Chapter 8 - common ethical issues

Question 1

what are the four principles that all health workers must adhere to?

Answer 1

Beneficience - to do good, according to the patients best interests
nonmalificience - to do no harm
autonomy - self-determination, respecting patient choice according to their values
justice - fairness in resource allocation, equity across individuals and society

Question 2

what are the three requirements for a patients consent to be valid?

Answer 2

1) informed - have all the info
2) uncoerced - be free to make that decision
3) competent - have the capacity to make the decision

Question 3

what is the mental capacity act (2005) ?

Answer 3

Act to help determine whether a patient has capacity:

1) understand the info
2) retain the info
3) weight up the info
4) communicate their wishes

Question 4

what are some guiding principles for the MCA 2005?

Answer 4

• always presume a patient has capacity
• provide all necessary measures to support a patient to make their own decision
• patients do have the right to make unwise decisions
• requirement to act in a patients best interests if they lack capacity
• least restrictive option
• capacity is decision and time specific

Question 5

what may improve with clinically assisted hydration?

Answer 5

sedation and myoclonus

Question 6

what may worsen with clinically assisted hydration?

Answer 6

ascites
pleural effusion 
increased uncomfortable urinary output 
peripheral oedema 
vomiting 
ICP

Question 7

how should a conversation regarding CAH be approached?

Answer 7

Find out their concerns + what they are requesting
Reassurance that dying people will be supported to drink if they wish to
Explain individuals hydration status/clinical need for CAH will be reviewed daily/every 12 hours
Discuss the risks vs benefits of CAH
If indicated, a trial of CAH for 12 hours can be offered
Involve family in mouth care if they wish

Question 8

how should a conversation regarding prognosis be approached?

Answer 8

first check how much they already know/what health care professionals have said before
check why they are asking this question
ask how they see themselves in their situation
check whether they would like to know all the information
if they still want to know - ensure you are familiar with their medical notes + explain in loose noncommittal terms i.e. weeks..days..months
be honest that we cannot predict the exact time and this would just be an estimate

Question 9

how should you approach a conversation with relatives who are adamant they do not want the patient to know the diagnosis?

Answer 9

listen and validate their concerns overtly, exploring all issues ie. cultural issues, societal issues, psychological
confirm the need to avoid lies/colluding
Try to find out exactly why they do not want their relative to know
Explain that patients do have a right to not know if they wish, however this must be the patients decision
Patients have the right to make an informed decision
reassurance that patients will be asked before if they want to know more information
Patients are usually more concerned by uncertainties surrounding death
Patients can be comforted by a label
Patients can pick up on conspiracy of silence which is distressing
Most patients have already worked out the diagnosis

Question 10

how should you approach a conversation regarding DNAR?

Answer 10

understand patients case and medical notes
understand patients desired QOL and perception of CPR/burden of CPR
Inform them clearly of the risks associated with CPR - i.e. poor QOL
Inform them of the chances of success i.e. 10% of patients survive
CPR is traumatic and chance of neurological damage is high
Explain gently that the final decision rests with the medical team - however they can get a second opinion if they wish
Decisions are regularly reviewed
the decision does not mean no further medical treatment