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

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

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

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

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

Hungtingtons
- Sons understanding
- Genetic inherited dominant with anticipation
- If son has gene likely to present earlier
- 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
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]