperwork should be stored in locked cupboards, and period it is to be retained noted. - When data analysis is performed, it should be anonymised.

Answer 36

- Surgical patients and patients with trauma. - If total anaesthetic + surgical time > 90 minutes. - If surgery involves pelvis or lower limb and total anaesthetic + surgical time > 60 minutes. - If acute surgical admission with inflammatory or intra-abdominal condition. - If expected to have significant reduction in mobility. - If any VTE risk factor present (see below). VTE risk factors - Active cancer or cancer treatment - Age > 60 years - Critical care admission - Dehydration - Known thrombophilias - Obesity (BMI > 30 kg/m2) - One or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions) - Personal history or first-degree relative with a history of VTE - Use of HRT - Use of oestrogen-containing contraceptive therapy - Varicose veins with phlebitis

Answer 37

Dabigatran: direct thrombin inhibitor. Rivaroxaban: direct factor Xa inhibitor. Apixaban: direct factor Xa inhibitor. Advantage: no INR monitoring required. Disadvantages: o Unknown long term safety profile (“black triangle drugs”). o Lack of reversibility. o Consideration of patient’s current INR control on warfarin (poorly controlled, housebound). o Renal function (must be stopped if eGFR

Answer 38

Review by Hull group (Hussain) International Journal of Surgery 2012. - The International Breast Cancer Intervention Study (IBIS) and European Institute of Oncology trials have shown a 2.3 fold increased risk of venous thrombo-embolism in women treated with tamoxifen compared to placebo. - 4 fold increased risk of VTE average across all cancers (annual incidence ~0.48%). - increased levels of platelet released serum VEGF.

Answer 39

``` If high risk for DVT (any 2): - Age >60 - FHx - BMI >30 - significant co-morbidities - recent chemotherapy STOP TAMOXIFEN 3WKS BEFORE AND AFTER, TEDS, LMWH UNTIL FULLY MOBILE. ``` If moderate risk - no risk factors - but recently had chemo STOP TAMOXIFEN 3WKS BEFORE AND RESTART AFTER SURGERY. If low risk (no risk factors, no recent chemo, surgery

Answer 40

Delayed presentation History not consistent with injuries sustained Inconsistent history, not compatible with developmental level of child Evasiveness, anger when details are sought History of abuse in child / siblings

Answer 41

Dr concerned with possible NAI refer to consultant paediatrician / lead clinician in child protection (CP nurse at our hospital) Strategy discussion with social services, police, and other relevant agencies - no concerns, no further actions - child / family in need, assess and provide required services - NAI -- child protection investigation ``` Appropriate emergency action taken Case conference convened by social services Decisions made about - Placing child / siblings on CPR - Child protection plan - Core group membership and tasks - Review case conference ```

Answer 42

A review by Chief Medical Officer of England was commissioned in 1997 due to increasing concerns of how pt information was used in the NHS and confidentiality issues. Dame Caldicott chaired this review The key principles are: 1. Justify the purpose(s) Every single proposed use or transfer of patient identifiable information within or from an organisation should be clearly defined and scrutinised, with continuing uses regularly reviewed, by an appropriate guardian. 2. Don't use patient identifiable informations unless it is necessary Patient identifiable information items should not be included unless it is essential for the specified purpose(s) of that flow. The need for patients to be identified should be considered at each stage of satisfying the purpose(s). 3. Use the minimum necessary patient-identifiable information Where use of patient identifiable information is considered to be essential, the inclusion of each individual item of information should be considered and justified so that the minimum amount of identifiable information is transferred or accessible as is necessary for a given function to be carried out. 4. Access to patient identifiable information should be on a strict need-to-know basis Only those individuals who need access to patient identifiable information should have access to it, and they should only have access to the information items that they need to see. This may mean introducing access controls or splitting information flows where one information flow is used for several purposes. 5. Everyone with access to patient identifiable information should be aware of their responsibilities Action should be taken to ensure that those handling patient identifiable information - both clinical and non-clinical staff - are made fully aware of their responsibilities and obligations to respect patient confidentiality. 6. Understand and comply with the law Every use of patient identifiable information must be lawful. Someone in each organisation handling patient information should be responsible for ensuring that the organisation complies with legal requirements.

Answer 43

The Human Tissue Act 2004 covers storage of tissue for research and medical use No tissue may be retained for more than 21days The patient must consent to the retention There must be measures in place to ensure the tissue is stored correctly and is only used on that named patient There must be processes in place for disposal of the tissue if not used Individual staff members are responsible for their own actions - seeking appropriate consents, approval to store tissues and following codes of practice For the Therapeutic License, there is a LEAD INDIVIDUAL within each specialty (including plastics) that may retain tissue for more than 48hrs The lead individual reports direct to the DESIGNATED INDIVIDUAL for Therapeutic Use, who reports to the MD MEDICAL DIRECTOR ultimately is the accountable officer The DIRECTOR OF OPERATIONS will performance manage the implementation of this policy s appropriate within Clinical Management Teams All Clinical Medical Teams that remove, store or dispose of human tissue are responsible for ensuring they have systems in place and be compliant with the HTA Code of Practice, and seek appropriate consent and approval to store tissue.

Answer 44

Significant Incident Type  All incidents rated as HIGH/VERY HIGH on Datix  Incidents reportable to the Scottish Fatalities Unit (SFU) e.g. maternal deaths  Incidents reportable to the Mental Welfare Commission  Incidents reportable as part of a Fatal Accident Inquiry (FAI)  Incidents reportable as „avoidable deaths‟ (identified via the Mortality and Morbidity Review process)  Incidents reportable via SHOT or SABRE (e.g. transfusion incidents)  Incidents reportable to the HSE/RIDDOR  Any other „Never Event‟ (very serious, largely preventable patient safety incident that should not occur if the relevant preventative measures have been put in place e.g. wrong site surgery)  Incidents resulting in an Internal Case Review (Clinical and Non Clinical e.g. systems failure for a piece of equipment, adult/child protection QA etc).

Answer 45

DIF 1 filled in by me, DIF 2 filled in by my line manager, sent to final approver in risk management, and then moved into main Datix application (Contact the appropriate Senior Manager to agree upon the process for investigation) Possible Outcomes - Act now. Put immediate controls in place, start investigation - Next working day. Put controls in place, start investigation - Within 1 week. Put controls in place, start investigation within 7 days - You may also agree to DOWNGRADE the incident if the manager does not assess it to be a significant incident Investigation Requirements - Communicate incident details to staff, patient and relatives (as appropriate to the incident type) - Start a timeline/chronology of events. Ask staff to start writing statements/recollections - Complete an initial assessment/recommendations - Bring together a Significant Incident response team to agree, manage and implement actions - Agree a timescale for the completion of the initial investigation - Agree a timescale for the completion of the actions - Record stages of the investigation process on Datix (if it is not already on the system) Reporting, Monitoring & Feedback - Findings and actions will be fed back to staff in the form of a report and debriefing - Wider sharing of the findings and actions will be circulated to the „governance meetings‟. - A summary of incidents, investigations and key findings will be presented to CGCG and CGC on a quarterly basis. - All individual investigation reports will be reviewed at the Risk Management Group on a quarterly basis.

Answer 46

The foundation of medical ethics is supported by four pillars, namely; 1. Autonomy - patient has the right to choose or refuse the treatment 2. Beneficence - a doctor should act in the best interest of the patient 3. Non-maleficence - first, do no harm 4. Justice - it concerns the distribution of health resources equitably. Added to the above four, are two more aspects which form the cornerstones of medical practice: 5. Dignity - the patient and the persons treating the patient have the right to dignity 6. Truthfulness and honesty - the concept of informed consent and truth telling All these together constitute the six values of medical ethics.

Answer 47

- Introduced Nov 2014. - Applies to all care providers registered with CQC. - The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The key principles are: 1. Care organisations have a general duty to act in an open and transparent way in relation to care provided to patients. This means that an open and honest culture must exist throughout an organisation. 2. The statutory duty applies to organisations, not individuals, though it is clear from CQC guidance that it is expected that an organisation's staff cooperate with it to ensure the obligation is met. 3. As soon as is reasonably practicable after a notifiable patient safety incident occurs, the organisation must tell the patient (or their representative) about it in person. 4. The organisation has to give the patient a FULL EXPLANATION of what is known at the time, including what further enquiries will be carried out. Organisations must also provide an APOLOGY and keep a written record of the notification to the patient. 5. A NOTIFIABLE PATIENT SAFETY INCIDENT has a specific statutory meaning: it applies to incidents where a patient suffered (or could suffer) UNINTENDED HARM THAT RESULTS IN DEATH, SEVERE HARM, MODERATE HARM OR PROLONGED PSYCHOLOGICAL HARM. Severe and moderate harm definitions are derived from the NPSA's Seven Steps to Patient Safety. Prolonged psychological harm means that it must be experienced continuously for 28 days or more. 6. There is a statutory duty to provide reasonable SUPPORT to the patient. Reasonable support could be providing an interpreter to ensure discussions are understood, or giving emotional support to the patient following a notifiable patient safety incident. 7. Once the patient has been told in person about the notifiable patient safety incident, the organisation must provide the patient with a written note of the discussion, and copies of correspondence must be kept.

Answer 48

- HR - Medical Director - Clinical lead - GMC will determine if this is a case to answer. - Medical Practitioners tribunal service. - Interim audit panel: imposes restrictions on your practice / suspend you. - Fitness to practice hearing

Answer 49

Apr 2013 (Tim Goodacre). 1. Information, consent & advertising 2. Regulation of practitioners 3. Regulation of providers 4. Medical implants, devices and other products; data and registries

Answer 50

Information, consent & advertising • One clear set of rules relating to cosmetic surgery advertising with decisive action taken against practitioners who break the rules • Statutory protection across all forms of media to prohibit any form of financial incentive and any promotion to under 18s • Accurate use of language with number of years practitioners have been on a specific GMS Specialist Register as the only objective measure of experience and a ban on terms ‘leading’ or ‘expert’

Answer 51

Regulation of practitioners • Practitioners who use the term surgeon in their title must be on the GMC Specialist Register and work within the defined scope of practice for their designated specialty • Cosmetic surgeons should be trained via the NHS and have appropriate mentoring programmes when they establish independent practices • ‘Fly in/Fly out’ visiting surgeons must be subject to exactly the same standards and regulations as UK surgeons, and healthcare providers must be able to prove that such surgeons have validated assessment of surgical competence / ability

Answer 52

Regulation of providers • Private providers of cosmetic surgery must adhere to the same code of conduct and standards as those expected of the NHS, including mandatory reporting of procedures undertaken • Provider institutions need to be subject to robust regulation through active inspection and enquiry. There should be an annual reporting mechanism to the agreed regulator, who should at all times have the expertise and authority to act in the public interest • Private cosmetic surgery providers must be made responsible for the aftercare of their patients, regardless of the timeframes in which the interventions took place. This is likely to require a system to support patients affected by provider bankruptcy

Answer 53

Medical implants, devices and other products; data and registries • A national, compulsory register for medical devices including breast implants must be developed • Improved surveillance of breast implants and other cosmetic devices must be conducted in order to ensure poor quality products are recognised and dealt with early • All injectable materials need to be registered as medical devices and CE marked, including both absorbable and permanent fillers, to ensure they are subject to the appropriate regulatory procedures • All practitioners using fillers and toxins by injection must maintain full records of treatments and record outcome data to a standard that can be audited independently

Answer 54

ICOBRA - International Collaboration of Breast Registry Activities. International consensus for an agreed minimum dataset for breast implant and device registries with other international societies of plastic surgeons.

Answer 55

The Scottish Cosmetic Interventions Expert Group (SCIEG) will regulate private clinics from Apr 2016. 3 phases: 1. private clinics. 2. high risk procedures, including dermal fillers. 3. develop a system of regulation for other groups of practitioners.

Answer 56

* The scope of the EU Medical Devices Directive should be extended to include all cosmetic implants including dermal fillers, In UK, fillers should be prescription-only medical device. * RCS should establish an Interspecialty Committee on Cosmetic Surgery, made up of representatives of all relevant specialty and professional associations. They are to set standards for cosmetic surgery practice and training, and certify all surgeons competent to undertake cosmetic procedures, taking account of training and experience. * All those performing cosmetic interventions must be registered. * The Health Education England’s (HEE’s) mandate should include the development of appropriate accredited qualifications for providers of non-surgical interventions and it should determine accreditation requirements for the various professional groups. * Surgical providers should provide both the person undergoing a procedure and their GP with proper records. * A breast implant registry should be established within the next 12 months and extended to other cosmetic devices as soon as possible, to provide better monitoring of patient outcomes and device safety.

Answer 57

• The RCS Interspecialty Committee on Cosmetic Surgery should develop and describe a multi-stage consent process for operations. Consent must be taken by the surgeon performing the operation to ensure that the patient and practitioner have a shared understanding of the desired outcome and the limitations, implications and risks of the procedure. • Evidence-based standardised patient information should be developed by the RCS Interspecialty Committee on Cosmetic Surgery, with input from patient organisations. • For non-surgical procedures a record of consent must be held by the provider. • Existing advertising recommendations and restrictions should be updated and better enforced. • The use of financial inducements and time-limited deals to promote cosmetic interventions should be prohibited to avoid inappropriate influencing of vulnerable consumers.

Answer 58

* The remit of the Parliamentary and Health Service Ombudsman (PHSO) should be extended to cover the whole private healthcare sector. This will de facto include cosmetic procedures of all kinds. * All individuals performing cosmetic procedures must possess adequate professional indemnity cover that is commensurate with the type of operations being performed. For surgeons working in this country, but who are insured abroad, indemnity insurance must be commensurate with similar UK policies. * The Review Committee supports the future development of insurance products such as risk pool arrangements, to cover product failure and certain complications of surgery.

Answer 59

Rohrich (2001) Review of tobacco smoking in plastic surgery. ``` Aetiology: - thrombogenesis - decreased oxygen delivery - microvascular injury - leucocyte, macrophage, fibroblast and platelet dysfunction - diminished oxygen utilisation impaired wound epithelialisation. ``` Literature review. - Increased risk of flap loss and donor site morbidity in TRAMs. - Increased risk of digital replant loss. - No difference in anastomotic failures in free flaps. However, there was increased risk of donor / recipient site wound healing problems. - Increased risk of skin slough after rhytidectomy. - Chang et al (PRS 2000) demonstrated a significant decrease in complications with smoking cessation for 4wks pre op in his free TRAM flap recons.

Answer 60

Revalidation = process by which all licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practice in their chosen field and able to provide a good level of care. It ensures the doctor continues to meet the professional standards set by the GMC and the specialists standard set by the medical Royal Colleges and Faculties.

Answer 61

You should have collected and reflected on the following information from your practice: 1. continuing professional development 2. quality improvement activity 3. significant events 4. feedback from colleagues 5. feedback from patients 6. review of complaints and compliments.

Answer 62

1. scope of your current practice statements of probity and health 2. evidence of participation in annual appraisal 3. statements of good standing from your regulator if you are working overseas 4. evidence that you have passed a particular assessment or evaluation.

Answer 63

Revalidation: every 5 years Responsible officer: provides a recommendation statement for: 1. Revalidate 2. Defer 3. Non-engagement

Answer 64

- in an emergency if a parent is not available and not contactable - parental neglect - abandonment of child

Answer 65

- clinically indicated treatment options - views of the child - views of the parents / relatives close to the child - cultural, religious and other beliefs - views of other professionals (healthcare or non-HC) - the extent to which the treatment will restrict the child and his future options (chose least restrictive)

Answer 66

Generally, consent from 1 parent is sufficient, BUT - if treatment is major or controversial (e.g. cosmetic surgery, ritual circumcision), try to obtain consent from both parents. - if unable, legal advice is necessary.

Answer 67

If it is potentially life saving, parents cannot refuse blood products (several prior cases). Most JW parents will allow, but if they refuse, doctors may transfuse in a true emergency. If not, legal advice and Hospital Liaison Committee should be consulted.

Answer 68

Police Reform Act 2002 - police have the power to request blood sample from patient who is not competent to consent, but dr can refuse if it will be damaging to the patient's clinical care - sample cannot be processed until patient regains capacity and consents - doctor cannot take blood from a competent patient without his consent, even at the police's request