Ethics Flashcards
you dont get on well w ur co-intern — she wont help u with work, wont take your bleep post call, is now making prescription mistakes + blaming them on u, generally bad mouthing you to the other interns
no. 1 priority = ensure patient safety isnt compomised
local level
talk to her when we’re not busy, in a quiet room away from the patients, if possible i would give away the bleeps so that we arent interrupted.
i would bring up the issues in a non-confrontational way and be polite – “i understand” “i might be wrong but”
try to see if im understanding things wrongly, maybe she has certain uncertainties or anxiety — something i can help with
do she need help — issues at home or work
help do the jobs together
show how to do procedures if neede
switch/cover shifts
suggest they talk to relevant help services —- occupational health, addiction services, PHMP practioners health matters programme
generally support them through whatever they’re going through
while i want to help them in whatever problem they’re facing, I wold still want to address the problem and make sure it doesnt continue
as doctors we’re meant to be a role model + have a responsibility to do so
if she is still resistant = escalate to higher levels
consult a reg who isnt involved + can trust
if need be i will escalate higher –> consultant –> intern tutor –> HR
doctors working in MDTs should ensure clear lines of communication + systems of accountability in place among team members to protect patients
if they said you should move to a different team, how would you feel?
accept it — if the tutor felt it was in the best interest of the patients then i would move
but i would go with it with a heavy heart
reflect
nurse calls you repeatedly at night to get paperwork done + badmouths you in front of patients — discuss
no. 1 priority = ensure patient safety is not compromised
(similar to the co-intern bad mouthing)
i understand that she may have been working in the wards and hospital for a very long time, she may like things to be done in a certain way, and it can be frustrating to have new doctors coming around every day who do things differently from her.
i would try to understand why she needs that paperwork done urgently, and explain my point of view on the priority of things i need to get done in the night.
I would try to reach a compromise and improve communication.
for example, before i take a break or nap, i would tell the nurses i am going to rest and ask if there is anything that needs to be done before then.
i would then explain to her that she cannot be badmouthing me in front of patients as it is unprofessional.
doctors working in MDTs should ensure that there are clear lines of commuication and systems of accountability in place among team members to protect patients.
reflect
workplace bullying — nursing staff being rude or ED reg shouting at you
no. 1 priority = ensure that patient safety isnt compromised
are there any more people affected by this — patients or team members
step back from the situation, dont take it personally — a difficult colleague is a colleague in difficulty
break down of communication can only be detrimental to patient safety
at a local level
i would avoid confrontations — esp in front of patients
be clear with them that it is inappropriate
try to establish a context is important
understant the person in the acute phase
important to establish if this is a once-off event or a pattern of behaviour that needs to be addressed (eg. racism, sexism)
building a supportive environment: need to stand up for what i believe is right and might want to protect any vulnerable persons
good professional practice supports performance & patient safety
partnership = one of the pillars of professionalism
if happening to another colleague — eg. found crying coz a consultant bullied them
comfort the colleague
establish whether patient safet is at risk
ultimately it would be best for both individuals to talk amongst themselves, but i can facilitate if required as a neutral 3rd party
the intern bullied is especially vulnerable as there is a mismatch of employment status — the consultant may be in a permanent post, and the intern may be reliant on the consultant to write letters or give recommendations
do a reflection afterwards
high court judge inpatient is threatening to sue the hospital as he heard someone in the ward has covid-19 and is worried he will catch it
OR
old man with lightheadedness on a trolley in the ED for 3 days + has private health insurance. his family is angry and wants to sue you
no. 1 priority = patient safety
familiarise myself with the patient and the context
what happened
previous complaints or difficulties with the patient
why is he upset and what are his concerns
i would also clarify the situation by talking to his nursing staff and the other doctors looking after him
when talking to the patient
i would bring the patient into a private and quiet room to de-escalate the situation, and would pass my bleep to someone so as to not be disturbed
i would apologise to the patient and allow him to air his grievances
i would also try to open channels of communication
i would make sure to KEEP VERY GOOD NOTES OF EVERY INTERACTION with these patients
address the patient concerns.
eg. the patient worried about infection
infection control is important for patient safety, good practice is one of the pillars of professionalism
i would take the complaint seriously and wants him to know that
i would explain the infection prevention measures currently in place, such as the patient being in an isolation room, and everyone being required to wear gowns before entering his room and disposing of those gowns so as to not pass the virus to other patients.
eg. the trolley guy
reassure him that we are doing our best to find a bed for him in the wards, we do our best to give the appropriate care to our patients, even if he is on a trolley.
i understand that it is not ideal but he is receiving his treatment which is important
and explain that both public and private hospital is full which is why he is still in the ED
the most important thing at the moment is to get you feeling better, if need be we can address the matter of legal complaints in the future
DONT disclose another patient’s medical info — ie cant tell him that someone does have the flu next to him
use this as an opportunity for health promotion –> encourage him to get the flu, pneumococcal, covid vaccines
if patient is still adamant about sueing = discuss with senior
reflect on the situation — what could i have done better to address his concerns
PEG feeding in advanced dementia: his wife is enquiring about possibility of PEG insertion but his daughter doesnt want it. wife asks for your advice whether to go ahead or not
OR
men comes in with acute pneumonia. his family wants a PEG tube but it isnt indicated
- determine whether or not a PEG tube is clinically indicated
in advanced dementia, studies show that a PEG placement doesnt prolong life — instead, oral assisted feeding is preferable
(note: advanced dementia, losing weight is the final stage of illness – be v.gentle when discussing this with his daughter)
- explore families ICE (ideas, concerns, expectations)
assess understanding + explore why wife/fam wants a PEG tube
saturday –> not a decision for a saturday night coz MDT isnt here to give input
link in with patients team & nursing home staff in terms of advanced care planning
nursing home liaison officer - talk about other options –> involving dietician & palliative care team
patients have right to refuse treatment, but no right to demand treatment
if family wants a PEG but MDT doesnt think he erquires one, the patient shouldnt even be asked if he wants one.
what is PEG feeding?
patients wife is enquiring about the possibility of tube feeding + wants to know about it
can her husand get one? should he? what does it do?
PEG tube stands for percutaneous endoscopic gastrostomy
it is a flexible feeding tube placed through the abdominal wall and into the stomach.
it allows food, fluid and medication to go directly to the stomach, bypassing the mouth and oesopagus
usually it is used if there is any difficulty swallowing or if swallowing is dangerous
due to risk of aspiration — so food or stomach contents going down the wrong way
how do you assess capacity?
what happens if it is decided that a patient lacks capacity?
there are 4 requirements to a patient’s ability to make a decision
1. able to understand information communicated to him
2. able to retain the information sufficiently long enough to
3. weight the information up and
4. communicate it to the team + believe its implications
capacity is decision-specific and not general
it is important to assess capacity at the appropriate time so as to optimise the patient’s decision making skills — since capacity can fluctuate.
if decided that a patient lacks capacity
he should still be involved in decision process as much as possible
in the absence of capacity, decisions should be make in the patient’s best interest, will and preference.
you can involve the family in the decision making process but the family CANNOT consent for them
enduring power of attorney DOESNT apply to medical decision — until the assisted decision making act comes to play soon
enduring power of attorney doesnt activate until the patient loses capacity
woman with poorly controlled diabetes + HTN is on teratogenic antihypertensives (ACEI/ARBs)
she finds out she is pregnant — 11 weeks + unplanned
she comes to the GP wanting to terminate her pregnancy
what advice would you give her? how would you address her concerns regarding the health of her foetus
address + explore concerns — does she want a termination because she is worried about foetal abnormalities?
- risk to foetus & mother
antihypertensives are teratogenic
ACEI = a/w with malformations if taken in 1st trimester, a/w kidney problems when taken in 2nd or 3rd trimester
switch to labetalol (1st line)/nifedipine/methyldopa
take aspirin 75mg from 12 weeks — increased risk of HTN in pregnancy
mother: stroke, VTE, renal failure, eclampsia, HELLP syndrome
foetus: IUGR, abruption, preterm birth, stillbirth
poorly controlled DM = another risk to mother & foetus
mother: hypo/hyperglycaemia, retinopathy, pre-eclampsia
foetus: malformation, macrosomia, dystocia, IUGR, stillbirth
discontinue sulphonylureas & statins
high dose folic acid 5mg
close monitoring for complications in DM
- Termination of Pregnancy
allowed up to 12 wks gestation for a termination of pregnancy
but in reality it is 11 weeks and 4 days — as 3 days must elapse during the decision making process
<9 wks ToP = medical in the community — mifepristone + misoprostol
>9 wks ToP = in hospital, medical or surgical (eg. vacuum aspiration under GA)
if any fatal foetal abnormality or risk to life of mother = can do a ToP past 12 wks — but ACEI wont constitute this
ultimately it is the mother’s choice
- health promotion
educate about contraception use after termination
reinforce importance of planning future pregnancy with poorly controlled DM —- consult endocrinologist 6 months in advance at least + high dose folic acid, etc
“is there anything else you would like to know that perhaps i havent touched on? you dont have to make any decisions now, here is a leaflet with everything we talked about today and you are always welcome to come back into the clinic at any time.”
then asked about pre-eclampsia
nursing home:
in patient + wants to go home instead of a nursing home — what are you going to do?
OR
women post fall, not suitable for discharge home + MDT has decided she needs long term care/nursing, but she feels she is safe to go home and disagrees
if and where possible, i would accept the wishes of the patient and work around it. however, there are a few steps before that.
before talking to the patient, i would want to find out more details of her case, why does she likely require long term care and nursing, what is her current baseline in terms of settling her basic ADLs, mobility and more, what is her living situation (who does she live with, are they capable of and willing to be looking after her?)
if she has not been informed already of the belief that she requires long term care, I would then break the bad news crefully
ideally i would have a family member there to comfort her and bring a member of the MDT with me
i would also give her a warning shot
during my conversation with the patient,
ask what she understands the situation and the issues regarding discharge
explore her ICE (ideas, concerns, expectations) regarding nursing homes
explain the issues she is currently facing that are the reason we believe it might be difficult for her to handle by herself in the community
also reassure that is nursing home need not be forever, it can act as a rehab step down facility for a few weeks, and then reassess if she can go home after
would like to bring family into this discussion as much as possible (of course if the patient gives permission) as the family may have to take on care giving roles
if the patient says i understand everything you say –> but i want to go home
i cant force the patient to go to a nursing home
but i would check her capacity
if capacity is intact, i would safety net as much as possible to facilitate the patients wishes
OT for home safety assessment + adaptations
home care package, meals on wheels, private nursing
explore other options — is there a relative they can go home with
does not have to be a decision made right now, i would give u time to think about it and w can discuss further
elderly lady from nursing home
came in for UTI
doesnt want to go back to nursing home
?negligence issue – has decubitus ulcers
on 1 occassion when she slipped and fell, her carer told her to get up by herself
so what would you do?
how fast would you go for a consultant?
what would you do if the higher up seems to brush this off?
patient safety is the no.1 priority — it is our responsibility to protect vulnerable patients in our care, we cannot discharge the patient into an unsafe environment
i would first talk to the patient, to understand her reasons why she doesnt want to go back
be empathic and listen to her
explore her ICE
does she want to go somewhere else?
is there a misunderstanding of the patient in re to physio & rehab vs negligence on part of nursing home
ultimately i would involve the senior members of the team (eg. consultant)
i would also involve the MDT, regarding their impression on her character (does she make things up, has she been eratic)
possibly report to the HIQA health information and quality authority
also call the nursing home to clarify
who in the hospital structure can you talk to about this?
intern tutor
nursing home liaison officer!!!!!!
risk incident form
refusing BiPAP
a morbidly obese man w respi failure wants to go home + is unhappy re his BiPAP. all involved medical personnel feel he shouldnt be sent home + O2 is highly recommended. psychiatry deemed that the person is mentally competent. what would you do?
alternative treatments for him
what kind of support services could we provide for him to enable him to live at home
OR
man CKD lives alone, requires dialysis —> patient is adamant that he doesnt want it
OR
patient trying to self-discharge
if and where possible i will accept the wishes of the patient and work around it, however there are a few steps i must do before that.
first i would want to find out the full details of his case, such as why he requires the BiPAP, what has happened when he doesnt have the BiPAP, what are the possible alternatives for him that i can suggest if need be.
before the conversation, i would like a family member to be with him if he consents, and a member of the MDT that can provide a perspective different from mine, such as physio.
i would then have a conversation with the patient
explore his ICE (ideas, concerns, expectations) regarding BiPAP
ask what he understands about BiPAP and his need for it, the issues re his discharge and reasons he wants to leave
is it just the BiPAP or the restriction of being in hospital?
or if dialysis: what is his understanding of dialysis? has him been informed of haemodialysis vs peritoneal dialysis
what does the patient know about the implications/risks of refusing treatment (DONT SAY CONSEQUENCES)
explain why the MDT feels he requires the BiPAP, in the perspective of the doctors, physio, etc
ask if he would like to speak to a nurse specialist who could give him more information
if patient accepts what you day —> but still refuses
i cant force the patient to accept treatment
i would assess capacity
if capacity is intake, i woud have to find ways to work around it
OT home adaptation
supplementary O2 at home, respiratory nurse home visits
if dm BiPAP but dw hospitalised = is BiPAP in the community possible?
doesnt have to be a decision make right now, the only reason why we are having this conversation is to plan for the future
if dialysis case: talk about being listed for transplant if eGFR <12
safety net
write down what was discussed
he can always consider his options
how would you involve the daughter in this conversation?
ask his consent to involve daughter
wants to make sure shes on the same page
breaking bad news
77 y/o COPD M w many comorbidities & prev ICU admissions is decompensating again
ICU docs say they wont admit him
talk to this patient, break the news to him, tell him about his care options
break bad news
- prepare myself
set time aside
ensure i have all the relevant facts
know my limits and how comfortable i am –> if possible i would have a senior with me
if patient consents i would have a family member e with him - make a good connection
sit down and introduce myself
inform that we are going to be talking about the plan while he is in hospital
ask the patient what he understands re his situation and his COPD
build up upon his knowledge — what has been done so far for him, previous admissions & what the outcomes were - give a warning shot
your admission this time around will likely be different from the previous rounds
(pause for a moment)
break bad news — the ICU doctors do not want to admit you to ICU.
rationale being if you are admitted to ICU again, it would likely do you more harm than good. they have referred you to palliative care. - acknowledge the shock
validate the emotions
deal with concerns or just give time to process
palliative care doesnt mean giving up - plan & follow up
plan for a next meeting
write down what was said in the meeting - reflect: what have i learned from this experience
does this mean im going to die?
(essentially tell him idk)
sometimes the body can surprise us with how much it can overcome, however currently the team believes that it is best for us to not put your body through more stress by being admitted into ICU.
our priority is to help you get as comfortable as you can be, and not do anything drastic that may do more harm than good.
OR
it is impossible for us to predict how different people will respond to different therapies — some respond well some dont.
the most impt thing we can do is to make sure ur symptoms are as best controlled as possible.
drunk colleague
consultant/co-intern smells of alcohol
no. 1 priority = ensure patient safety isnt compromised
as a drunk colleague is an immediate risk to patient safety, it is important i act immediately
i would first start at a local level,
talk to them in a quiet room away from the patients, if possible i would give my bleep away so as to not be disturbed
i would bring up issues in a non-confrontational way — “i might be wrong and please forgive me if i am, but ive noticed that you smell of alcohol and dont look quite right. are you ok?”
if confirmed drunk = ask them to leave work in the interest of patient safety
i would then try and establish a context — is this a once off event or a pattern of behaviour that needs to be addressed more strictly
as a doctor having a duty of care –> i cant be complicit in this kind of behaviour
explore underlying issues and if i can help at all
issues at home or work
anything going on i can help
offer assistance –> occupational health, addiction services, PHMP practitioners health matters programme
if they are resistant to leave work in their drunken state = involve others of higher levels
reg –> consultant –> intern tutor
would suggest they self-report this incident to HR, but if not i will
what if they say they can get on with it today?
lack insight — dangerous!!!
have a duty to protect patients
what would be different if illegal drugs were used?
completely different. more serious approach as i cannot be complicit with illegal drug use
ESSENTIALLY:
if concerned about colleague’s health or professional competence due to misuse of alcohol or drugs, physical or psychological disorder —- primary duty = protect patients
if risk to patient safety
current risk = inform relevant authority of ur concerns w/o delay
no current risk = advise colleague to seek expert professional help + consider referral to medical council’s health committee
flesh eating bug
intern on a busy team
patient swabs positive for MRSA but has no wound infection
nurse told him and he is v.upset –> thinks its a flesh eating bug
wants to talk to a Dr immediately and wants to discharge himself
how would u explain the difference between colonised and infected?
explain if MRSA is a flesh eating buy
how to explain difference between colonised & infected:
our body has alot of bacteria that lives on our skin and surfaces. theyre just sitting there and not doing any harm, they may help with our digestion or help fight off other bacteria that can do harm.
in your case, the MRSA is a bacteria that can infect vulnerable people but for you theyre just living on your skin and not doing any harm
however as this bacteria can harm other people or harm you if you go into a vulnerable state, we still need to treat it
this is done via mupirocin nasal ointment or body wash for 5 days
then repeat the swab to make sure you no longer have it
it is not a flesh eating bug, it is a bacteria that is sitting on your skin and not doing harm
discharge form
have you seen a medical discharge against medical advice form?
do you think it is a good thing to get the patient to sign?
conflict between patient rights and a doctor’s duty of care
ideally a discharge against medical advice should be avoided at all costs —> risk of sig patient harm + to safety
partnership between patients and doctors is a core pillar of professionalism
if possible this should be avoided by
discussing the patient’s concerns — why they what to leave + apologise if an apology is due
do a capacity assessment — ensure patient knows of the risks involved
involve a senior team member + family member (if the patient consents)
if the patient still decides to self discharge
arrange follow up and other preparations to ensure a safe discharge
and facilitate the patiens as much as possible
it is not signing away a doctors responsibility
safety net: the door is always open if they want to come back — dont hesitate to
