Ethics Flashcards

Question

New diagnosis epilepsy counciling framework

Answer 1

Explain the diagnosis in lay terms 'Disorganised electrical activity in the brain' Treatment options - Issues / complications if not Safety issues - Swimming - Time spent at height - Baby feeding - Driving Explore social aspects - Alcohol - Smoking - Staying out late / lack of sleep - Affect on work - Driving - Contraception - risk of pill failure, if pregnant will need folic acid Recap what was discussed Check understanding Give info on services Eg Specialist nurses / support groups Organise follow up

Answer 2

Autonomy - difficult to take patients views into account. Did they have any advance directives / prior views we can use Beneficence and non maleficence - Feeding may increase nutritional status and aid recovery - Risks of complication during insertion. - Risk of aspiration if gastric stasis Justice - Heavy resource burden caring for PEG tubes

Answer 3

Appointment of a deputy - to make descisions re finances - Person needs to be legally competent - Needs to be accepted by court of protection - No input on welfare / medical descisions Appointment of lasting power of attourney LPA - Must be registered with the office of the public guardian Independent mental capacity advocate

Answer 4

Section 5(2) - Emergency holding power - Any doctor - 72hrs - Good practice to convert to section 2 or 3 Section 2 - Admission for assessment - 2 doctors + approved social worker / relative - 28 days Section 3 - Admission for treatmenet - Section to diagnosed with mental disorder -> converted for treatment - 6 months duration and reviewed Section 4 - emergency admission to hospital - 1 doctor (usually GP) and approved social worker / relative

Answer 5

First unprovoked seizure Must notify DVLA No driving for 6 months from the date of the seizure, or for 12 months if there is an underlying causative factor which could increase risk Epilepsy or multiple unprovoked seizures Must notify DVLA No driving for 12 months from the date of the last seizure Single transient ischaemic attack Don’t need to notify DVLA No driving for 1 month Stroke and cerebral venous thrombosis May need to notify DVLA No driving for 1 month Clinical recovery assessment at 1 month to determine ongoing driving guidance Notify DVLA if neurological deficit at 1 month Traumatic brain injury May need to notify DVLA No driving for at least 6 months Relicensing may be considered after 6 to 12 months dependent on clinical and radiological feature

Answer 6

Angina Don’t need to notify DVLA No driving when symptoms occur: at rest, with emotion, at the wheel Acute coronary syndromes (ACS) Don’t need to notify DVLA No driving for 1 week after ACS if successful coronary intervention (PCI) and if the following are met: No other revascularisation planned within 4 weeks, and LV ejection fraction is at least 40% before hospital discharge If not treated by successful coronary intervention or any of the above are not met, driving may resume only after 4 weeks from the acute event Elective percutaneous coronary intervention (PCI) Don’t need to notify DVLA No driving for 1 week Coronary artery bypass graft (CABG) Don’t need to notify DVLA No driving for 4 weeks Arrhythmias May need to notify DVLA Must not drive if arrhythmia has caused or is likely to cause incapacity May start driving without DVLA notification if the underlying cause has been identified, and the arrhythmia is controlled for at least 4 weeks Must notify the DVLA if there are symptoms that are likely to cause incapacity and/or arrhythmia is not controlled for at least 4 weeks, and an underlying cause has not been identified Pacemaker implant (including box change) Must notify DVLA of pacemaker implantation No driving for 1 week

Answer 7

Insulin-treated diabetes Must notify DVLA All the following criteria must be met in order to drive: Adequate awareness of hypoglycaemia No more than 1 episode of severe hypoglycaemia while awake in the preceding 12 months and the most recent episode occurred more than 3 months ago Practises appropriate glucose monitoring Not regarded as a likely risk to the public while driving Meets the visual standards for acuity and visual field Under regular review Impaired awareness of hypoglycaemia Must notify DVLA Must not drive until a clinical report confirms that adequate hypoglycaemia awareness has been regained

Answer 8

Minimum eyesight standards Must not drive and must notify DVLA if unable to meet the minimum standards The law requires drivers to have minimum eyesight requirements of: able to read a car registration at 20 metres, and have a visual acuity at least Snellen 6/12 with both eyes open or in the only eye if monocular The law also requires all drivers to have a minimum field of vision Cataract May not need to notify DVLA Often safe to drive, but minimum eyesight standards must be met

Answer 9

Introduce self Assess patients level of knowledge Explain condition / procedure Any medications - When to use PRNs - Important side effects to be aware of Lifestyle / social - Smoking / alcohol / weight / diet - Driving - Contraception Plan Recap and assess understanding Follow up organised

Answer 10

Has mum **consented** to the discussion SPIKES - do you want anyone else here for the discussion Hungtingtons - Sons understanding - Genetic inherited dominant with anticipation - If son has gene likely to present earlier - Issues with getting tested - can be a lot to take - No cure - Possibility for prenatal screening Relates to his mother - Social - options for care / NH - Legal - advanced directives / refusal of treatment - POA - Assisted suicide is illegal - new bill in progress for assissted dying Recap plan Check understaning Any further questions Follow up - leaflets / geneticist / appt with whole family

Answer 11

OD itself - How many and over what time period (influences interpretation of levels etc) - Anything else - Other meds - EG alcohol / antiepileptics - Suicidal intent ? - Understand that it is lifethreatening Check capacity PMH - Any psych / low mood / DSH / Make a treatment plan - Bloods +/- infusion - Psych review Recap understanding

Answer 12

Situation - find space without interruptions. Perception - what is thier understanding Information - What do they want to know Knowlege - your son had died and the only thing keeping his organs alive is the ventillator He has permanently lost the potential for consciousness and the capacity to breathe Emotion - allow to express Summarise - understanding and next steps Organ donation - Did you know your son had an organ donor card? - Will need to have HIV testing - Will require an operation - Not all organs may be used - Will involve a delay in release of the body Recap and formulate a plan Check understanding Give info on organ donation

Answer 13

Diabetic education - Review insulin regime - compliance (non compliance due to weight gain / family issues / lack of understanding ) - Imporance of sugar control - DKA is a life threatening condition - Other CV risks stroke / heart / smoking Anorexia - Current diet - Importance of balanced diet - Weight, body image - Depression Family problems - May need family therapy for anorexia Recap and formulate plan check understanding and ansewer questions Leaflet eg anorexia Follow up plans [Food can be given as a medical treatment under the mental health act]

Answer 14

Have discussion in Private - avoid family members weighing in First inform that all discussion will be confidential and not shared with anyone eg family without explicit consent Check understanding of issue and beliefs around blood products. Then explain procedure and plan. Blood loss so far is significant. We would normally prescribe blood to help protect vital organs. I respect your wishes not to recieve blood and would never do so without your consent. We will do everything we can to stop the bleeding but this may not be possible fast enough and you may die. We can discuss this and make sure we have it down in writin incase you need to be put to sleep to have more investigations or if you become drowsy with blood loss. This is important as you wont be able to make those descisions if this happens Do you have an advanced directive stating your views on this There are many different parts of blood - Red blood cells, platelets and clotting factors. **Red cells** - carry oxygen to keep organs alive. If they keep falling due to bleeding you could die - Some jehovas witnessess would accept a transfusion if thier life was at risk. We can give a transfusion with total confidentiality from friends and family - Some jehovas witnessess would not accept blood even if they would die without this - What are your thoughts? **Platelets** - Another type of blood cell from a persons blood. They help to form blood clots and help to stop bleeding. Would you consider this? **Clotting factors** - These are proteins from a persons blood with help to form clots. These are not cells, but molecules and are sometimes accepted by jehovas witnessess. - We can sometimes use clotting factors made in the laborotory, not from a persons blood **If your kidneys began to fail**- would you accept us to use a machine to help do the work of your kidneys. Your blood would circulate in a machine and there would be no break in the circuit. **Cell salvage**- try and re use blood lost during prodedure and put back into the body after going through a machine to clean it. **Is there anything else that youd like to discuss**? We have discussed a lot of things. Its important I know you understand what we've discussed -**can you tell me what we've agreed on?** **I will write this down** in the medical notes and then we can both sign it to say we've agreed and discussed the risks and that you would not accept any cells or proteins even if you will die You are now going to theatre to speak with the surigcal team. You are free to change your mind at any point should you wish. Any of the nurses can contact me at any point if you'd like to speak to me about this or anything else. We will not give you any treatment you do not wish to have Assess concerns Beliefs Expectations of treatment Explain descisions and implications then check understanding Summarise whats discussed then make repeat discussion

Answer 15

Weeks - months before - Epo injections - Take unit of blood and freeze (some wont alow this) Days to weeks - Stop all anticoag / anti platelets Anaesthetic - Increase FIO2 for op to encourage DO2 Surgery - TXA - Cell salvage - Any blood products eg platelets / clotting factors - Surgical technique Help - Jehovas wittness counciler in each hospital - Also watchtower.org website

Answer 16

Yes Unless there is a signed document you have seen stating they would not receive blood even if lifesaving Duty is to the patient first - without proof of relatives views you cannot withold life saving treatment . Involve the legal team and patient advokate

Answer 17

S - Nursing staff, patient and significant others PIKES K - the MRI shows you have multiple sclerosis. What do you know about MS? It is a chronic condition which affects the nerves in your brain and body. It is a relapsing and remitting condition which means your symptoms will come and go. Over time some symptoms may not recover fully. There are a number of medications the neurology team can talk to you about which help reduce the frequency and severity of relapses. Approx 15% progress to progressive symptoms but most do not Social - Currently well and can return to work - Need to let work know you have a condition which may affect this - People are able to have children. This will need to be discussed with neurologists later Wheelchair - most people don't Leaflets with info for MS society Can arrange follow up with your partner present once you've had time to think of any other questions Arrange FU with neuro

Answer 18

Offer to have other members of family What worries do you have? Patients with **good blood sugar control should have a normal pregnancy** with no more increase in complications than the rest of the population. - Without good diabetic control risk of missacarriage and other complications Main risks - **Larger babies** - and risks of shoulder getting stuck, may need to have **c section** Medication - Will need to adjust medication so we use only metformin and insulin in pregnancy - We will teach you with one of the nurses **how to inject insulin** - If your blood sugars are hard to control we sometimes admit you to hospital while we adjust your regime How is your **morning sickness**? We can give you some anti sickness medications which will help stabilise your sugars Meds - May need to adjust other meds such as blood pressure tablets Social - Good healthy diet - Smoking / alcohol - Driving - must contact **DVLA** but you can continue to drive so long as you have good sugar control - There is a risk of having low blood sugars so keeping a **snack** on you which can give you a burst of sugar is important **Follow up** - I will arrange follow up with the specialist diabetes team here at the hospital which invovle a diabetic **consultant in diabetes, obstetrician, midwife and dietician**. There will be more close monitoring of you and your baby with blood and urine tests as well as extra US scans for the baby **Telephone helpline for support** Do you have any further questions? Could you give me a summary of what we've discussed Here is some information about diabetes in pregancy and arrange your follow up with me next week

Answer 19

What do you know about gestational diabetes? - It is also to do with high sugar levels and occurs in some women when they become pregnant due to hormone changes. - In most people it resolves when you have the baby although in some people it can unmask a diagnosis of diabetes Have you had other pregnancies? **Control** - Your diet and exercise has not worked to keep your blood sugars in control so we will have to move onto using medicatoins. There is 1 tablet we can try and then the next option is insulin Social - Good healthy diet Any further questions / concerns Could you summarise what we've discussed ? I will arrange follow up

Answer 20

No, but we will need to keep a close eye on the blood sugars after birth to see if we need to use any exta feed

Answer 21

Baby - Still birth - Macrosomia / shoulder - Miss carriage - Preterm Mum - Preeclampsia - Worsening of diabetic retinopathy can worsen rapidly

Answer 22

S - usually best to talk alone initially for this one Can you tell me about your condition and what you've been told . Everything you tell me is strictly confidential. K - You have picked up an atypical infection which is usally one you get with a immune system that isnt working as well Is there anything you're worried this could be? HIV explain - HIV and AIDs not the same - It is a virus which weakens your immune system and causes infections - It is picked up through unprotected sex / blood contact with infected people - Nowadays very treatable and many patients have a undetectable viral load meaning they aren't infective. - There is no cure however and you will need to be on treatment forever Risks for HIV - Ever had a blood transfusion - Tatoo - Injected drugs - Sexual history - regular partner / anyone else / known PWID / Prostatute / MSM Confidential issues - We will not share anything you tell us with your partner - However if you test positive we will need to talk to you about how to tell your partner as it is important they are tested early - this helps prevent them from getting sick with the symptoms of a low immune system - We wont talk to them without talking to you first The test is a blood test and the results are usually back within a couple of days. If it is negative we will have to do the test again after 3 months from your last exposure as this is how long it can take to be positive Social - Very important to practice protected sex. - You should speak to anyone you have recently had unprotected sex with - You do not need to tell work or change job but you need to be careful if you cut yourself that people dont come into contact with your blood - Ideally tell your GP Follow up - this has been a lot to take in. - Here is a leaflet with answers to the most common questions. - I will arrange a follow up appointment over the phone in a few days with the results of the test Can you tell me what we've discussed today

Answer 23

Unlikely to be successfull Not in accord with patient wishes - Advance directive Succcessfull woul result in a quality of life that would not be acceptable for the patient

Answer 24

- Private - Apply for exemption with primary care trust- eg compassionate grounds - Clinical trials - maybe for other drugs May need to refocus care eg palliative

Answer 25

P BRANI - Procedure - explain - Benefits - Theraputic / diagnostic - Risks - "all interventions have some degree of risk" split into common and not serious, uncomon and serious. Generic - pain, bleeding, infection, failure, reaction to local anaesthetic Specific - Alternatives - eg medical management - Nothing - what happens if we do nothing - Instinct - Gan give reccomendation if asked

Answer 26

**LP** - 10% Post procedure headache (may last several days) - Back pain and brusing - simple pain relief - <1/1000 Damage to nerves -> leg pain / bladder and bowel symptoms - Infection - meningitis. risk reduced by aseptic technique and wash - <1/10,000 Blood clot / haematoma in spinal cord which may require surgery **Chest drain** - 1/100 PTX (air leak in chest wall) - Cough - Air leak in soft tissues - Drain moving / blockage - may require agents to unblock or replaced - <1/500 Structures: Left - heart, spleen, lung. Right: Lung, liver. Major bleeding may result in death but i have never seen **Ascitic drain** - Fluid leak from drainage site - dressing / suture / drainage bag - Blocked tube - reposition / replaced - Hypotension - requirement of HAS 20% 100mls / 3L drained - Infection - 1-2/100 Damage to bowel which mah require an operation