Ethics

Question 1

What protocol for breaking bad news?
What is involved in each step

Answer 1

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.

Question 2

4 pillars of ethics

Answer 2

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.

Question 3

Most important parts of medical ethics for consent

Answer 3

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

Question 4

What do you do if a patient lacks capacity

Answer 4

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

Question 5

Requirements for an Advanced care plan if involving life sustaining treatment

Answer 5

Must have been made with capacity

Must be in writing

Must be signed + wittiness signed

Question 6

When does an advanced care plan no longer use

Answer 6

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

Question 7

Who can you call if no capacity or family

Answer 7

Independent mental capacity advocate

Question 8

Questions to decide if DOLS reqiured? What is a DOLS ? If need to stop the patient leaving what must it be

Answer 8

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

Question 9

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?

Answer 9

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

Question 10

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?

Answer 10

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

Question 11

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

Answer 11

Importance of high risk for further events

Driving - restriction is 4 weeks
- If completed PCI and EF >40% may reduce to 1 week

Question 12

DNAR discussion family key points?

I think you’re giving up on them too soon?

Can I get a second opinion?

Answer 12

Consent to discuss with relatives

SPIKES if required

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

Could you tell me what we’ve discussed so I can check we didnt miss anything

Can discuss again at a later date

Document in notes

Consultant signed

Question 13

How to approach patient who doesnt want to discuss DNAR

Answer 13

Ask for consent to discuss with family

Rarely could involve an IMCA

Question 14

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?

Answer 14

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

Question 15

Patient deteriorating despite medical treatment discussion?

Are they going to die more quickly with morphine?

Answer 15

• List reasons treatment not working
• POA / Advance directives
• Now plan to focus on comfort rather than treatment
  Improve quality in remaining life

Patient wishes / 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

Treatment Advances Comfort Wishes for Palliative care

Question 16

Why is confidentiality important

Answer 16

Patient has autonomy over thier care

Encourages patients to share information

Breaching can damage doctor patient relationship
Also legal implications

Question 17

Use of patient information for publication ?

For teaching?

Answer 17

Usually requires written consent + info as to how it will be anonymised

Teaching - should have consent especially if formal teaching session. Again should anonymise

Question 18

3 times can you breach confidentiality

Answer 18

When a patient lacks capacity and it is in their best interests

When the information is required by law

When a breach in confidentiality is in the public interest

Question 19

You can breach confidentiality when it is in the public interest, what does this mean?

Answer 19

The patient or public are at risk of serious harm

Question 20

When must you breach confidentiality

Answer 20

Reporting of notifiable diseases
- Always nice to let the patient know

Reporting a death to the coroner

When a court order and warrant requires information

Question 21

See a patient with new DKA now ready for discharge

Asked by consultant to refer to community diabetes team and inform GP
Now patient has already left

Do what?

Answer 21

Ideally patient would have been informed about the follow up plans

Sharing this information is in the patients best interests

Also info is only been shared by medical teams

Question 22

See known epileptic with seizures drive to hospital
How proceed?

Answer 22

Info gather - and give benefit of doubt

Does the patient know rules
Understanding of condition

Then re explain info and rules around driving - including risks and prosecutions / invalid insurance
-> Advise patient to contact DVLA
-> Only if they refuse should I notify DVLA
(As this poses risk to patient and public )

Also notify patient in writing if possible

Question 23

Friend who is surg reg has HIV. They ask you to tell no one.

Approach

Answer 23

Risk to patient safety

Info gather
- Explain they need to talk to Occy health, supervisor and GP
- Inform I will have to inform seniors

Question 24

Episode of LOC after walking to door
Normal neuro exam and CT

On exam find lots of bruising and she admits to domestic abuse but asks you to tell no one

Do what?

Answer 24

She has capacity

Explore why she doesn’t want you to share info

Can help signpost towards areas of support

If high risk / vulnerable adult without capacity can inform social services.

Question 25

New diagnosis epilepsy counciling framework

Answer 25

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

Question 26

Use principles of ethics to discuss possibility of PEG feeding for post stroke semi conscious

Answer 26

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

Question 27

What are the 3 parts of the mental capacity act

Answer 27

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

Question 28

Mental health act sections

Answer 28

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

Question 29

Driving rules
Seizure?
Epilepsy?
TIA?
Stroke?
TBI?

Answer 29

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

Question 30

Driving
Angina?
ACS?
pci?
CABG?
Pacemaker?

Answer 30

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

Question 31

Driving
Diabetes?
Unaware Hypos?

Answer 31

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

Question 32

driving
Reduced vision ?
Cataract?

Answer 32

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

Question 33

Framework for general information deleivery

Answer 33

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

Question 34

Young man whos mum has huntingtons with dementing illness and ‘wants to die’. She is not coping at home.
She has asked son to help her die.
He has come to discuss with you and plans to start a family.
What needs to be covered?

Answer 34

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

Question 35

Young woman has taken a paracetamol overdose and wants to die. pointers to discuss.

Answer 35

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

Question 36

Patient has brain stem death in ICU. Young and has organ donor card in wallet. Discuss with parents about organ donation

Answer 36

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

Question 37

Young IDDM with DKA again. Family problems, very thin and lanugo hair . Council on diabetic control and weight loss

Answer 37

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]

Question 38

Bleeding in a jehovas wittness.
Plans for emergency endoscopy
Please speak to him. Hb 6.2

Points for discussion

Answer 38

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

Question 39

Are there any options for bloodless surgery? I’m jehovas ? Who can help me?

Answer 39

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

Question 40

Can you give blood to a Jehovah witness who is unconscious if family tell you you cant give blood?

Answer 40

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

Question 41

New diagnosis breaking bad news MS confirmed MRI
Discussion points

Answer 41

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

Question 42

Diabetes in pregnancy
New diagnosis T2DM on meds and tells you she is pregnant. Morning sickness is causing her blood sugars to be erratic

Answer 42

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

Question 43

New diagnosis of gestational diabetes and sugars have been rising despite diet and exercise
Previous healthy baby.

Answer 43

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

Question 44

Will my baby be born diabetic if I am?

Answer 44

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

Question 45

What are all the risks I face if I dont get good diabetic control in pregnancy

Answer 45

Baby
- Still birth
- Macrosomia / shoulder
- Miss carriage
- Preterm

Mum
- Preeclampsia
- Worsening of diabetic retinopathy can worsen rapidly

Question 46

Man presents with pneumonia bilateral and oral candida - please consent to a HIV test and risk assessement

Answer 46

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

Question 47

3 scenarios where DNACPR should be put in place

Answer 47

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