End of life, DNACPR and medicolegal issues

Question 1

What is the role of the coroner?

Answer 1

Coroners are independent judicial officers who enquire into deaths reported to them.
It is the coroner’s duty to establish the medical cause of death if it is unknown.
To enquire whether it is unnatural or due to violence.

Question 2

Which deaths need to be reported to the coroner?

Answer 2

1. Unnatural deaths - poisoning, use of a medical product
2. Violent deaths
3. Self-harm/suicide
4. Neglect
5. Injury relating to employment
6. Deaths in custody
7. Unknown cause

Question 3

What will the coroner/coroners office do following referral?

Answer 3

Investigate the circumstances of the death. May involve:

• notes
• talking to doctors
• investigation results
• post-mortem

The coroner is an exception to the duty of confidentiality. If the coroner passes the investigation to the police, this then extends to the police too.

Question 4

What is the role of the coroner’s enquiry?

Answer 4

• Coroner’s inquest is a fact-finding injury, not a trial.

- It is held when a death may be unnatural or unknown cause.

Question 5

What is the role of the medical examiner?

Answer 5

• To scrutinise deaths occurring in their geographical area of responsibility (ultimately all deaths once fully established)
• Independent from the coroner, but work in partnership
• To answer 3 main questions:
  i) What did the patient die from and is the medical certificate for cause of death (MCCD) accurate?
  ii) Does the death need to be reported to the coroner?
  iii) Does the death raise any governance concerns?

Question 6

What are the aims of the medical examiner?

Answer 6

• Provide better scrutiny for non-coronial deaths
• Ensure appropriate direction of deaths to the coroner
• Provide a service for the bereaved to ask questions about relatives care
• Improve quality of death certification
• Improve quality of mortality data

Question 7

What is NCEPOD?

Answer 7

National Confidential Enquiry into Patient Outcomes and Deaths.
It is a registered charity, independent from government and other regulatory bodies.

Question 8

What are the principles underling the Mental Capacity Act 2005?

Answer 8

• A person must be assumed to have capacity unless proven otherwise.
• A person must be given help to make their own decision before being treated as lacking capacity.
• A person must not be treated as lacking capacity merely because they make an unwise decision.
• A decision made for a person lacking capacity must be in their best-interests.
• The decision in best-interests must be the least restrictive to their freedom or autonomy.

Question 9

How do you assess a patient’s capacity?

Answer 9

1. The must be able to understand the information
2. Retain it
3. Weigh it up (risks and benefits)
4. Communicate that decision

Question 10

Who can make decisions on behalf of an adult who lacks capacity?

Answer 10

• Patient with an advance directive (decision specific)
• Doctor acting in the patient’s best-interests
• Office of the public guardian registered LPA (can only refuse life-saving treatment if specified)
• Court-appointed deputy (cannot refuse life-saving treatment)

Question 11

What is a patient safety issue?

Answer 11

A healthcare event that is:

• Unexpected
• Unintended
• Undesired
• Associated with actual/potential harm

Question 12

Why are critically ill patients at particular risk of patient safety incident?

Answer 12

1. Vulnerable patient from a physiological perspective - more likely to result in actual harm
2. Often unable to communicate their wishes or symptoms associated with harm
3. Patient’s having multiple invasive procedures
4. Patient’s having multiple therapies
5. High acuity of patients with multiple problems.

Question 13

What are the stages at which medication errors can occur?

Answer 13

1. Prescription
2. Transcription
3. Preparation
4. Dispensing
5. Administration

Question 14

What are medication errors?

Answer 14

An error in prescription, transcription, preparation, dispensing or administration that does NOT NECESSARILY cause harm.

Question 15

What are adverse drug events?

Answer 15

Medication error where harm DOES OCCUR

Question 16

Why are medication errors occur in Intensive Care?

Answer 16

1. Patient factors:
   - severity of illness
   - prolonged hospitalisation
   - lack of capacity
   - altered pharmacodynamics
2. Environmental/human factors:
   - High turnover of patients
   - high stress working conditions
   - emergency admissions with lack of medication background
3. Medication specific:
   - Polypharmacy
   - multiple modes of administration

Question 17

How can you reduce medication errors in ICU?

Answer 17

1. Human factors:
   - avoid excessive working hours
   - avoid distractions at each stage of prescription, preparation and administration
   - appropriate staffing
2. Prescribing factors:
   - appropriate training
   - electronic prescribing
   - standardisation of medication
   - pharmacist involvement

Question 18

What is a never event?

Answer 18

• A SERIOUS INCIDENT
• Wholly PREVENTABLE
• guidance and safety RECOMMENDATIONS to prevent at a NATIONAL level

Question 19

What never events are you aware of?

Answer 19

1. Surgical:
   - wrong site
   - wrong implant
   - retained foreign body
2. Medication:
   - Wrong route
   - overdose methotrexate
   - incorrect insulin
3. General:
   - Use of misplaced NG tube
   - transfusion errors
   - scalding patients
   - falls from poorly secured windows
   - failure to install collapsible curtain or shower rails.

Question 20

How can never events be minimised?

Answer 20

1. Barcode scanners
2. Two person checking drugs/blood
3. Surgical checklist
4. Locssip checklists
5. Standardisation of procedures
6. Route cause analysis and training

Question 21

What would you do if you were involved in a never event?

Answer 21

1. Prioritise patient safety and stability
2. Remove the source of harm
3. Duty of candour to inform patient and NOK.
4. Report never event to consultant
5. Complete incident report as per local policy and Serious Incidents Framework (RCA).