Ethics

Question 1

What are 4 cornerstones of ethics?

Answer 1

Autonomy
Beneficence
Non maleficence
Justice

Question 2

What are key features of capacity?

Answer 2

Must be able to understand, retain, weigh up and communicate decision
Be free from external influence

Question 3

What is gillick competence?

Answer 3

Patients under 16 can consent but not refuse treatment if deemed mature enough to understand implications of actions
Refusal of consent can be overridden by parent or course if in best interests

Question 4

What is difference between battery and assault?

Answer 4

Assault: threat or attempt to physically injure
Battery: actual physical contact or injury without consent
Civil offences

Question 5

What are key 3 parts of mental capacity act (2005)?

Answer 5

Appointment of deputy: monetary matters, needs acceptance by court of protection
Appointment of LPA
Independent mental capacity advocate: independent person if neither of above are present

Question 6

What needs to be taken into account when assessing best interests of patient? (4)

Answer 6

Patients wishes
Carers/relatives wishes
Circumstances of decision - is patient likely to regain capacity in future?
Is decision about life saving therapy motivated by thoughts to bring about death?

Question 7

What are legal issues around advanced decisions to refuse treatment?

Answer 7

Made when patient has capacity for when they don’t, need to be free from coercion and understand consequences
Can be verbal but best if written, witnessed and signed
If about life saving treatment, must include phrase “even if life is at risk”
Ideally copy to GP
Doctor at risk of battery if does not comply

Question 8

What is a section 5 (2)?

Answer 8

Applied by physician of any speciality on an inpatient to enable psych assessment to be made
72 hours duration

Question 9

What is a section 2?

Answer 9

Admission for assessment order
Two written medical recommendations and approved social worker or relative on patient in community
28 days duration
Patient has right of appeal to tribunal within 14 days

Question 10

What is section 3?

Answer 10

Admission for treatment order
Applied as in a section 2 on patient already diagnosed with mental disorder
6 months duration then reviewed

Question 11

When must a doctor breach patient confidentiality to relevant authorities?

Answer 11

Notifiable diseases
Drug addiction
Abortion
In vitro fertilisation
Organ transplant
Births and deaths
Police request
Search warrant signed by judge
Court order
Terrorism or serious crime

Question 12

If a breach of confidentiality to authorities must be made, what needs to be done?

Answer 12

Patient should be notified in writing of reason for disclosure, content, who has been told and the likely consequences

Question 13

What ethical issues arise from end of life decisions?

Answer 13

Sanctity of life: wherever possible human life should be maintained
Non maleficience: extending life may result in suffering
Justice: trivial life extension occurs at enormous monetary expense
Withdrawing treatment: passive act, not killing
Killing vs letting die: active vs passive
Doctrine of double effect: morphine to palliate pain may cause resp arrest but intention was not to kill

Question 14

What are arguments for and against euthanasia?

Answer 14

For: respecting patients autonomy, beneficience may prevent suffering, suicide is legal but unavailable to disabled
Against: good palliative care obviates need, risk of manipulation, coercion, exploitation of vulnerable, undesirable practices may occur - slippery slope

Question 15

What is SPIKES model of breaking bad news?

Answer 15

Setting: private, give bleep to someone, time, other health care workers present, relatives if available
Perception
Invitation
Knowledge
Emotions and empathy
Strategy and summary

Question 16

How to deal with an angry /complaining patient?

Answer 16

Listen without interruption
Acknowledge they are angry and explore why
Empathise, you understand why they are upset
Apologise if there has been an error
If they want to take things further: PALS and complaints procedure

Question 17

What are strategies for a non compliant patient?

Answer 17

Explore why non compliant: side effects, Medication not working?
Educate them on importance
Offer solutions: direct supervision, change of therapy

Question 18

What are strategies for a self discharging patient?

Answer 18

Explain why they should not leave
If have capacity, may leave at own risk against medical advice
If lack capacity, may be detained by reasonable force, acting in best interests by common law. Unless restraining gives risk of serious injury to them or restrainees
Contact GP/ relatives to inform of events and risk to patient
TB patient can be detained as risk to public, under public health act

Question 19

What are strategies for a patient continuing to drive despite contraindication?

Answer 19

Duty of patient to declare to DVLA
Mention lack of insurance
Safety issue to themselves and other road users
Can be issued a fine if don’t declare
Ask for written evidence that they have informed if you suspect not
Inform that you will write to DVLA if they don’t

Question 20

What are driving rules for first unprovoked seizure with low risk of recurrence?

Answer 20

6 months fit free
5 years if HGV licence and not on medication

Question 21

What are driving rules for 2 or more seizures (epilepsy)?

Answer 21

12 months seizure free
6 months during medication changes
10 years if HGV, off medication

Question 22

What are driving rules for ACS?

Answer 22

1 month if medical management
1 week if stented and normal LV function
6 weeks for HGV if symptom free and no inducible ischaemia on functional testing

Question 23

What are driving rules for stroke/TIA?

Answer 23

1 month if no persistent deficit
HGV 1 year if no persistent deficit

Question 24

What are driving rules for insulin dependent diabetes?

Answer 24

Must notify DVLA, may drive if no visual impairment and aware of hypoglycaemia
HGV: banned

Question 25

What are important issues to address when discussing a new diagnosis of epilepsy?

Answer 25

Social aspects: alcohol, sleep, driving effect on job
Medical: treatments, side effects, pregnancy risk and pill failure
Safety: avoid swimming or bathing alone, heights, driving

Question 26

What are issues to discuss in a patient with a family history of Huntingtons?

Answer 26

Autosomal dominant
No cure, supportive management
Genetic anticipation
Genetic screening and family planning - prenatal testing - may need abortion
Life insurance and employment implications
Social: care needs
Legal: ADRT, LPA

Question 27

What issues may arise from a person taking an overdose and refusing treatment?

Answer 27

Competency: do they understand life threatening, is overdose affecting judgement, is psychiatric illness affecting judgement, if no capacity treat against will under common law
Implied consent: having arrived in hospital
ADRT: suicide notes may be ignored as cannot be sure of circumstances when written/changed mind/under duress
Mental health act cannot be invoked to treat overdose patients

Question 28

What are important points to discuss regarding organ donation?

Answer 28

Need for operation to harvest organs
HIV testing prior to donation
Not all organs taken may be used
Time delays to certification of death and release of the body
Coroner discussion must occur first if criminal action
Offer transplant coordinator for region for further counselling
Need for swift decision
Donor card is sufficient legal authority to proceed but also need relatives consent
2 consultants must verify brain stem death and treatable causes have been excluded - irreversible and permanent

Question 29

What are important points to discuss with poorly controlled insulin dependent diabetic?

Answer 29

Compliance issues: weight gain, social issues
Education on importance of glycaemic control and risk of DKA
Other cardiovascular risk factors
Importance of balanced diet - dietician if needed
Long term risks of poor control - eyesight, nerve damage, kidney damage

Question 30

What are legal rules on post mortems and coroners referrals?

Answer 30

If coroner referral made, MCCD cannot be issued until coroner agrees
If post mortem needs to occur, legally required and can be done even with family objection as cause of death needs to be identified
This will delay release of body for funeral
Usually done within a week

Question 31

What issues need to be addressed with health care staff and infectious disease?

Answer 31

Liaise with occupational health
What vaccines have they had and when if applicable
Exposure prone procedures
If HIV positive, infection risk to them
Pulmonary TB: can’t work until clear sputum smear or 2 weeks treatment