Ethics Flashcards
Note keeping:
What does SOAP stand for in problem orientated medical notes?
SOAP:
Subjective detail given by patient
Objective findings of clinician including investigations
Assessment of hypothesis formulated
Plan of management including therapy and referral
Note keeping:
Why keep notes? including referrals
• Aide memoire for clinician
• Help facilitate accurate and effective communication with other healthcare professionals
• Enable patients to participate with own healthcare - patients may see them
• For clinical governance
• Legal record
○ 40 % of legal actions are indefensible bc of poor quality of notes
○ 20% of cases are reported to be difficult to defend bc of poor quality of notes
Including with referrals:
· You cannot rely on the patient to do your job in liaising with other health professionals
· Letters should allow healthcare professionals to pick up care seamlessly
· Give idea of degree of urgent
Note keeping :
What is the four fold duty with prescriptions
· If you sign it even on advice of another- you are legally responsible
· Four fold duty:
○ Correct name and drug
○ No CI
○ Correct dose and directions given
○ Provision of appropriate monitoring and follow up
Note keeping:
What should students do with notes, and what about advise given over the phone?
· Student notes
○ Students can usually add to health records
○ But check with HCP usually valued
○ Make sure you indicate status- VERY CLEARLY
· Advice on phone
○ Write it down
○ Studies show that advice that was believed to be given is not what is acted on
○ Legally still liable
Note keeping:
What are the 10 commandments of note keeping (Norwell’s)?
· Legible
· Date/time of consultation
· Signed by name/printed underneath signature
· Use of abbreviations only approved
· Never alter or disguise entries
· No insulting or humorous comments
· Check everything is written under your name
· See and evaluate notes thoroughly before filing
· Do not dispose of notes
· Understand the law relating to access to records
Note keeping:
Who owns health records public health vs. private health service?
→ Public health service ○ DOH owns records ○ Patients do have legal right to access in most cases → Private health service ○ Depends on the contract ○ Often owned by client
Note keeping:
What are some examples of groups of people who want access records?
Who can access them? i.e when can media, or children etc
· Patients (Adults/children) (competent/incompetent)
· Health care professionals
· Healthcare students
· Researchers
· Relatives
· Lawyers
· Police
· Social services
· Insurance companies or employers
· The media
· The death patient
Adult Competent Patients: can access unless serious harm or relates to another person
Incapacitous adult: perhaps (and those with an LPA in England/Wales can too)
Children: complicated!
HCPs: Patients can constrain clinical info between team [GMC para 10 “Confidentiality”] but unusual and unhelpful
Relatives: no special rights; role of best interests
Lawyers: consent necessary if not the pts lawyer.
Police: complex (usually serious cases only)
Social Services: child protection
Media/Insurance: ONLY with consent of patient!
The dead: Not very easily!
Note keeping:
What is the GMC’s view on patients having a moral/legal right to deny access to some health professionals and/or students?
· Must respect the wishes of patients who object to particular personal information being shared within the healthcare team or with others providing care, unless disclosure would be justified in the public interest
· If a patient objects to disclosure that you consider essential to the provision of safe care, you should explain that you cannot refer them or otherwise arrange for their treatment without also disclosing that information
Provision of safe care is a bit of a contradiction healthcare and patients both have access- it is unclear what to do
Note keeping: what are key sources for records and the law:
· General data protection regulation (GDPR) regulation EU 2016/679 adopted april 2016 and entered into application in may 2018
· Replaces all data protection legislation in EU member states
· Data protection act 2018 is the Uks implementation of GDPR
○ Healthcare records are more sensitive information- extra legislation
○There are data protection principles that those who are responsible for using personal data must follow
There in particular is stronger legal protection for things like health which are sensitive information
Note keeping: what are data protection principles (GDPR 2016, DPA 2018)
- used fairly, lawfully, transparently
- used for specified, explicit purposes
- used in a way that is adequate, relevant and limited to only what is needed
- Accurate and where necessary kept up to data
- Kept for lo longer than is necessary
- Handled in a way that ensures appropriate security, including protection against unlawful or unauthorised processing, access, loss, destruction or damage
Personal responsibility:
What does the NHS constitution for England (2015) say about personal responsibility
Patients and the public you responsibilities- “NHS belongs to all of us, there are things we can all do for ourselves and for one another to help work effectively and to ensure resources are used responsibly”
“Please recognise that you can make a significant contribution to your own and your families, good health and well being and take personal responsibility for it”
Compared to other countries like Japan, Germany and the USA- the UK have done the least in regard to personal responsibility
Personal responsibility
What is the empirical premise for establishing moral responsibility for health claim?
Life choices–> health problems (note has to apply to a particular patient and a particular problem to ground a case for allocation/no allocation of healthcare resources for this particular person
Factual claim i.e behaviour X causes diseases Y- we must know that it is true, and we must have evidence- this takes a long time
Personal responsibility
What is the metaphysical premise for establishing moral responsibility for health claim?
Note these can be applied to defend your position in the cases about 1 transplant
People are free with regard to engaging in the behaviour resultant from health related life choices
This is hard to prove
Freedom of will- if you want to end up with personal responsibility then you must demonstrate free will
Personal responsibility
What is the epistemological premise for establishing moral responsibility for health claim?
Note these can be applied to defend your position in the cases about 1 transplant
People have sufficient information and understanding of the association between behaviour and its consequences and thus about to make an informed choice
Ensure that people have sufficient information about the risks- they do not need to understand it
Personal responsibility
What is the rationality premise for establishing moral responsibility for health claim?
Note these can be applied to defend your position in the cases about 1 transplant
People have capacity to make decisions on the basis of reasons or are reason responsive
What would it mean to be sufficiently rational for the purposes of moral responsibility- consider cases such as addiction
Ensure that people have reason responsiveness- have the capacity to see and understand the +/- but be able to process and make decision responsive to reason
Personal responsibility
What are the 6 premises for establishing moral responsibility for health claim?
- Empirical
- Metaphysical
- Epistemological
- Rationality
- Normative
- Normative action guiding
Personal responsibility
What is the normative premise for establishing moral responsibility for health claim?
People who are free, able to make sufficiently informed informed choice and rational are morally responsible for their decisions
Personal responsibility
What is the normative action guiding premise for establishing moral responsibility for health claim?
People who are morally responsible should be held accountable (e.g bear some cost)
Personal responsibility
What is the GMC’s professional guidance in regard to personal responsibility?
You must NOT allow your views about a patients lifestyle, culture, beliefs, race, colour, gender, sexuality, age, social states or perceived economic worth to prejudice the treatment you offer, you must not refuse or delay treatment because you believe a patients actions have contributed to their condition
Personal responsibility
What is the legal position in regard to personal responsibility?
LAW: not v. clear
Likely that if doctors were to deny access of healthcare to patients on the grounds of personal responsibility that they would be acting unlawfully
However taxing products e.g tobacco is lawful
End of life:
What is CPR and what is DNACPR
CPR: Emergency procedure for people in cardio-respiratory arrest
DNACPR: Binding legal document that states that resuscitation should not be attempted if a person suffers cardiorespiratory arrest
Must be witnessed, signed, dated
Patients must have capacity and if not then best interests used
here is an important philosophical aspect to this as media perceive CPR has being a miracle, therefore when CPR is not done, it can be thought of as a decision that the person should die/not be alive
Just b/c old does not mean that should have DNACPR - some situations where older person is fit and healthy and does not require a DNACPR just the same as someone younger and very unwell may need one
End of life:
When should a DNACPR be implemented?
· CPR is not likely to be successful
· Patient is mentally competent and does not want to be resuscitated
· Lacks capacity but has a legally valid advanced directive (see also lasting power of attorney) stating they do not want CPR
· Resuscitation is not in the best interest of the patient b/c the quantity/quality of life of patient following CPR is likely to be short/poor
End of life:
What’s the deal with futility and CPR?
· Technically futile treatments is a treatment that simply will not work
· Sometimes CPR is futile in literal sense I,e no chance of success
· However the term futile is often used even when treatment may achieve some goal
· How can we decide what is viable quality of life after CPR if people do survive *which is low chance, and can be traumatic with significant injuries
· Futility must be defined relative to the aim:
If goal is complete health then CPR is often futile
If goal is prolongation of life for a few hours/ days then CPR is often not futile
End of life
What is the deal with DNACPR and competent patients?
What should you do with patients under the age of 18?
Competent adults have the right legally and ethically to refuse treatment
· This includes the right to refuse life saving treatment
· Therefore competent adults have the legal and moral right to refuse CPR and a DNACPR order
This right to refuse consent to treatment is vital to protect patients autonomy
DNACPR forms on behalf of those under 18 years of age, completed by someone else – even though those under 18 are not able to refuse life saving treatment, their wishes should still be considered when discussing DNACPR.
The treating doctor would take these wishes into account when deciding on this course of action.
For example, some children with long term leukaemia are expert patients in what they are going through, and what they are willing to accept in regards to intensive and sometimes traumatic treatments, sometimes they are tired and don’t wish to continue treatment and this should be respected as much as is feasible.
End of life:
What do doctors legally have a duty to do if they want to place a DNACPR on medical notes?
Doctors now have a legal duty to (usually) consult with and inform patients if they want to place a DNACPR order on medical notes, the Court of Appeal in England ruled e.g the case of Mrs. Tracey with lung cancer who was involved in RTA- then was put on DNACPR
It is inappropriate (and therefore not a requirement of article 8 ) to involve the patient in the process if the clinician considers that to do so is likely to cause her to suffer physical or psychological harm- but must be sufficient!
The Ruling - breach of article 8 procedural obligation to involve Tracey before first notice completed- grant a declaration against trust that it violated Tracey;s article 8 right to respect for private life in failing to involve her in the process which led to the first notice.. Since a DNACPR decision is one which will potentially deprive the patient of life saving treatment, there should be a presumption in favour of patient involvement. There needs to be convincing reason not to involve patient
End of life
What is the deal with DNACPR and advanced statements
· Competent patients can issue advanced decisions giving directives as to which treatment they do not wish to get if they become incompetent at a later state
· An advanced statement can include a statement to the effect that resuscitation should NOT be attempted
This decision is LEGALLY binding (subject to some caveats)
End of life
What’s the deal with DNACPR and incompetent patients?
· When incompetent, physicians must decide whether to issue a DNACPR order on the basis of best interest
· Questions:
Can it ever be in a patient’s best interest not be resuscitated?
Is this is the same as saying that it is the patients’ best interest to die?
End of life
Winspear case with incapacity and DNACPR
Recent case of incapacity
1. In order to make a fully informed decision, where it is both practicable and appropriate they must discuss the patients' situation and the decision with those close to patient (subject to any confidentiality restrictions expressed if, and when the patient has capacity) 2. Where both practicable and appropriate, they should delay contacting those close to patient to do this. Of note, in the recent judgement it was stated by the judge that 'a telephone call at 3:00am may be less than convenient or desirable that a meeting in working hours, but that is not the same as whether it is practicable'
End of life
What are the risks/benefits of CPR?
Primary benefit: is chance of extending life however survival rates are low
CPR: also invasive and includes the following risks:
• Rib/sternal fractures
• Hepatic and splenic ruptures
• Prolonged ITU care (including ventilation and dialysis)n
• Brain damage following hypoxia
• Traumatic death
End of life
What are some practical aspects of DNACPR orders
What are some problems associated with DNACPR orders
If a DNACPR order are to be used the following points must be adhered to:
• Effective recording of DNACPR decision in a form that is recognized by all those involved in giving care
• Effective communication and explanation of DNACPR decisions (where appropriate) with the patient
• Effective communication and explanation of DNACPR decisions (where appropriate and with due respect for confidentiality) w/ patient’s family, friends etc
• Effective communication of DNACPR decisions b/w healthcare workers and organizations involved with the patient
Practical problems:
○ Awareness and understanding of guidelines is poor
○ Many DNACPR orders are made w/o adequate communication to patients (or family)
○ Health professionals are often unaware that DNACPR orders apply to CPR only
○ Discussions relating to DNACPR orders are often not adequately documents in notes
○ Senior health care professionals should be making decision regarding DNACPR but not always available when decision must be made
There are various polices on this in each hospital!
