Ethics Flashcards
Page 376 - Page 479
Sue, an 18 year old girl, presents to your clinic with lower abdominal pain and fishy-smelling vaginal discharge for the past three days. You are a male doctor and a female nurse is on duty at the clinic. You mention to the patient that she needs a vaginal examination, but she declines to be examined by you and says that she wants a female doctor to examine her. Which one of the following is the most appropriate action in this situation?
A. Call her boyfriend to be present while you are examining her.
B. Treat the patient without vaginal examination.
C. Convince the patient that female chaperon will be present during the examination.
D. Defer the examination and inform the patient about the associated risks of not doing the examination.
E. Ask the nurse to perform the vaginal examination.
D. Defer the examination and inform the patient about the associated risks of not doing the examination.
Informed consent is required before an intimate examination is carried out on a patient. Intimate examinations include examination of the breasts, genitalia and anus/rectum. Patients have a right to decline examination as long as the decision is informed.
This patient does not want to be examined by a male doctor; therefore, her wish should be respected, and the examination is deferred, but she must also be informed about how delayed treatment might affect her health and alter the course of treatment.
Patients may ask for the presence of a chaperon, but it is not the patient’s concern here. The chaperon or a female nurse can be present during the examination, but they cannot do the examination on your behalf. The patient is unwilling to be examined by a physician of opposite sex and presence of a female nurse or chaperon does not fulfill her wish. A patient may ask for a particular chaperon to be present or a particular health practitioner (maybe gender- based) to undertake the examination. Such requests are complied with where possible.
While the patient is uncomfortable with being examined by a male doctor, presence of his boyfriend (option A) or a nurse or chaperon (option C) is incorrect. She does not want you to perform the examination; so, her wish should be respected and any attempt to convince her otherwise is avoided.
Option B: Treating without appropriate investigation and just based on a speculated diagnosis is not an acceptable option.
Option E: A nurse cannot perform the examination on your behalf as it is your responsibility to treat her based on your own direct findings during the exam.
NOTE - It is wise to have a chaperon, nurse, or observer of the same sex in general present when performing intimate examination, particularly when examining a patient of the opposite sex. If the patient refuses another health practitioner to be present during the examination, this should be documented. Having a staff member within your hearing is an advisable practice as a protective measure against possible accusations.
A 42-year-old woman comes to your clinic complaining of headache and asking for a sick leave certificate. She has separated two years ago and currently lives with her two children Sarah and Beth, 7 and 4 years old respectively. She admits to smoking cigarettes and using alcohol on a regular basis. During the examination, she looks depressed. More probing causes her to break in tears and confess that she cannot resist gambling. She has lost all of her money and cannot provide care for her children anymore. Which one of the following would be the most appropriate next step in management?
A. Refer her to specialist gambling treatment bodies (e.g., gamblers anonymous).
B. Inform the Child Protection Service.
C. Arrange for financial support.
D. Arrange for cognitive behavior therapy.
E. Perform motivational interview.
B. Inform the Child Protection Service.
This patient has features of problem gambling requiring help and support, but the main issue and the most important step would be the two little children she has back at home. Pathological gambling is not normally associated with violence against children; rather the abuse tends to exist in the form of ‘neglect’.
This woman’s problematic behavior has posed her children at risk; therefore, the next step in management would be protecting the children from the harm threatening them by informing child protection authorities.
Option A and E: Once the children’s safety is ensured, attention should be turned to the patient. Motivational interview would be the most important initial step, followed by referral to specialist gambling treatment agencies if the patient is willing or has persuaded so.
Option C: Options suggesting ‘arranging for financial support, local funding-for-poor programs, etc.’ are incorrect because such measures, if necessary, will be taken by authorized agencies after the patient has been referred to them.
Option D: Cognitive behavioral therapy or other methods such as cognitive therapy or brief interventions can be applied when felt necessary.
RACGP - AFP - Problem gambling
A mother brings her 18-year-old mentally retarded daughter at eight weeks pregnancy. The mother requests abortion for her daughter as she is unable to look after herself. The patient does not want an abortion. Which one of the following is the most appropriate action to take?
A. Perform medical abortion as it is close to nine weeks; otherwise she will require surgical abortion.
B. Do not perform abortion as the patient did not consent.
C. Refer the matter to Family Court.
D. Get consent from the local council.
E. Discuss the matter with the father of the girl in a week.
C. Refer the matter to Family Court.
Because of mental retardation, this patient does not have capacity to make decisions and give consent. Although the mother can give consent on her behalf, but there are particular procedures for which no relative, no matter how close, can give consent on the patient’s behalf and the case must be referred to either the Supreme Court or the Family Court. In Australia, these two courts can exercise their role as the supreme parents of children.
An application to the court should be considered in situations so serious that neither the incompetent young person, nor the parents or guardian can give valid consent to. These situations are as follow:
* The procedure is very high risk (for example, separating conjoined twins).
* There may be life-changing effects such as in:
Sterilization of mentally disabled young persons
Abortions
Removal of life support
Removal of organs for transplants
Gender re-assignment
* Bone marrow harvest
* There is a strong objection from a dissenting parent
* A child with capacity to make decisions is refusing healthcare and there is significant risk of harm in them doing so
* The procedure involves invasive, irreversible (oophorectomy) or major surgery. Life-saving emergency surgeries are exceptions
NOTE - Abortion in individuals who are incompetent due to mental disability should be consented to by the Supreme Court or the Family court. Neither the patient, nor the carer consent is not valid for this procedure.
Option A: Performing the abortion without a court order is illegal and inappropriate.
Option B: The refusal of an incompetent patient does not eliminate the need for further action while the carer’s concerns have not been addressed yet.
Option D: Local councils are not authorized to make decision on this issue. As mentioned earlier, the decision is in the power of the Supreme Court or Family Court.
Option E: Like the mother, the father of the child is not authorized to make decisions in this regard.
A 34-year-old man is brought to the Emergency Department with fever, headache and a change in mental status leading to significant disorientation. A head CT scan is obtained which is normal. Based on the diagnosis of meningitis, he is planned to be started on intravenous antibiotics after a lumbar puncture is performed. The patient is agitated and is fighting with anyone who tries to get near him. Some of his friends from work accompany him. Every time an LP is about to be attempted, the patient pushes away the LP needle. Which one of the following would be the most appropriate action to take in this situation?
A. Sedate the patient and perform the LP.
B. Wait for his relatives to arrive for consent.
C. Use blood cultures as an alternative.
D. Arrange for a brain MRI.
E. Ask his co-workers to sign the consent form.
A. Sedate the patient and perform the LP.
The scenario describes a patient who is unable to give either an informed consent or informed refusal to the procedure. He does not have the capacity to understand his medical condition and the consequences of deferring the LP or antibiotics. On the other hand, there is no valid substitute decision maker (proxy) or family member to make decisions on the patient’s behalf. Under such circumstances, when there is an urgent life-threatening or even severely painful medical condition and the patient is not competent to give consent to or refuse the treatment and there is no substitute decision maker or family member, the patient’s best interest will guide the management.
Since performing an LP followed by intravenous antibiotics is the most important and essential step in management of suspected meningitis, which is potentially life-threatening, the patient should be sedated, and undergo LP.
Option B: Waiting for the relatives to arrive for consent before starting the treatment is not appropriate as untreated meningitis carries significant risk of morbidity and mortality.
Option C and D: MRI or blood culture is not accurate for diagnosis and guidance of further treatment of meningitis.
Option E: Co-workers are not qualified to consent on the patient’s behalf.
An Indigenous woman brings her four-month-old boy for vaccination. During the interview, she does not make any eye contacts and avoids conversations. When you ask her to hold the child for you, so that you can inject the vaccine she denies. Which one of the following would be the most appropriate management?
A. Send a nurse for a home visit.
B. Check her behavior in the next visit.
C. Ask one of her family members to accompany her in the next visit.
D. Call the Child Protection Service.
E. Involve her in a parental program.
C. Ask one of her family members to accompany her in the next visit.
In visiting indigenous patients, cultural differences should always be borne in mind. These differences sometimes are a significant barrier in establishing appropriate communication and rapport with the patient.
In some cultures, any relationship between people of opposite sex is considered a taboo and unethical. In some cases, outsiders cannot easily be trusted, and therefore it is recommended that an Aboriginal health worker be involved when assistance is required with a cultural issue. Here, there are some pointers towards the failure in communication between the doctor and the patient. Firstly, she avoids eye contact. Second, she is reluctant to converse and finally she refuses to hold the child for vaccination because when you get close to the baby you may get close to her and, by this, breach her circle of safety.
In situations like this, the best step can be involvement of another family member in next visits to make the patient feel more comfortable.
Thus far, no concern regarding child abuse or neglect has risen, because the mother has brought her child for vaccination and this indicates that the mother cares about the baby and his safety. For this reason, calling the child protection authorities or sending a nurse for a home visit would not be necessary.
The patient’s behavior is not likely to change in the next visit if no active measures are taken.
A summary of communication tips for dealing with indigenous people are as follow:
* Do not assume English is a first language, particularly in remote areas.
* Do not assume a nod means understanding and/or agreement to treatment.
* Check hearing because it might have been impaired due to chronic ear infection.
* Appreciate the different family network, particularly the tendency of grandmothers and aunts to care for children.
* Do not assume a broken appointment means the patient will not return for treatment. Often family and cultural duties take precedence.
* Be aware of cultural sensitivities.
* Do not touch a patient, particularly of the opposite sex, without seeking permission and explaining what you are doing.
* Be aware that patients may not be comfortable with direct questions about their family and health.
* Do not be too stern or authoritative during a consultation.
* Ensure receptionists and other staff understand the cultural sensitivities of Indigenous patients.
* Be accepting, respecting and non-judgmental.
Murtagh’s General Practice – 5th Edition – page 1400
A 73-year-old woman has a living will clearly mentioning that she does not wish to be admitted if she is terminally ill. Today, she is brought to the Emergency Department after she sustained a fall at home and had a femoral neck fracture. In the emergency department, she becomes drowsy after a morphine shot is given to her for pain control. Regarding her will, which one of the following would be the next best step in management?
A. Arrange for transferring to the operating room for surgical fixation of the fracture.
B. Arrange a family meeting.
C. Admit her.
D. Refer her for palliative care.
E. Check the validity of her will.
C. Admit her.
C. Admit her.
Patient Autonomy:
- Individuals have the right to make decisions about their own bodies if they are competent.
- If a patient is not competent, their previous instructions (like a living will) guide treatment decisions.
Scenario Details:
- The patient has a living will stating she should not be admitted if terminally ill.
- She has a femoral neck fracture and is drowsy due to opiates, which is a reversible condition.
Key Points:
- The patient’s current condition (femoral neck fracture and opiate overdose) is not a terminal illness.
- Because her condition is treatable, she should be admitted for treatment.
- After treating the opiate overdose, her fracture can be addressed, and future care plans can be discussed with her.
Conclusion:
- Admit her for treatment, as her living will does not apply to her current, non-terminal condition.
Based on the concept of autonomy, every individual has every right over their body if they are competent or capacitated. In circumstances where the patient lacks competence to decide, a previous instruction by him/her such as a valid living will or advance directives will guide the treating team as to treatment.
This patient has a living will that she should not be admitted if she is terminally ill. Her decision then should be respected and acted upon if such circumstance arises, but as neither femoral neck fracture nor a completely reversible adverse effect of opiates (drowsiness) is concordant with definition of a terminal illness, she should be admitted for treatment of opiate overdose and reversal of the current condition. Once she is out of this state, further management plan including fixation of her fracture by surgery or other measures can be discussed with her.
Australian Medicolegal Handbook - Elsevier– pages 134-148
A 26-year-old immigrant man stole a car and while on the run he hits a woman on the road. Eventually, he ended up hitting the guardrail in a highway and injuring himself. He is in the hospital now and behaves aggressively and rude. He requires orthopedic attention and care. While in the ward, he insists to smoke a cigarette but smoking is not allowed in the ward. He warns you, as his treating doctor, that he will sue you because he knows many influential people and will make you lose your job. Which one of the following is the most appropriate action in this situation?
A. Discharge him because he is not cooperative.
B. Contact immigration authorities to take over for legal proceeding.
C. Tell him that you can only give him nicotine gum or patch.
D. Call the police to arrest him and take over.
E. Take him to a safe place and let him smoke under supervision.
E. Take him to a safe place and let him smoke under supervision.
In mental health setting, cigarettes have been used as a patient management tool by staff, mediating exchanges and relationships between staff and patients and between patients. Examples include using control over supply of cigarettes to patients to comply with requests such as taking medications, getting dressed, agreeing to speak to the treating doctor, etc. Although it has been a place of debate if implementation of non-smoking policies in psychiatric wards is of benefit, it is still in practice.
In this situation though (emergency setting) where a severely agitated and disturbed patient is approached, allowing him to smoke may help in de-escalation of the patient without unnecessary coercive treatments. A common practice in Australia, when such a situation arises, is to allow the patient to smoke under appropriate supervision and in place that the risk of others being exposed to cigarette smoke is nil or at least minimum.
Discharging an uncooperative agitated patient not only is inconsistent with the duty of care, but it also may pose the patient and others at significant risk; therefore, not an appropriate action.
Discharging the patient (option A) or surrendering him while he is in need of medical care both for his psychiatric and orthopedic problems to the immigration office (option B) or the police (option D) is not appropriate. The police can deal with the patient, if necessary, after adequate care has been taken medically.
Nicotine gums and patches (option C) may be helpful in reduction of agitation in patients who are quitting smoking, but unlikely to satisfy this patient.
You are the on-call psychiatrist on a night shift when you are informed by the nurse of the psychiatry ward that a 48- year-old lady with severe depression has refused to eat or drink for the past two days. She believes she does not have bowels. She was brought to the hospital by her son. On examination, she is severely dehydrated, but refuses to receive any oral intake. Electroconvulsive therapy (ECT) is considered for her by you as an authorized psychiatrist for ECT, but she refuses to give consent to the procedure. Which one of the following is the most appropriate next step in her management?
A. Take consent for ECT from her son.
B. Take consent from the Mental Health Tribunal.
C. Take consent from hospital administrator.
D. Treat her with ECT without consent under duty of care.
E. Give her nasogastric feeding and anti-depressants.
D. Treat her with ECT without consent under duty of care.
ECT is widely used as a treatment option. In Australia, the most frequent indication for ECT has been major depression, especially if associated with psychotic features (such as in this patient). Regulations regarding when to use ECT and how to obtain consent vary from state to state.
For voluntary patients who have adequate capacity to make decisions for themselves, ECT can be administered by authorized physicians if:
* The procedure and techniques have been fully explained to the patient
* All associated discomforts and potential adverse effects have been explained to the patient
* Alternative treatments (if available) has been explained to the patient
* The patient has been offered to ask any question regarding the procedure
* The patient is aware of his/her right to withdraw consent and discontinue the procedure at any given time
* The patient has been noted that she/she can have legal and medical advice before giving consent
NOTE - Consent to ECT should be in writing.
For involuntary ECT, consent process and authorization varies in different states. ECT is different from other procedures in terms of substitute decision making processes. In South Australia, for example, ECT should be authorized by the Guardianship Board; however, should emergency arise, ECT can be given without applying the case to the Guardianship Board. In the Australian Capital Territory and New South Wales, Mental Health Tribunal is the authorized body for approval of ECT on involuntary patients.
Despite differences among different Australian states (and for the exam purposes) the following rules Produced by Australian Health Ministers Advisory Council (AHMAC) can be applied in general:
The Tribunal may approve the performance of electro-convulsive therapy upon a person who is an involuntary patient, a forensic patient, a patient under supervision or is subject to a community treatment order but it must not give its approval unless satisfied that:
* The person is not capable of giving informed consent
AND
* Two medical practitioners (at least one a psychiatrist) have formed the opinion after considering the person’s clinical condition, history of treatment and any appropriate alternative treatments that electro-convulsive therapy is reasonable and a proper treatment to administer for a the person and that without that treatment the person is likely to suffer serious mental or physical deterioration.
Electro-convulsive therapy in life saving emergencies:
The authorized psychiatrist may authorize the performance of electro-convulsive therapy upon a person who is an involuntary patient, a person under supervision or a forensic patient without having obtained the approval of a tribunal if the authorized psychiatrist has the opinion that electroconvulsive therapy is necessary to save life of a person or to prevent the person from suffering irreparable harm.
The authorized psychiatrist must report electroconvulsive therapy to the tribunal after it is performed.
In simple words, involuntary patients in an emergency condition, where delay can lead to serious harm to them or others, are treated with ECT by an authorized psychiatrist without any need for approval from Mental Health Tribunal, Guardianship Board, etc.
Where the situation is not likely to result in serious harm to the patient or others, the decision as to whether ECT is performed as involuntary treatment should come from authorities.
This patient is suffering from severe dehydrated that can be life threatening or at least pose substantial risk to her health; therefore, she is in an emergency. Under this circumstancees, ECT should be proceeded with without consent and under the duty of care as per the above.
Again, it is of paramount importance that physicians seek advice regarding the state legislations in practice.
Reference
* SA Health Department - Electroconvulsive Therapy Policy Guideline
* Queensland Health Department - The Administration of Electroconvulsive Therapy
A 52-year-old woman is involuntarily admitted to the psychiatric ward due to major depression with psychotic features. She refuses to take anything by mouth including her medications because she believes that she will die if she eats. Electroconvulsive therapy (ECT) has been decided for her as a life-saving measure and explained to her but she refuses to consent to this treatment. She is clinically stable for now. Which one of the following is the next best step in her management?
A. Take consent from the Mental Health Tribunal.
B. Give ECT without consent under duty of care.
C. Obtain consent from her husband.
D. Give her nasogastric feeding and anti-depressants.
E. Obtain consent from the hospital administrator.
A. Take consent from the Mental Health Tribunal.
ECT is widely used as a treatment option. In Australia, the most frequent indication for ECT has been major depression, especially if associated with psychotic features (such as in this patient). Regulations regarding when to use ECT and how to obtain consent vary from state to state.
For voluntary patients who have adequate capacity to make decisions for themselves, ECT can be administered by authorized physicians if:
* The procedure and techniques have been fully explained to the patient
* All associated discomforts and potential adverse effects have been explained to the patient
* Alternative treatments (if available) has been explained to the patient
* The patient has been offered to ask any question regarding the procedure
* The patient is aware of his/her right to withdraw consent and discontinue the procedure at any given time
* The patient has been noted that she/she can have legal and medical advice before giving consent
NOTE - Consent to ECT should be in writing.
For involuntary ECT, consent process and authorization varies in different states. ECT is different from other procedures in terms of substitute decision making processes. In South Australia, for example, ECT should be authorized by the Guardianship Board; however, should emergency arise, ECT can be given without applying the case to the Guardianship Board. In the Australian Capital Territory and New South Wales, Mental Health Tribunal is the authorized body for approval of ECT on involuntary patients.
Despite differences among different Australian states (and for the exam purposes) the following rules Produced by Australian Health Ministers Advisory Council (AHMAC) can be applied in general:
The Tribunal may approve the performance of electro-convulsive therapy upon a person who is an involuntary patient, a forensic patient, a patient under supervision or is subject to a community treatment order but it must not give its approval unless satisfied that:
* The person is not capable of giving informed consent
AND
* Two medical practitioners (at least one a psychiatrist) have formed the opinion after considering the person’s clinical condition, history of treatment and any appropriate alternative treatments that electro-convulsive therapy is reasonable and a proper treatment to administer for a the person and that without that treatment the person is likely to suffer serious mental or physical deterioration.
Electro-convulsive therapy in life saving emergencies:
The authorized psychiatrist may authorize the performance of electro-convulsive therapy upon a person who is an involuntary patient, a person under supervision or a forensic patient without having obtained the approval of a tribunal if the authorized psychiatrist has the opinion that electroconvulsive therapy is necessary to save life of a person or to prevent the person from suffering irreparable harm.
The authorized psychiatrist must report electroconvulsive therapy to the tribunal after it is performed.
In simple words, involuntary patients in an emergency condition, where delay can lead to serious harm to them or others, are treated with ECT by an authorized psychiatrist without any need for approval from Mental Health Tribunal, Guardianship Board, etc.
Where the situation is not likely to result in serious harm to the patient or others, the decision as to whether ECT is performed as involuntary treatment should come from authorities.
Impaired judgment and false bizarre beliefs of this patient, along with the major depression is indicative of major depression with psychotic features, which is one of the most common and well-known indications for ECT as a highly effective treatment. This patient, who clearly lacks decision-making capacity, is subject to involuntary treatment after approval from Mental Health Tribunal.
Option B: Since the patient is clinically stable, no emergency situation is present to mandate ECT without approval from the aforementioned authority.
Option C and E: ECT widely is different from other medical procedures where consent from relatives of a patient who is subject to involuntary treatment can be obtained; therefore, consent from other people such as relatives, hospital administrator, another colleague, a medical senior, etc. are incorrect options.
Option D: Nasogastric tube to feed or give medications does not eliminate the need for ECT where it is clearly and necessarily indicated.
Only medical practitioners are permitted to provide ECT, and it must be performed in a hospital approved for this purpose, whether public or private. A minimum of two medical practitioners must be present, of whom one should be experienced in the administration of ECT and the other in anesthesia.
One of your patients is a 37-year-old doctor, who has just recently found out he is HIV positive. You are the only one that knows about this. Which one of the following you are legally obliged to inform?
A. His hospital administrator.
B. Medical Board.
C. His patients.
D. His patients only if he performs surgeries where transmission is possible.
E. No one without his consent.
E. No one without his consent.
Healthcare workers (HCWs), who are HIV positive, have a right to privacy as long as they are not posing others at the risk of the infection. Therefore, you cannot inform anyone of his condition without his consent if he is not posing others at risk.
Option A, B and C: There are guidelines and protocols for HCWs with blood-borne viruses, and it is assumed that they follow these guidelines and precautionary measures as a part of their job. Neither the treating physician, nor the patient is obliged to inform any authorities including Medical Board, state government, the insurance company or his employer.
Option D: An HCW is not legally obliged to inform his/her patients of his/her HIV positivity. The risk of transmission of the infection to the patients is extremely rare, especially when the physician takes precautionary measures and/or is under treatment with antiretroviral therapy. However, HCWs should understand their obligation to report their infections with blood-borne viruses (BBV) status if required under jurisdictional legislation and should be informed of relevant policies. They should understand their obligation to report all sharp injuries, whether or not there was a risk of patient exposure.
TOPIC REVIEW
The following should be considered for HCWs with BBVs:
* All HCWs infected with a BBV should remain under regular medical supervision.
* HCWs must not perform EPPs (exposure-prone procedures) if they are human immunodeficiency virus (HIV) antibody positive.
* HCWs must not perform EPPs while they are hepatitis C virus (HCV) RNA positive but may be permitted to return to EPPs after successful treatment or following spontaneous clearing of HCV RNA.
* HCWs must not perform EPPs while they are HBV DNA positive, but may be permitted to return to EPPs following spontaneous clearing of HBV DNA or clearing of HBV DNA in response to treatment.
A 26-year-old female comes for cervical cancer screening by HPV testing. She never had sexual activity with a man, but is a lesbian and has a girlfriend. She prefers to see a lesbian-friendly health care provider for her test. Which one of the following would be the most appropriate action to take in this situation?
A. She does not need cervical cancer screening.
B. Refer her to a lesbian-friendly clinic in the area.
C. Do the test yourself and then refer her to a gynecologist.
D. Ask your clinic nurse to do the test in your clinic.
E. Advise her to follow safe sex practice principles even with a female partner.
B. Refer her to a lesbian-friendly clinic in the area.
Specific subtypes of human papilloma viruses (HPV), most commonly types 16. 18, 31, 33, 35, are associated with premalignant and cancerous cervical lesions. HPV can spread through sexual intercourse, as well as skin-to-skin contact in female-to-female sexual relationship. Therefore, lesbians need pap smears like heterosexual women.
There is NO evidence to suggest that HPV infection rate is lower in lesbians, and rates of cervical abnormalities for lesbians are like those of heterosexual women.
As this patient prefers to see a lesbian-friendly healthcare provider, the next best step would be encouraging her for screening and referring her to a lesbian-friendly clinic in your area. Failing to do so may result in the patient not seeking screening. This not only poses the patient at risk; it may also lead to lawsuit for the physician once the patient contracts cervical cancer.
Option A: Lesbians need cervical cancer screening like heterosexual women. Telling her that she does not require pap smears is not correct.
Option C: Performing a cervical cancer screening test without the patient’s consent is an act of battery and should be avoided.
Option D: It is a wise practice to have a female nurse or chaperon present while the doctor takes sample for HPV testing, particularly if the doctor is male, but taking samples is the responsibility of doctors not nurses.
Option E: Advising precautionary measures such as safe sex practice is appropriate but does not eliminate the need for screening tests as the most important issue here.
Murtagh’s General Practice – McGraw Hill – 5th Edition – pages 929, 932
You are a resident at the Emergency Department. An angry father approaches you because the social worker has been asking him if he has punished his child physically. The child is five years old and has been in the Emergency Department four times this year with several episodes of trauma not consistent with the alleged history given by the parents. Today, the child is brought with a complaint of ‘slipping into a hot bathtub’ with a burn wound on his legs. The father threatens to sue you and says ‘how dare you think that about me, I love my son!’ Which one of the following would be the most appropriate next step in management?
A. Admit the child to remove him from the possibly dangerous environment.
B. Call the police.
C. Ask the parents if there has been any abuse.
D. Speak to the wife privately about possible child abuse.
E. Report the family to child protective services.
E. Report the family to child protective services.
Once a healthcare worker forms an opinion, on reasonable grounds, that child abuse has occurred or is in progress, reporting to Child Protection Service is mandatory. The physician is legally protected if the case is found out not to be due child abuse, if reporting has occurred in good faith.
In this case, with several episodes of injuries with unfitting accounts, child abuse is very likely and the family should be reported to the Child Protection Service immediately.
NOTE - The power of removing the child from the parents is not within the physician’s authority. This is undertaken by authorities such as child protection services or courts of law.
Option A: Admitting the child for protection would be unnecessary as the child can be satisfactorily safeguarded while in hospital.
Option B: Calling the police would have been indicated if the assault is in progress, which is not the case here.
Option C and D: When the belief of child is formed, talking to the parents would be incorrect as it is unlikely to change the course of action. Abusive parents are not likely to give the exact account of the event and admit to child abuse, nor are they likely to change their behavior without intervention.
RACGP - The White Book: Child abuse
During visiting an 82-year-old man for an upper respiratory tract infection, you notice multiple bruises on different body parts. He lives with his daughter and her boyfriend, and confides in you that the bruises are the result of being physically abused by her daughter’s boyfriend. He adamantly insists that you should not inform the police or any other authorities because he can deal with his problem by himself. You perform a mental status exam, including a ‘serial seven’ the result of which is normal. Which one of the following would be the most appropriate management option in this situation?
A. Discharge him home after management of the bruises.
B. Obey his wish but arrange for regular follow-ups.
C. Ask him to see a social worker before he leaves the hospital.
D. Inform the daughter about abuse so that she knows what is happening with her father.
E. Notify the police immediately.
B. Obey his wish but arrange for regular follow-ups.
Elder abuse must be considered by any health practitioner seeing elderly patient as they have an essential role in the recognition, assessment, understanding and management of elder abuse and neglect. Once faced with elderly abuse, the first thing to consider is to assess if the patient has the capacity to make decisions (as in this case where the mental status of the patient has been evaluated).
The elderly should be consulted about the criminal nature of abuse and that it is unacceptable and there is always means to prevent it. They should be made aware of they legal rights and that they can seek legal action and protection if they wish so at any time.
If the elderly patient has the decision-making capacity and refuses any intervention, their decisions must be respected, but he/she should be advised to contact you or other support agencies for help in the future. The status of the elderly should be checked through regular follow-ups.
RACGP - The White Book: Elder abuse
A 22-year-old Aboriginal man is in the waiting list for kideny transplant due to end-stage renal disease (ESRD). In the meanwhile, he is on dialysis three times a week. He has presented to you as his treating physician and says he does not want to undergo dialysis and wants to withdraw from treatment. Which one of the following would be the most appropriate action to take?
A. Arrange for a donor for him.
B. Ignore his wish and treat him.
C. Arrange a family meeting.
D. Discuss his decision with him to make sure he understands the consequences.
E. Refer the case to the court.
D. Discuss his decision with him to make sure he understands the consequences.
Patient autonomy is the cornerstone of all healthcare ethics. Every competent adult has the absolute right to do what they desire with their own health and life. Competency is a legal term and not determined by the healthcare workers. Capacity, which is a different term, is what used instead in medical decision-making process. These two, however, can be used interchangeably.
When a patient decides not to accept or withdraw from a treatment, the most appropriate next step is always a full discussion with the patient about the potential consequences of his/her decision and making sure that they understand them.
Option A: Arranging for a donor just because he does not want to go on with the treatment is not appropriate. Every patient should follow specific protocols.
Option B: Ignoring a competent patient’s expressed wish and acting differently is an act of battery and punishable by the law.
Option C and E: Arranging a family meeting for discussion about a competent patient’s wish is not appropriate. Neither is referring the case to the court because the law is quite straightforward on this matter.
You are assessing a 16-year-old girl, who has cut her wrist intentionally. You talk to her and after a thorough assessment you are reassured that she is not suicidal, nor does she have any suicidal ideations at the moment. Her parents separated two years ago. Currently, she is living with her mother, but she wishes to live with her father. Both her parents and the school psychologist are concerned about her and insist to be informed of her condition. Which one of them should you inform?
A. Only the father.
B. Only the mother.
C. Both parents.
D. Only the school psychologist.
E. None of them.
E. None of them.
The case represents self-mutilation in the absence of an intention to die or suicidal thoughts. This is termed non- suicidal self-injurious behavior. The behavior is purely for non-suicidal reasons, either to relieve distress or to make a change in others or the environment, or for anxiety relief.
This girl is 16 years old and considered an adult in most areas of healthcare. She has a legal right to confidential healthcare.
The exception is when there is a significant concern of risk to self or others. This patient, based on the opinion of a healthcare professional, is not suicidal and does not pose any harm to herself, at least for now; therefore, she is excluded from this exception. Her current problem should not be informed to anyone without her expressed consent; however, she should be encouraged to seek help and counselling from professionals (e.g., school psychologist), or her supporting resources such as her parent.
Confidentiality is a means of providing the client with safety and privacy and therefore, protects client autonomy. For this reason, any limitation on the degree of confidentiality is likely to diminish the effectiveness of counselling.
It should be noted though that if the patient was acutely suicidal, she lacked competence and involuntary actions could have been considered.
NOTE - Notifying the parents of a dependent minor cannot be performed without their consent. Should any dispute arise between the duty of the health professional and the child’s refusal of parental notification, the issue should be referred to an authorized third party such as a court.
RCH - Engaging with and assessing the adolescent patient
A mother brings her two-year-old daughter to your clinic because she is concerned about a lesion on her child’s external genitalia. On examination, the lesions turn out to be genital wart (condyloma acuminata). The mother has the history of treatment for a CIN1 cervical dysplasia. Which one of the following can be the most likely cause of her genital wart?
A. Perinatal infection from the mother.
B. Sexual abuse.
C. Primary infection.
D. Breastfeeding.
E. Autoinoculation.
A. Perinatal infection from the mother.
Sexually transmissible diseases (STIs) are rarely seen in cases of sexual child abuse but if present, strongly suggest the possibility. In other words, a child with STI has suffered sexual abuse until proven otherwise; this, however, does not mean that sexual abuse is the most likely explanation.
Anogenital warts or condyloma acuminata are caused by the human papilloma virus (HPV).
Studies indicate that in adults, genital HPV infections are primarily sexually transmitted. In children, the mode of transmission of HPV infection is not as straightforward. Sexual transmission is recognized as a possibility in children, but other possible modes of transmission have been documented as well.
In summary, the modes of HPV transmission in children include:
Sexual abuse
* Oral-genital contact
* Genital-genital contact
* Genital-anal contact
* Fondling
* Digital penetration of the vagina or anus
Nonsexual transmission
* Autoinoculation
* Direct contact with caretaker
* Contact with objects or surfaces contaminated with HPV
Vertical transmission (from mother to infant)
* Via bloodstream prior to birth
* During vaginal delivery through infected birth canal
* Via cesarean section with or without early rupture of membranes
Sexual abuse must never be eliminated when considering possible modes of transmission for anogenital HPV. Many forms of sexual abuse can result in transmission of HPV, including genital-genital contact, genital-anal contact, oral- genital contact, fondling, and digital anal/genital penetration.
However, Adams’ (2001) classification scale for evaluating medical findings of suspected sexual abuse lists anogenital warts/condyloma in a child younger than two years of age as a nonspecific finding for sexual abuse. In such cases perinatal transmission must be considered first as the most likely explanation.
Vertical transmission of the HPV virus does not mean that warts must be present at birth or shortly after birth. HPV is a latent virus and can reside in the skin and mucous membranes without causing warts. The warts may not appear until months or even years after birth. Some authors believe the time between infection and the presentation can be as long as five years. Some believe in a shorter period of up to two years. In general, vertical transmission of HPV can still be the main cause even if lesions first appear years after birth.
Vertical transmission can occur through the bloodstream prior to birth, or at the time of birth as the infant passes through the infected birth canal. Delivery via cesarean section (with or without premature rupture of membrane) does not eliminate the possibility of vertical transmission of HPV. There are even reports of congenital condyloma after caesarean section without premature rupture of membranes.
Some authors also believe that that HPV transmission can occur in utero through semen, ascending infection from the mother’s genital tract, or transplacentally.
Anogenital warts (HPV) also can be transmitted via autoinoculation. Children with a common wart on their hands or elsewhere on their body can transmit the virus by touching their warts and then touching their own genitals.
Non-sexual transmission can also occur from direct contact with caretaker contaminated with genital HPV or common warts. For example, caretakers with genital warts who touch or scratch their genitals and then, without washing their hands, change a baby’s diaper or assist a child with toileting/bathing may transmit the virus to the child’s genitals. HPV transmission via contact with contaminated objects or surfaces is also possible.
The mother has been treated with CIN1. Although HPV serotypes associated with cervical cancer are different from thosecausing anogenital warts, presence of cervical neoplasia could suggest co-infections with other types of HPV as well. In this child, with the mother’s possible infection and the child’s age, the most likely cause to the child’s anogenital warts appears to be perinatal infection from the mother.
If the child was older the likelihood of sexual abuse would be more pronounced, as perinatal infection must have presented by 2 years of age, as most authors believe. Although not a rule, the younger the child, the more likely the HPV infections is due to perinatal infections rather than sexual abuse.
A 34-year-old construction worker presents to your clinic after a foreign body entered his left eye while working. He is from Algeria and does not speak English. His supervisor is accompanying him in the visiting room and asks if he could translate for the patient. Which one of the following is the most appropriate action to take in this situation?
A. Ask for an accredited translator to be present.
B. Bring an accredited interpreter on the phone.
C. Ask the supervisor to leave the room and do not intervene because the patient’s privacy could be breached.
D. Ask the patient if he wants his supervisor to do the interpretation.
E. Let the supervisor to do the interpretation.
B. Bring an accredited interpreter on the phone.
Language differences pose a challenging situation on doctor-patient relationship where the treating doctor and the patient speak different languages. The problem is prominent in countries such as Australia where the number of those unable to efficiently speak and/or understand English is considerable owing to high rate of immigration from overseas.
It is essential that in situations where a patient has some difficulty or uncertainty in understanding English, a qualified healthcare interpreter is used. The fact that a healthcare interpreter/ translator has been used should be noted in the patient’s medical records. Most consent forms have a space for statement that the translator has translated the contents of the form and the information given by the patient.
It should be noted that a member of the patient’s family, a friend or another non-accredited person should not, in general, act as interpreter, as both legal and ethical questions could be raised about the validity of any consent obtained. An exception is when the medical issue is minor and use of a close friend or family member is the expressed wish of the patient.
In this case scenario, the treating doctor should ask for an accredited healthcare interpreter to be present; however, since it is often impossible to have a qualified interpreter available on the spot, the Telephone Interpreting Service (TIS) should be used as the most convenient means of accessing to an interpreter. This service has a dedicated telephone number for doctors in private practices and the service is free when doctors are providing care. The service is claimable under Medicare to Australian citizens or permanent residents.
If an unqualified interpreter has been used, for example in an emergency, a qualified interpreter should be obtained as soon as possible to ensure that the patient has understood what has taken place.
It is not appropriate to use the supervisor to translate despite the fact that the patient might have consented to it. When the translator is present, the doctor could reliably ask the patient about his preference is he prefers the supervisor to be present.
RACGP - Using interpreters
All of the following situations allow the doctor-patient confidentiality to be breached except:
A. When the patient consents to allow personal details to be revealed to a third party.
B. If there are other health professionals who have a legitimate therapeutic interest in the care of the patient including medical students.
C. If there are other health professionals who have a legitimate therapeutic interest in the care of the patient excluding medical students.
D. If there is overriding public interest.
E. Where disclosure of the information is required or permitted by operation of the law.
B. If there are other health professionals who have a legitimate therapeutic interest in the care of the patient including medical students.
For a proper doctor-patient relationship it is important to ensure that information provided by patients to the treating doctor will remain strictly confidential.
The general rule is that doctors may not, without the consent of their patients, disclose to any third party information acquired in the course of their professional relationship. This rule of confidentiality extends also to disclosure to family members.
However, there are exceptions where confidentiality can be breached. These exceptions are as follows:
Where the patient gives valid consent for his/her medical information to be revealed to a third party - e.g. the patient asks you to reveal his medical information to his/her employer, insurance company, etc.
Sharing information in the healthcare team - in many health care situations, consent for sharing confidential information between members of the ‘health-care team’ is implied and it is presumed that patients know and accept that this will happen. These members include other health professionals who have a legitimate therapeutic interest in the care of the patient. Medical students cannot be considered legitimate in this sense and are excluded, unless the patient consents to. In fact, medical students should be considered thirds parties.
Exceptions established by law - these include the notification of infectious diseases, births and deaths, and deaths reportable to the coroner. In some states, doctors are obliged to notify the relevant registration authority if a health- care professional, who is a patient, is ill and the community is believed to be at risk; this exception is backed by immunity from civil action.
Overriding community interest - when community interest overrides that of the patient, disclosure of the patient’s medical information is not considered a breach of confidentiality. An example is when a doctor advise the police of a patient they believe should not be driving a motor vehicle, or a psychiatrist believes a patient is a serious threat to others.
A mother brings her 6-month-old daughter for advice regarding vaccination of her baby. The child has not received any vaccine so far because the mother had believed it is more natural, but she was a little concerned after she read in an article that vaccination is beneficial for children. You explain to her the benefits of the child being vaccinated. At the end, she decides not to vaccinate her child. Which one of the following is the most appropriate approach in this situation?
A. Inform child protection services.
B. Call the police as she is putting the baby’s health at risk.
C. Inform the local community council.
D. Respect her decision.
E. Apply for guardianship to the guardianship court.
D. Respect her decision.
According to current regulations in Australia, vaccination is not compulsory and parents can choose not to vaccinate their children. Physicians are required to fully explain the benefits and risks of vaccination to parents, and respect their wishes if they refuse vaccination of their children.
Any option suggesting reporting of such parents to authorities such as child protection services, police, court, etc is incorrect.
A 6-year-old child is presented with multiple bruises. Based on reasonable grounds, you form the idea that the child has sustained physical abuse. Which one of the following is the most appropriate next action you should take?
A. Full blood exam.
B. PT, APTT.
C. X-ray.
D. Take photographs of the lesions.
E. Notify the Child Protection Service.
D. Take photographs of the lesions.
When a healthcare professional, based on reasonable grounds, forms a belief that child abuse has occurred, immediate action should be taken.
The priorities in dealing with child abuse are:
1. To diagnose, treat and document the child injuries
2. To notify and involve the Child Protection Services immediately
3. To provide, when consent is given, a verbal or written report to Child Protection Service and the Police (this is different from notifying the Child Protection Services on perceived child abuse)
This child does not appear to be in immediate need for treatment as the first priority; therefore, taking photographs of the lesions to document them is the next best step in management.
NOTE - Notifying the Child Protection Services does not need any consent from the parents, care or guardian. In fact, it is advisable that the doctor withhold from the parent that he/she has made a notification if it is believed that the accompanying parent has been involved in child abuse. However, the doctor must establish that consent has been given (by one of the parents or the child's legal guardian) to perform a clinical examination and to provide a report (not notification) to Child Protection and the Police. Ideally this should be in writing. If consent is unobtainable, the child should only be examined if a medical emergency exists.
Option A, B and C: Full blood exam and coagulation profile would be needed if the bruises were considered to have been caused by a medical condition with hemorrhage tendency. These tests might later be indicated for further assessment after the bruised are proved not to be a consequence of injuries. X-ray exam might be considered somewhere during assessment process if indicated. It is not a priority now.
Option E: Notification to child protection services comes next after documenting the injuries and treating them.
RACGP - The White Book: Child abuse
A 13-year-old girl comes to your GP clinic asking for options regarding abortion. She left home 12 months ago and is living with his 18-year-old boyfriend. Last evening, she went to a party where she became drunk and was forced to have unwanted sex with a man. She wants to know if she could have an abortion in case she gets pregnant. On examination, there is no evidence of trauma. Which one of the following should be notified first?
A. Sexual assault service.
B. The police.
C. Her parents.
D. School.
E. Child protection services.
E. Child protection services.
According to current legislation in Australia, doctors, nurses and midwives are obliged to lodge a mandatory report to the child protection services whenever they have formed a ‘reasonable belief’’ that a child under 18 years has been or is being sexually abused or assaulted. This holds valid for all peoples younger than 18 years of age regardless of whether they are dependent or independent (mature) minors; therefore, the next step in management in this scenario is reporting to child protection services.
The doctor, to whom a mature minor discloses the sexual assault, should initially inform the child of legal requirements of mandatory reporting and the limitations on doctor-patient confidentiality.
The key point to appreciate and fully absorb is the legal concept of ‘child’ in the term ‘mature child’. No matter how mature or independent they might be, they are children as long as they are younger than 18 years and reporting any alleged abuse/assault is a ‘must’.
NOTE - This is different from incidences when a mature child voluntarily involves in a sensual sexual relationship. In such cases no mandatory reporting is required if the child is 13 years or older.
When a belief of child sexual abuse or assault is formed, the practitioner should discuss the mandatory reporting requirements with the mature minor and include the following in the discussion:
* How the minor would like a report to be progressed
* Their preferences for alerting (or not) their carers/parents
* Their preference for informing (or not) the Police
* If the minor views themselves at any ongoing risk of (further) sexual abuse
* Any alerts for the child protection service or the police
* Any further information the mature minor would like to have included in the report
Child protection services should make a mandatory report to the police; however, if the mature minor in discussion with the mandatory reporter, determines they do not want the police to be involved, this information needs to be included in the report. Child protection services and the police will take this into account whenever there is no ongoing risk to this child or any other child.
NOTE - It is always appropriate and advisable to persuade or encourage a mature minor to inform her parents/cares or to allow the doctor to do so on their behalf, but if the mature refuse to do so, it should be avoided as it unnecessarily breaches the doctor- patient confidentiality.
Her school (option D) is not required to be informed in any case; even if the child is dependent and not mature.
Sexual assault services (option A) are dedicated bodies that provide the victims of sexual assault with counselling services, forensic examinations and psychological care. Although it is advisable that sexual assault victims be counselled about the benefits of such services and offered referral, no mandatory reporting to sexual assault services is required.
TOPIC REVIEW
A child or minor is a person who is younger than the age of majority. In Australia the age of majority is 18 years. This is the age at which citizens can exercise all the civil rights available to Australians; however, a child of or over 16 years of age can give consent for medical treatment. In certain situations, a child younger than 16 years of age may give consent as well if he/she is considered competent by Gillick competence rule.
Based on Gillick competence principle, a minor (< 16 years, but not younger than 13 years) is considered competent to consent to treatment if:
* she/he lives independently of her/his parents (i.e. emancipated minor), AND
* she/he appears to have sufficient understanding and intelligence to enable her or him to understand fully what is proposed and the risks and benefits.
If these criteria are met, a minor can consent to treatment without any requirements to informing a parent or guardian or obtaining consent from them.
To put it in a more clear and straightforward way, always approach a minor as a consenting adult if:
1. she/he is 13 years of age or older, AND
2. she/he lives independent of his/her parents, AND
3. she/he appears to fully understand the situation, treatment options and risks and benefits.
You are a medical officer in a tertiary hospital. A patient is about to undergo abdominal surgery. When the patient is being transferred to the operating theatre, the nurse informs you that the consent for the surgery has not yet been obtained. Which one of the following is the most appropriate step regarding consent?
A. Send the patient to the operating room and ask the anesthesiologist to obtain the consent.
B. Obtain the consent yourself and send the patient for the surgery.
C. Download information from the internet and discuss it with the patient and obtain consent.
D. Call the treating surgeon and ask him to obtain consent.
E. Ask the attending nurse to obtain consent from the patient on his way to the operating theatre.
D. Call the treating surgeon and ask him to obtain consent.
The ultimate responsibility of obtaining consent is with the clinician directly in charge of the treatment; therefore, the operating surgeon should be called for obtaining consent from the patient. However, it is possible for that clinician to delegate authority to other healthcare professionals, such as more junior members of staff. The proviso for such delegation is that the person obtaining consent must be fully equipped to deal with the consent process.
A 17-year-old girl presents to your clinic requesting an abortion at 12 weeks pregnancy. Her pregnancy is the result of a rape that happened a while back in a party while she was drunk. You are against abortion morally and think that abortion can be only ethical in cases of severe congenital anomalies. Which one of the following should the most appropriate step in management of this patient?
A. Refer to another GP for a second opinion.
B. Inform her parents.
C. Inform the Sexual Assault Services.
D. Refer to a tertiary hospital for further management.
E. Perform the abortion despite your will.
A. Refer to another GP for a second opinion.
The very first step in management of this patient is reporting the incidence of sexual assault to child protection services. Any options suggesting mandatory reporting to child protection services would be the most appropriate option.
According to current legislation in Australia, doctors, nurses and midwives are obliged to lodge a mandatory report to the child protection services whenever they have formed a ‘reasonable belief’’ that a child under 18 years has been or is being sexually abused or assaulted WITHOUT taking into account whether the child is dependent or independent (mature). Gillick competence rule does not exclude any child from being reported to child protection services whatsoever if the case is sexual assault or abuse. All children younger than 18 years are subject to mandatory reporting by the treating doctors, nurses and midwives, teachers, principals and the police in such incidences.
The main point of the scenario appears to be the conflicting ethical issues regarding termination of the pregnancy between the doctor and the patient. In instances where such conflicts exist and the doctor does not feel comfortable in dealing with consultation regarding abortion, he/she should advise the patient to see another GP or a women’s health center as early as possible (ideally before 12 weeks gestation).
Termination of pregnancy should be performed by approved clinics and abortion service providers.
NOTE - Beyond a specific gestational age (20 weeks is South Australia, 22 weeks in Queensland, 18-20 weeks in NSW, etc.) the termination of pregnancy might be subject to further review and assessment e.g., requiring approval from a panel appointed by the Minister of Health in South Australia after 22 weeks.
Option B: This girl is older than 16 years and can consent to most medical treatments/procedures including termination of pregnancy. No parental consent is required to do so, nor is there any obligation to inform them.
Option C: Sexual assault services are dedicated bodies that provide the victims of sexual assault with counselling services, forensic examinations and psychological care. While offering referral is appropriate, informing them without the patient’s consent is a breach of doctor-patient confidentiality.
Option D: Referral for further management is considered after discussion with the patient about the procedure
and obtaining informed consent for referral after the patient is fully informed of the risks and potential complications. While the doctor is against termination of pregnancy, such discussion should be taken over by a third party (e.g., another doctor) who is impartial and does not feel uncomfortable with the issue of termination of pregnancy.
Option E: The doctor is not to obliged to become involved in abortion if it is against his/her ethical principles.
Melisa, 14 years old, presents to your practice for termination of pregnancy at 13 weeks gestation. She left home at the age of 12 years and has been living with her 20-year-old boyfriend for the last eight months against her parents’ wishes. Her boyfriend left her after he knew she is pregnant. Which one of the following is the most appropriate next step in her management?
A. Inform the Child Protection Service.
B. Refuse her request because she is underage.
C. Refer her for termination of pregnancy after consultation and obtaining informed consent.
D. Tell her that her parents should consent to pregnancy termination.
E. Contact the police because the sexual relationship was illegal due to the age difference.
C. Refer her for termination of pregnancy after consultation and obtaining informed consent.
A child or minor is a person who is younger than the age of majority. In Australia, the age of majority is 18 years. This is the age at which citizens can exercise all the civil rights available to Australians; however, a child of or over 16 years of age may give consent for medical treatment. In certain situations, a child younger than 16 years of age may give consent.
Based on Gillick competence principle, a minor (< 16 years, but not younger than 13 years) is considered competent to consent to treatment if:
* She/he lives independently of her/his parents (i.e. emancipated minor), AND
* She/he appears to have sufficient understanding and intelligence to enable her or him to understand fully what is proposed and the risks and benefits.
If these criteria are met, a minor can consent to treatment without any requirements to informing a parent or guardian or obtaining consent from them.
In summary, according to Gillick competence rule, a person under the age of 16 years is still able to give consent for medical treatments including operative procedure on him/her providing that:
* He/she is 13 years of age or older, AND
* lives independent of his/her parents, AND
* he/she appears to fully understand the situation, treatment options, risks and benefits.
Although the relationship is illegal, because she is under the age of 16 years, they have been living together with their own consent, and the boyfriend has not been a teacher, relative, or someone in whom the child puts her trust because of their position. Providing this is the case, the police in Australia or the various child protection authorities would not normally take action against either the girl or her parent. Informing the Child Protection Services would be the correct answer and the next best step in management if the child was sexually assaulted.
Unless she gives permission to do so, it would be inappropriate for her parents to be advised of the pregnancy and unnecessary for them to give consent to the procedure.
Nicole, 72 years, is one of your patients, who presented with a breast lump. Physical exam finding of an inverted nipple and pea-au-de-orange made you highly suspicious of breast cancer. You ordered a mammogram, the result of which confirmed the diagnosis. Her eldest son calls and tells you that he thinks that her mother has breast cancer and asks you that you do not tell her mother of diagnosis, if it turned out to be cancer, because she might become depressed. Which one of the following would be the most appropriate action in this situation?
A. Tell her son that you should meet Nicole alone and you have to inform her of the diagnosis anyway.
B. Tell her son to bring all family members for a family meeting.
C. Arrange an appointment with the son for further discussion.
D. Call Nicole and ask her to bring a family member with her for the appointment.
E. Follow the son’s wish, as breaking the news might put Nicole at risk.
A. Tell her son that you should meet Nicole alone and you have to inform her of the diagnosis anyway.
As a rule, a patient is entitled to be informed of the diagnosis as soon as it is made. The information should not be withheld on requests of relatives and carers. In this case, you should meet Nicole alone and you must inform her of the diagnosis anyway.
It is Nicole’s decision whether to share any information about her diagnosis, health condition, or treatments proposed.
Options B, C and D: Any option suggesting family meetings or arranging a meeting with the requesting relative is definitely wrong. In fact, telling about the patient’s medical information to a third party, irrespective of their closeness or intimacy is an act of breach of doctor-patient confidentiality. Nicole does not need to bring a family member unless she wishes so.
Option E: There may be circumstances under which providing information could cause the patient harm, and the treating doctor decides to withhold information from the patient. This is frequently referred to as therapeutic privilege. Particular information may be withheld where the practitioner believes, on reasonable grounds, that providing it may damage the patient’s health. The responsibility is on the practitioner to show that providing the information would be reasonably likely to cause significant harm. This decision is made in very limited situations by the treating doctor, not on a relative’s or carer’s request.
You have a patient with severe multiple sclerosis that is advanced and progressive, who now has developed renal failure secondary to diabetes. The patient is alert and has elected to put the DNR order in place at her own discretion. Today, he has presented for follow-up and you notive that he has a markedly elevated serum potassium of 8 mmol/L. Which one of the following is the most appropriate management of this patient?
A. Dialysis cannot be done because of the DNR order.
B. You can do the dialysis if the DNR is reversed for the procedure.
C. Proceed with the dialysis; ignore the DNR order.
D. Give insulin and glucose until the DNR status is discussed with the family.
E. Seek a court order to overrule the DNR order.
C. Proceed with the dialysis; ignore the DNR order.
A “Do Not-Resuscitate’ (DNR) order is very specifically defined as refraining from resuscitative efforts, such as chest compression, antiarrhythmic medications (e.g. amiodarone, atropine, adrenaline, etc.), and electrical cardioversion in the event of the patient’s cardiopulmonary arrest. A DNR order has nothing to do with any other forms of care the patient is receiving.
DNR order has no impact on the use of dialysis, and DNR order should be ignored when assessing the patient for dialysis. Hyperkalemia is life-threatening. It is not reasonable to use an inferior therapy such as insulin and glucose or resins for management of hyperkalemia when dialysis is indicated. In this scenario, DNR order should be ignored and dialysis performed after obtaining the patient’s consent. The patient, however, still has every right to refuse the dialysis. This is different from the DNR order.
This patient is awake, alert and able to understand his own medical condition; therefore, the patient’s family is not relevant in the process of decision making if the patient has the capacity to understand his or her own medical condition.
Robert, aged 68 years, is in the operating theatre undergoing a colon resection due to colon cancer. Prior to the surgery, the risks of the surgery was fully explained to him. After discussion with the treating surgeon, he decided to sign a “Not for Resuscitation (NFR)” form, if anything happens to him during the surgery or afterwards. During the operation, he starts bleeding suddenly and profusely and in a matter of seconds and before anything can be done, he becomes pulseless and his heart stops beating. The blood pressure is not recordable. Which one of the following is correct regarding this situation?
A. Transfuse fluids and blood products, and resuscitate him as this has occurred as a complication of the surgery.
B. Do not resuscitate because the patient’s blood pressure and pulse are not recordable and he has arrested.
C. You can give fluid, blood products and medications, but no chest compression or electric cardioversion.
D. Only administer intravenous fluids and blood products to restore circulating volume but do not perform chest compression or cardioversion.
E. DNR orders are not valid when they are not related to the underlying disease.
B. Do not resuscitate because the patient’s blood pressure and pulse are not recordable and he has arrested.
It is common to have patients presenting for surgery with a ‘Do Not Resuscitate’ (DNR) order written in their files. Physicians and patients suffer from misconception about the potential benefits and harms of resuscitation in the operating room (OR), and even definition of resuscitation in the OR requires clarification prior to surgery.
Cardiopulmonary resuscitation (CPR) in the OR has a very different prognosis than CPR in other areas. The percentage of patients resuscitated in the OR, who return to their pre-CPR functioning, is 50-80% versus 4-14% for those patients who are resuscitated in other areas. This difference is due to several factors such as the fact that the arrest is always witnessed in the OR and the cause is often known that allows prompt effective intervention targeted at the cause.
Another reason for this difference is that causes of arrest in the OR are often reversible effects of anesthesia or hemorrhage, and not due primarily to the patient’s underlying disease. This fact makes physicians even more uncomfortable with DNR orders in the OR because they may feel that their actions has led to the arrest, and they are ethically obliged to resuscitate the patient, even if the patient has clearly expressed wishes to the contrary. This is a significant misunderstanding. Physicians should be aware of the fact that competent patients or their appropriate surrogates have the right to refuse medical procedures and care, even if the care is to counteract the effect of previous medical intervention.
In this case scenario, the patient has been fully informed of the risks of the operation, yet he insists on a DNR order to be in place. DNR means if the patient suffers a cardiopulmonary arrest, represented by undetectable blood pressure and pulse and inability to breathe spontaneously, resuscitative measures such as chest compression, electrical cardioversion, acute administration of antiarrhythmic drugs such as epinephrine, or atropine must NOT be performed in respect to the patient’s wish, even if the arrest could be reversed rapidly and effectively. This holds true even if the arrest is just a simple consequence or complication of the procedure.
Just using intravenous fluids and blood products without establishing artificial circulation, at least initially, by means such as chest compression is futile and not appropriate.
Again, once the patient arrests, measures considered as a part of basic life support (BLS) or advanced life support (ALS) such as chest compression, assisted ventilation, use of medications, or electric cardioversion cannot be used for the patient.
A 42-year-old patients of your, who suffers schizophrenia and is on controlled-release ziprasidone, presents for a follow-up. During the visit you notice a mole on his face that is highly suspected to be melanoma. You explain that the mole should be excised and send for pathology and further follow-up will be required, but he refuses and says the mole will heal on itself. Which one of the following is the most appropriate next step in management?
A. Tell him about the risks of melanoma and benefits of treatment.
B. Formal mental state examination.
C. Refer him for a psychiatric opinion.
D. Admit him involuntarily.
E. Refer the case to Mental Health Tribunal.
A. Tell him about the risks of melanoma and benefits of treatment.
At common law and under some statutes, adults (people over 18) are presumed to be competent, although it is possible to rebut the presumption by showing that an adult lacks competence. A functional test, settled on by most common law jurisdictions, is used to assess the competency of a patient by healthcare professionals to examine the ability of a patient to consent to or refuse a specific treatment. A patient is competent if he/she is able to:
- understand and retains treatment information
- believe the information
- weigh the information and reach a decision and communicate their decision
NOTE - even if the reasoning is not sound or even delusional, the doctor cannot consider the patient incompetent to make decisions. Reasoning is a very important indicating the patient's competency even if the reasoning is irrational or delusional to the treating doctor. The following examples demonstrate how the capacity to reason advocates the patients rights for autonomy: (see photo)
This patient has been offered treatment for a suspected melanoma and falsely believes that he does not need treatment. In such situation, the most important step is discussing with him the risks melanoma can pose to his health, treatment options and material risks associated with the treatment. He should then be able to believe the information, weigh them and reach a decision and communicate his decision.
Option B and C: This patient should not be assumed incompetence. However, if the patient, after discussion, still refuses treatment against his best interest competence should be assessed comprehensively. This may include:
- Assessment of the patient’s understanding and beliefs through discussion with them
- Formal tests of cognitive capacity (such as the Standardized Mini-Mental Status Examination)
- Clinical psychological or neuropsychiatric assessment
- Consideration of corroborative history from other people; for example, family members and health professionals such as the patient’s general practitioner
Option D: Involuntary admission is the appropriate option if the patient is considered to be at immediate risk of self harm or harm to others, or seem that due to a psychiatric condition is not capable of taking care of himself/herself. None of these conditions are present and involuntary admission is not appropriate.
Option E: Referral to Mental Health Tribunal might be considered for patients when an order for involuntary treatment is required, and if they are found to be incompetent for making decisions.
The Australian Medicolegal Handbook; pages 80-85
A 78-year-old woman, who is a patient in your GP clinic, presents to you for a health check-up before she goes on a European tour that includes bush walking and travelling through mountains. On examination, you notice a decline in her recent memory, as well as having trouble in remembering new people’s names and addresses. You perform a Mini mental state exam (MMSE) for her, the result of which is 24/30. You recommend that she cancel her tour until further assessment is carried out because due to her current condition you think she is unfit to travel alone. She refuses and tells you that she will stick to her plan. Which one of the following is the next best step in management?
A. Apply the case to Guardianship court.
B. Admit her to the hospital.
C. Contact the department of immigration and tell them about her condition.
D. Send her to a nursing home.
E. Do nothing.
E. Do nothing.
Patients with dementia thrive in familiar environments and by following a familiar routine. Adherence to routines produces a sense of safety by knowing what is going to happen next and avoidance of confusion. Routines are interrupted when traveling. For patients with cognitive impairment, traveling can be confusing. Being away from familiar surroundings, eating and sleeping in unfamiliar places, disrupted sleep pattern, having to speak and interact with strangers (such as airport and hotel staff) and having to follow directions that may not be fully understood and become confusing for dementia patients. Confusion causes distress that may result in an unusual, potentially catastrophic behavior. The first rule to consider about travelling is that no person with dementia should ever travel unaccompanied because there are many decisions to make, directions to follow, and unfamiliar surroundings to navigate that a person with dementia will find it overwhelming.
This woman has an MMSE score of 24, suggesting mild dementia. Examination also reveals cognitive function impairment associated with this MMSE score.
She also needs thorough investigation for exclusion of organic and possibly reversible causes of dementia such as hypothyroidism and vitamin B12 deficiency. Depression should be considered as a cause of pseudodementia that can mimic dementia. Another important step is a full and formal assessment of her mental state and psychological status because MMSE is a screening rather than an accurate diagnostic tool. MMSE should be assessed and interpreted according to the patient’s educational status because while an MMSE score of 23 can be normal for a patient with 7th grade education, it is clearly abnormal for another patient with college education.
In the meanwhile, this patient should be strongly advised to refrain from travelling alone, especially to unfamiliar places. She should also be offered further assessment and follow-up; however, if she refuses to do so, nothing more can be done. She is still a consenting adult and mild cognitive impairment will NOT preclude her from making decisions for her.
Option A: Applying for guardianship is not appropriate because this woman has only mild cognitive impairment and is competent and can make decisions for herself.
Option B: Hospital admission is not necessary. Further assessment, if planned, is performed in outpatient setting.
Option C: Mandatory reporting to immigration department is not required. By traveling alone, this patient is not putting anyone but herself at risk. Also, it is not a doctor’s duty or responsibility to provide such information to such authorities. More importantly, immigration department has nothing to do with this woman’s travel authorization.
Option D: An MMSE score of 24 or a recent decline in memory is not an indication for placing this patient in a nursing home.
TOPIC REVIEW (See Table)
A 56-year-old woman presents to your GP practice requesting a prescription of oxycodone for her painful knees due to long-standing osteoarthritis. She is from interstate and arrived in Victoria 2 weeks ago to stay with her daughter. She hands over a prescription letter from her local GP back at home. On further questioning about the medication history and if she is having any concerns, she admits to having an addiction to narcotics years ago but not anymore. Which one of the following, would be the most appropriate approach in this situation?
A. Give her a prescription for oxycodone.
B. Call her doctor and ask about the prescription.
C. Deny her request.
D. Call your local pharmacy and ask if you can give her a prescription.
E. Give her a non-opiate painkiller instead.
B. Call her doctor and ask about the prescription.
This scenario represents a common situation GPs face in their practice: requests for prescribing drugs of dependence such as opiates. The challenge intensifies when it comes to first-time patients with such requests as in this case.
In such circumstances, it is of paramount importance to rule out drug-seeking behavior, especially if there is a past or recent history of addiction to narcotics. Another important step to consider is thorough history and assessment of the indication for which oxycodone started in the first place, the duration of use, any adverse effects including dependency, and if the prescription is still valid. These would be achieved through contacting and involvement of her regular doctor in decision- making.
It is important to note that oxycodone is a schedule 8 drug and is strictly regulated; therefore, giving this patient a prescription for it (option A) without verification through proper channels would be inappropriate. Following verification of the prescription and its validity from her local doctor, you may write a prescription for her medication, if your state regulations permit it. Pharmacists have no role in making such decisions and contacting the local pharmacy to seek permission (option B) for a prescription is not correct. Prescription is decided at the doctor’s discretion.
This patient could potentially be managed with alternative pain control measures including non- opiate painkillers, lifestyle modification, physiotherapy, and eventually joint replacement; however, abrupt withdrawal of opiates and replacing them with non-opiate painkillers (option E) is not advisable.
Optimal pain management is an essential part of the duty of care doctors have towards their patients. Therefore, denying the patient’s request (option C) without proving her with an appropriate pain management plan is neither ethical nor proper.
TOPIC REVIEW
The 6 Rs of managing high-risk opioid prescribing:
1. Rotation of opioids
2. Reduction (tapering)
3. Replacement pharmacotherapy
4. Reversal with naloxone
5. Referral to allied health practitioners/other specialists
6. Restriction of supply
Under the Pharmaceutical Benefits Scheme (PBS), oxycodone is a Schedule 8 drug. (See elaborated review in photo below/page 468)
Mother of an eight-year-old boy brings him to your practice with complaints about his behavior. She believes that her son has recently become rude and does not listen to her. She sometimes beats him and locks him up in a room as a punishment for his behavior. The mother also mentions that she has become irritable recently and cannot sleep as usual. Which one of the following is the most appropriate step in management?
A. Talk to the boy.
B. Notify the Child Protection Service.
C. Refer the mother to Good Parenting programs.
D. Inform the police about the child abuse.
E. Refer the mother for psychiatric counselling.
B. Notify the Child Protection Service.
Family violence is coercive and controlling behavior by a family member that causes physical, sexual and/or emotional damage to others in the family, causing them to live in fear or being threatened. Family violence is most commonly committed by one partner towards another (‘domestic violence’ or ‘intimate partner abuse’) and/or by an adult towards a child or children. Other forms include elder abuse or sibling abuse. Any kind of abuse may have long- term detrimental effects.
The way the mother is using to punish the child for his behavior is likely to pose risks to both his physical and emotional well-being. According to the above, the mother’s action should be reported to child protection authorities.
Reporting child abuse of any kind is mandatory for all medical practitioners and must be reported to authorities as soon as possible (e.g., Child Protection Service). In this case, it is even more paramount because the mother has the symptoms of a psychiatric problem.
Talking to the boy for obtaining collateral history or referring the mother for counselling and good parenting program may be considered later in the course of action; however, securing the child’s safety, is of significance priority.
In this scenario, contacting the police directly would not be necessary. Calling the police may be justified in cases of in emergency situations, but not here.
