Ethics Flashcards
What protocol for breaking bad news?
What is involved in each step
SPIKES protocol
S – Setting
Arrange for some privacy
Involve significant others
Sit down
Make connection and establish rapport with the patient
Manage time constraints and interruptions.
P – Perception of condition/seriousness
Determine what the patient knows about the medical condition or what he suspects.
Listen to the patient’s level of comprehension
Accept denial but do not confront at this stage.
I – Invitation from the patient to give information
Ask patient if s/he wishes to know the details of the medical condition and/or treatment
Accept patient’s right not to know
Offer to answer questions later if s/he wishes.
K – Knowledge: giving medical facts
Use language intelligible to patient
Consider educational level, socio-cultural background, current emotional state
Give information in small chunks
Check whether the patient understood what you said
Respond to the patient’s reactions as they occur
Give any positive aspects first
e.g.: Cancer has not spread to lymph nodes, highly responsive to therapy, treatment available
locally etc.
Give facts accurately about treatment options, prognosis, costs etc.
E - Explore emotions and sympathize
Prepare to give an empathetic response:
1. Identify emotion expressed by the patient (sadness, silence, shock etc.)
2. Identify cause/source of emotion
3. Give the patient time express his or her feelings, then respond in a way that demonstrates you
have recognized connection between 1 and 2.
S – Strategy and summary
Close the interview
Ask whether they want to clarify something else
Offer agenda for the next meeting
eg: I will speak to you again when we have the opinion of cancer specialist.
4 pillars of ethics
Respect for autonomy: Patients have the right to make informed, uncoerced decisions about their healthcare. This includes the right to privacy, and a doctor’s duty to maintain confidentiality.
Beneficence: Means to “do good”.
Non-maleficence: Means to “do no harm”. This includes not killing, causing pain or suffering, incapacitating, offending, or depriving others of the goods of life.
Justice: One of the four pillars of medical ethics.
Most important parts of medical ethics for consent
autonomy
Informed - ability to make the decision with sufficient information
Capacity to make decision - Mental capacity act
- Understand
- Retain - can give in multiple formats
- Weigh up
- Communicate
Voluntary. - must not be pressured / coerced
What do you do if a patient lacks capacity
Should make a decision in the patients bests interests
Should cause the least restriction on the patient
Patient should be as involved as possible
Involve family
- Lasting power of attorney
- Any prior wishes, any religious or spiritual views
- Current quality of life and how will be affected
Need to check for a advanced care plan
Requirements for an Advanced care plan if involving life sustaining treatment
Must have been made with capacity
Must be in writing
Must be signed + wittiness signed
When does an advanced care plan no longer use
If they have retracted it before losing capacity
If the circumstances have arising not expected by ACP
If they have listed a LPA to have decision over that aspect
Who can you call if no capacity or family
Independent mental capacity advocate
Questions to decide if DOLS reqiured? What is a DOLS ? If need to stop the patient leaving what must it be
Is the person subject to supervison
Is the person free to leave
It restriction on their movements in a person lacking capacity
Must be proportional
- Ie closing doors and leading back vs physical restraint / sedation
Speak to 82 lady
Usually well and independent
Treated for UTI and delirious asking to go home, has pulled out cannula .
Does not remeber conversations and has fallen twice
Questions from daughter
Why is she acting so stange?
Im concerned about her falling, how can you stop this?
When is she going to go back to normal?
Are you going to let her go home?
Who is making decisions?
Why strange
- Delirium - lost capacity
- Any advanced directives / unwanted procedures / spiritual procedure
- Would likely require a DOLS
Fall
- Will require increased supervison
- Movement with help of staff
Return to normal
- Hopefully with treatment of UTI
- Very variable and difficult to predict
Go home?
- Wont discharge patients not safe to go home
Decisions
- All decisions made on behalf of mum will be in best interests
- Any significant discussions will be made with daughter
Collapsed unknown man
-> UGIB with Hb 50
- Endoscopy with treatment
Wife attended
Why blood transfusion he is jehovas wittness and on record?
Any more blood against will?
How do I complain?
Why
- Didn’t know jehovas when treated
- Sorry and was unknown, when we dont know must act in patients best interests
More blood
- No will respect all wishes
Complain
- Can refer to Patient Advice and Liason service
50m delivery driver with NSTEMI
Medical treatment awaiting angiogram and echo for 3 days as IP
Can i have ix as outpatient
can i drive? does it change if i get treatment
Importance of high risk for further events
Driving - restriction is 4 weeks
- If completed PCI and EF >40% may reduce to 1 week
DNAR discussion family key points?
I think you’re giving up on them too soon?
Can I get a second opinion?
Consent to discuss with relatives
Discuss level of knowledge about patients
- any previous discussions
- any power of attorney
- any spiritual beliefs
Explain
- If became so unwell the heart stops what would you want to happen
Regularly have this discussion with family as routine when coming into hospital
Patient not imminently approaching death
Quality of life very likely to be worse
“Giving up too soon”
- Why are you saying that
- Explain success rates low
- Doesn’t change treatment
ie not just palliatve care
- Dont want to put patient through distressing treatment
Second opinion?
- Can discuss with senior member of team
- After could get a second opinion
Can discuss again at a later date
Document in notes
Consultant signed
How to approach patient who doesnt want to discuss DNAR
Ask for consent to discuss with family
Rarely could involve an IMCA
Withdrawal of care
Eg disabling stroke and stopping NG feeding
Key discussion points?
How do you know they wot improve?
How long survive without feeding?
Arguments against withdrawal?
Need to involve whole team
Likely multiple consultants
No improvement made
Ability for an natural death - rather than prolonged artificial
Focus on keeping comfortable and dignified
No improvement
- Input from specialists
- No improvement over time period
How long
- Variable up to couple weeks
Arguments against
- Input of whole team
Patient deteriorating despite medical treatment discussion?
Are they going to die more quickly with morphine?
List reasons treatment not working
Now plan to focus on comfort rather than treatment
Improve quality in remaining life
Where would the patient want to die - can we arrange home with GP
Will involve other teams
Eg palliative
Morphine
- plan to make the patient more comfortable and focusing on quality of life rather than faster death
