Ethics formative

Question 1

What are the 3 types of consent?

Answer 1

Implied

Verbal

Written

Question 2

What act allows doctors to allow in the best interest of patients when they lack capacity?

Answer 2

Mental capacity act 2005 (england)

Adlts with incapacity act (scotland)

Question 3

What are the key features of the mental capacity act 2005?

Answer 3

A person is assumed to have capacity unless it is established that he lacks capacity

A person is not treated as unable to make a decision unless all practical steps to do so have been taken without success

A person is not to be treated as unable to make a decision merely because he makes an unwise decision

An act done or a decision made under this Act on behalf of a person who lacks capacity must be done or made in his best interests and should not be done if the outcome can be achieved in a way that is less restrictive of the person’s rights and freedom of action

Question 4

Who can consent?

Answer 4

A patient with capacity

A court for a child

A parent for a child

The court can state that a treatment is lawful for an adult

Someone acting under the mental capacity act or the adults with mental health act.

Question 5

In the mental capacity act, who is described as lacking capacity?

Answer 5

They are unable to make a decision if :

Unable to understand the information relevant to the decision

Unable to retain that information or use or weigh it as part of the process of making that decision

Unable to communicate his decision by any means

Unable to decide one way or the other or the consequences of failing to decide

Not unable if can communicate in any way, nor if able to retain the information for short period of time long enough to make the decision

People who are under 16

(the childrens act in Sclotland presumes competence to any child who is aged 12 or over)

Must take reasonable steps to ascertain if the patient lacks capacity - make use of communication aids

Must take reasonable steps to ascertain if it will be in the patient’s best interests - this might involve talking to a wider range of family/friends or looking to see if there is an advance directive

Question 6

When making decisions on behalf of someone, how can you peserve their freedom?

Answer 6

Where it is determined that an intervention is to be made, such intervention shall be the least restrictive option in relation to the freedom of the adult, consistent with the purpose of the intervention

Question 7

What is the definition of adult and unable according to the adults with incapacity act Scotland?

Answer 7

“Adult”: means a person who has attained the age of 16 years

“Incapable”: means incapable of:

(a) acting: or
(b) making decisions; or
(c) communicating decisions; or
(d) understanding decisions; or
(e) retaining memory of decisions

Question 8

What is the office of public guardians?

Answer 8

The Office of the Public Guardian (OPG) protects people in England and Wales who may not have the mental capacity to make certain decisions for themselves, such as about their health and finance.

Question 9

What is the role of the mental welfare comission?

Answer 9

Protect people with an intervention or guardianship order

Visit the adult - bring matters of importance to health boards or local authorities

Question 10

What does the continuing power of attorney relate to?

Answer 10

Finance and property

Question 11

What does the welfare attorney relate to?

Answer 11

Personal welfare

Question 12

What is the responsiblity of the solicitor when creating a power of attorney / welfare of attorney order?

Answer 12

1. They must have interviewd the patient immediately before the granting
2. He must take measures to ascertain that the patient knows the nature and the power of the order
3. Makes sure there are no external factors / stressors
4. Document has to be registered with the public guardian.

Important to note thet the patient has to have consent before being able to do this!

Question 13

When is research allowed on people with incapacity?

Answer 13

Reseasrch of similar nature cannot be carried out on someone who is capable

The purpose of the research is to obtain knowledge of the causes, diagnosis, treatment or care of the adult’s incapacity or the effect of any treatment etc

Question 14

When might it not be possible to go through the consenting process?

Answer 14

1. Patient unconscious?
2. Patient does not have capacity?
3. Expediency?
4. Cannot communicate?

Question 15

What is meant by Gillick Competency?

Answer 15

Children under 16 can consent to medical treatment if they understand what is being proposed. It is up to the doctor to decide whether the child has the maturity and intelligence to fully understand the nature of the treatment, the options, the risks involved and the benefits.

A child who has such understanding is considered Gillick competent (or Fraser competent). The parents cannot overrule the child’s consent when the child is judged to be Gillick competent. For example, a 15-year-old Gillick competent boy can consent to receiving tetanus immunisation even if his parents do not agree with it.

The court can over rule this competency

Question 16

What is an advanced directive?

Answer 16

It is made when the person has capacity for the potential future where they lack capacity - preferred treatment/non-treatment is outlined

Question 17

What steps must be taken to make the advanced directive valid?

Answer 17

In writing

Signed

Clear written statement applying to the specific treatment

Advanced directive can be made invalid if the person changes their mind (does something agains tthe advanced directive)

Question 18

What predisposing factors might increase chances of making mistakes as a doctor?

Answer 18

Excessive work load

Poor self-care

Maladaptive coping strategies

Shift and night work

Time pressure

Poorly functioning teams

Poor communication

Bullying and harrassment

Poor levels of social support at work

Stress (burnout, mental and physical health)

Anxiety

Depression

Alcohol and drug use

Behavioural addictions

Question 19

What is the effects of alcohol and drugs in the workplace?

Answer 19

–Absenteeism, inefficiency; poor decision-making; impaired customer relations

–Inconsistent performance; poor quality of work; lower productivity (slower); more mistakes and accidents

Alcohol impairs:

• thinking
• concentration
• Judgment
• Mood

Question 20

What are the barriers to seeking help?

Answer 20

Work related:

• difficulty taking time off
• Heavy workload

Fear and Shame:

• Fear of lack of confidentiality (and punitive response)
• Fear of stigma

Concerns about professional future

Lack of knowledge about what to do:

• Insufficient knowlede of services
• Experience of how other colleagues have been treated

Question 21

What are individal and organisational means to cope with stress/mental health at work?

Answer 21

•Individual

–Reduce stigma

–Change the culture

•Facilitative and encouraging rather than punitive

–Support /“morally reward”

–Mentoring

–Coaching

–Opportunities for continuing education

•Organisational

–Involve doctors / dentists at all levels

–Workplace stress management strategies

–Trust initiatives

–HEE initiatives

–College initiatives

• Startwell and PSS (RCPsych)
• First Five (RCGP)

Question 22

What is meant by resilience?

Answer 22

•The ability to withstand and bounce back from adversity

Question 23

What determines the capacity for resilience?

Answer 23

–Self-directedness

•strongest correlation with resilience

–Co-operativeness

–Harm avoidance

–Persistence

Question 24

WHat are predictors of resilience?

Answer 24

•Personal Factors

–Personality

–Previous adversities

–Coping strategies

•Organisational Factors

–Workload

–Hours

•Socio-cultural Factors

–Culture within medicine / dentistry

–Rise of blame and claim culture of litigation in wider society

–Didactic teaching

Question 25

What people are most resilient?

Answer 25

Being female Maintaining work life balance (relaxation, meditation, exercise, help-seeking) Laughter/humour Beliefs/ spirituality Self-reflection/insight/mindfullness Professinoal identity

Question 26

What are the aims of the practitioner health programme? This is essentially the care practitioners receive when they are having trouble (actual therapy can include CBT and group psychotherapy)

Answer 26

Safeguard patients Maintain good health care delivery Enhance well being of health professionals Practioner health programme: * Located in an established GP surgery * Confidential * Separate IT systems * Separate staff * Separate rooms

Question 27

What resource is available for GPs who are struggling in England?

Answer 27

NHS GP Health Service * Objectives: * Retain in work * Return to practice * Reduce stigma NOT Occupational health and it does not replace the NHS

Question 28

What treatments are available in the GP health service?

Answer 28

* Assessment and case management provided by GPs, psychiatrists, and specialist mental health and addiction nurses * General psychiatry * Addiction psychiatry * Psychological therapies, e.g. Cognitive behaviour therapy (CBT) * Short term psychotherapeutic intervention * Local interventions groups (therapeutic groups to address specific issues affecting mental health in a particular area)

Question 29

What is the practical application of using the GMC guidance?

Answer 29

* Putting patients first * Being honest * Having the knowledge to practise medicine legally * Knowing one’s limitations * Being knowledgeable and keeping up to date * Treating people with dignity * Treating people consistently * Being able to admit you are wrong

Question 30

What are the 4 domains of good medical practice?

Answer 30

Knowledge, skills and performance Safety and quality Communication, partnership and teamwork Maintaining trust

Question 31

What is personal data?

Answer 31

Basically anything that you can use to identify somone •The GDPR defines personal data as: ‘any information relating to an identified or identifiable natural person (‘data subject’); an identifiable natural person is one who can be identified, directly or indirectly, in particular by reference to an identifier such as a name, an identification number, location data, an online identifier or to one or more factors specific to the physical, physiological, genetic, mental, economic, cultural or social identity of that natural person’

Question 32

What is the guidance regarding keeping personal information?

Answer 32

* Be processed lawfully, fairly and in a transparent manner * Be processed for specified, explicit and legitimate purposes and not in any manner incompatible with those purposes (this means that bascially it must be necessary) * Be adequate, relevant and limited to what is necessary in relation to the purposes (not too much not too little) * Be accurate and up to date * Must not be kept for longer than is necessary * Be secure.

Question 33

What does the equality act 2010 define protected characteristics as?

Answer 33

* age; * disability; * gender reassignment; * marriage and civil partnership; * pregnancy and maternity; * race; * religion or belief; * sex; * sexual orientation.

Question 34

What are the limbs of a successful megligence claim?

Answer 34

1. Failure in Ones Duty of Care (Falling below the standard) 2. ‘Foreseeable’ damage must result ‘Causation’ Wilsher v Essex Health Authority

Question 35

What are ethics?

Answer 35

•The body of moral principles or values governing or distinctive of a particular culture or group

Question 36

What are the duties of a doctor?

Answer 36

Make the care of your patient your first concern Treat every patient politely and considerately Respect patients dignity and privacy Listen to patients and respect their views Give patients information in a way they can understand Respect the rights of patients to be fully involved in decisions about their care Keep your professional knowledge and skills up to date Recognise the limits of your professional competence Be honest and trustworthy Respect and protect confidential information Make sure that your personal beleifs do not prejudice your patient's care Act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practice Avoid abusing your position as a doctor Work with colleagues in the ways that best serve patient's interests In all these matters you must never discriminate unfairly against your patients or colleagues. And you must always be prepared to justify your actions to them.

Question 37

What is meant by the duty of candour?

Answer 37

This means that you must be open and honest with patients when something goes wrong with a patient’s treatment or care which causes, or has the potential to cause, harm or distress. You must apologise to the patient and offer an appropriate remedy or support to put matters right (if possible) and explain fully the short and long term effects of what has happened. This duty requires you to be open and honest with all parties as well as any relevant organisations such as your employer, practice principal or the Health Authority or Board; you must take part in reviews and investigations when requested. You must raise concerns where appropriate if you believe a patient’s best interests potentially have been or actually have been compromised. As a doctor or a student you should encourage other peers and colleagues to be open and honest; you must not stop someone who has concerns from raising concern

Question 38

When is it okay to breach confidentiality?

Answer 38

“If you consider that failure to disclose the information would leave individuals or society exposed to a risk so serious that it outweighs the patient’s and the public interest in maintaining confidentiality, you should disclose relevant information promptly to an appropriate person or authority. You should inform the patient before disclosing the information, if it is practicable and safe to do so, even if you intend to disclose without their consent

Question 39

What is the effect of malicious unfounded criticism of colleagues on social media?

Answer 39

May unermine patients trust in the care or treatment they receive, or in the judgement of those treating them (rule 47 of social media guidance states: You must not make malicious and unfounded criticisms of colleagues that may undermine patients' trust in the care or treatment they receive, or in the judgement of those treating them.)

Question 40

Take home messages on social media guidance?

Answer 40

Strict privacy settings Respect colleagues and patients Be conscious of your online image and how it may affect your professional standing Do not accept patients as friends/followers Declare conflicts of interest Be aware of defamation laws

Question 41

Does your behaviour outside the clinic affect fitness to practice?

Answer 41

Yes 'your conduct at all times should justify your patients trust in you and the publics trust in the profession'

Question 42

If you do something unprofessional of a serious degree what will the GMC find you guilty of?

Answer 42

Infamous conduct in a professional respect

Question 43

What is the role of the GMC?

Answer 43

* Setting the standards for doctors * Overseeing doctors’ education and training * Managing the UK medical register * Investigating and acting on concerns about doctors * Helping to raise standards through revalidation

Question 44

What behaviours of a medical student might the GMC investigate?

Answer 44

* Criminal convictions or cautions – even when occurs outside of clinical environment. e.g. caution for drunken behaviour on holiday * Alcohol consumption that affects clinical work, the work environment, or performance in the educational environment. * A pattern of excessive misuse of alcohol. * Plagiarism/ cheating in exams. * Signing peers into sessions when they are absent. * Sharing with fellow students or others, details of questions or tasks from exams you have taken.

Question 45

What are potential reasons for a complaint?

Answer 45

Error Grief Poor understanding/poor explanation Unrealistic expectations Failure to appreciate needs/wishes of patient

Question 46

Why do patients sue?

Answer 46

**Predisposing factors;** Rudeness, inattentiveness, miscommunication **Precipitating events** Adverse outcome, iatrogenic injury, incorrect care, system errors

Question 47

What is the majority of litigation a result of?

Answer 47

Poor communication between doctor and patient

Question 48

What are the types of criminal allegations made against doctors?

Answer 48

Indecent assault Prescription fraud Manslaughter Murder Deception offences

Question 49

What is the time restraint for an informal complaint?

Answer 49

5 days In this time the complaints officer must decide if the complaint can be dealt with informally and also deal with the complaint to the satisfaction of the complainer. You must tell the complainer immedialetly if you wish to handle the complaint informally and then you must gain the complainer's agreement - DOCUMENT

Question 50

What is the time restraint for a formal complaint?

Answer 50

Must acknowledge within 3 working days

Question 51

When is a response required from a formal complaint procedure?

Answer 51

Full response is required within 20 days unless impossible - if this is the case then you must let the patient know when they will get their response and you must also give them reason for their delay.

Question 52

What can a patient do if they are unsatissfied with the response given from their complaint?

Answer 52

They can contact the complaints advisor again or they can go to the Public Services Ombudsman. Patients also have the right to claim for a judical review if they think they have been directly affected by an unlawful act or decision of an NHS body or individual

Question 53

Looking at the lectures, it appears that the public serivce ombudsman can take advice from professional unbiased practitioners to make an assessment of how the care was delivered. They can pick up where a health board went wrong and they can also pick out faults in the way the health board dealt with the complaint - for example not being open/transparent, failing to address concerns.

Question 54

What are possible systems of quality assurance and quality improvement?

Answer 54

Taking part in regular reviews and audits of your own work and that of your team, responding constructively to the outcomes, taking steps to address any problems and carrying out further training where necessary. Regularly reflecting on your standards of practice and the care you provide. Reviewing patient feedback where it is available.

Question 55

To keep patients safe you must:

Answer 55

Contribute to confidential inquiries. b. Contribute to adverse event recognition. c. Report adverse incidents involving medical devices that put or have the potential to put the safety of a patient, or another person, at risk. d. Report suspected adverse drug reactions. e. Respond to requests from organisations monitoring public health. When providing information for these purposes you should still respect patients’ confidentiality.

Question 56

Are you obliged to help in the community?

Answer 56

You must offer help if emergencies arise in clinical settings or in the community, taking account of your own safety, your competence and the availability of other options for care.

Question 57

What should you do if you suspect your health might be a detriment to practice? ( a condition you might pass on, or the condition / its treatment might affect your performance)

Answer 57

Must consult a suitably qualified colleague You must follow their advice about changes to your practice they consider necessary You must not rely on your own assessment of the risk to patients

Question 58

If you have a conscientious objection, what steps would you need to take?

Answer 58

You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient’s lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role.

Question 59

If a patient under your care has suffered harm or distress as a result of something going wrong, what should you do?

Answer 59

a. Put matters right (if that is possible) b. Offer an apology c. Explain fully and promptly what has happened and the likely short-term and long-term effects.

Question 60

When should you end a professional relationship with a patient?

Answer 60

When the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient

Question 61

When is it not acceptable to accept a gift from a patient?

Answer 61

If it affects or is seen to affect the way you prescribe for, treat or refer patients or commision services for patients

Question 62

So from reading through the slides there seems to be a common pattern with the role of the GMC - they are here mostly to make sure that doctors are able to practice safely and to maintain public trust in the profession.

Question 63

Who can you raise concerns with?

Answer 63

The consultant in charge of the team, the clinical or medical director or a practice partner

Question 64

When might you raise a concern directly to the GMC?

Answer 64

a. If you cannot raise the issue with the responsible person or body locally because you believe them to be part of the problem. b. If you have raised your concern through local channels but are not satisfied that the responsible person or body has taken adequate action. c. If there is an immediate serious risk to patients, and a regulator or other external body has responsibility to act or intervene.

Question 65

What is meant by the duty of candour?

Answer 65

This means that you must be open and honest with patients when something goes wrong with a patient’s treatment or care which causes, or has the potential to cause, harm or distress. If you are unsure of the consequences immediately seek the advice of an appropriate senior colleague to peer review your view and subsequently tell the patient (or the patient’s advocate, carer or family) when something has gone wrong even if the patient is not aware or has not complained.

Question 66

Are euthanasia and phsycian assisted suicide legal?

Answer 66

Not in the UK

Question 67

What is meant by the doctrine of double effect?

Answer 67

Doctors must not intend to hastnen death, but may in certain circumstances administer treatment that will hasten death

Question 68

When does the patient not get the treatment they desire?

Answer 68

If the doctor does not consider the particular medicine to be indicated - they can however ask for a second opinion

Question 69

When is family allowed to make decisions on behalf of the patient?

Answer 69

If they ahve been legally appointed proxy decision maker AND the patient lacks capacity

Question 70

When are patients deemed to be incapable?

Answer 70

–Patients can be presumed to have capacity –They are only ‘incapable’ if they are incapable of: 1. acting; or 2. making decisions; or 3. communicating decisions; or 4. understanding decisions; or 5. retaining the memory of decisions

Question 71

If the patient lacks capacity, what should the intervention take into consideratin?

Answer 71

Their past and present wishes The views of relevant others

Question 72

When might refusal of treatment be invalid? (advanced directive/advanced refusal of treatment)

Answer 72

–Refusal may be invalid if: 1. The patient is not capable at time of writing or is or has been duress (forced to do it) 2. There is reason to doubt authenticity •Does not apply if: 1. Treatment options have changed 2. Patient has acted in a way that suggests they have changed their mind So it does not apply if the patient has been forced to do it, you think that the advanced directive is fake, the treatment options have changed or you think that the patient has changed their mind

Question 73

Main points in social media guidance

Answer 73

Don't breach confidentiality Make sure that your conduct justifies your patients trust in you and the public trust in the profession as a whole Do not use social media to discuss professional issues Don't show anything that may cause distress Don't share univesity documents

Question 74

Defence organisations

Answer 74

MPS MDU

Question 75

What should you do if a patient tries to add you on social media?

Answer 75

If a patient does request you as a friend on a social networking site, send a polite message informing them that it is your policy not to establish online friendships with patients

Question 76

Who can get punished for defamation?

Answer 76

The original defamer but also the persons who repeat the statement

Question 77

What is a vulnerable adult according to the department of health?

Answer 77

The Department of Health defines a vulnerable adult as a person aged 18 years or over who is or may be in need of community care services by reason of mental or other disability, age or illness, and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation

Question 78

Who has the responsibility of safeguarding?

Answer 78

Everyone

Question 79

What are risk factors for abuse?

Answer 79

Lack of mental capacity. Increasing age. Being physically dependent on others. Low self-esteem. Previous history of abuse. Negative experiences of disclosing abuse. Social isolation. Lack of access to health and social services or high-quality information

Question 80

What are the main types of abuse?

Answer 80

Physical Sexual Psychological Financial or material (theft, fraud, expoloitation, pressure in connection with wills, property inheritance, or financial transactions, misuse or misappropriation of property, posessions or benefits. Neglect or acts of omission Discriminatory abuse Domestive Modern slavery Organisational abuse (neglect and poor care practice within an institution or specific care setting such as a hospital or care home) Self-neglect

Question 81

The Department of Health for England and Wales states six principles of good safeguarding practice....

Answer 81

Empowerment: presumption of person-led decisions and informed consent. Protection: support and representation for those in greatest need. Prevention: it is better to take action before harm occurs. Proportionality: proportionate and least intrusive response appropriate to the risk presented. Partnership: local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse. Accountability: accountability and transparency in delivering safeguarding.

Question 82

What is the definition of an adult at risk?

Answer 82

1. unable to safeguard their own well-being, property, rights or other interests; 2. at risk of harm; and 3. because they are affected by disability, mental disorder, illness or physical or mental infirmity, are more vulnerable to being harmed than adults who are not so affected.

Question 83

What might the appearance be of someone who is being abused?

Answer 83

An abused adult may seem withdrawn, unkempt, lose weight, and have poor skin care. Unexplained injuries. Personality changes such as withdrawal, aggressiveness, irritability and emotionally liable. This may be due to illness or may be due to neglect. It is important to establish whether the person can reach a drink, can feed him or herself and is able to ask for help.

Question 84

Managing the conversation with an individual when abuse is suspected

Answer 84

Make sure the alleged abuser is not present. It may be helpful for the potentially abused person to be accompanied by a trusted person. Ensure they have appropriate support to express themselves clearly, including an interpreter if necessary. Be clear what will happen with the information that the victim discloses. Establish the facts of the allegation of abuse and acknowledge the impact of the abuse on the victim. Making sure the potential abuser is not present when asking about concerns should help the abused person to talk openly. Being accompanied by a trusted person may help a vulnerable adult feel supported and more confident in sharing information

Question 85

When would you be required to pone 999/112/911 regarding the care of someone who is you suspect is being abused?

Answer 85

Circumstances that would require immediate action would include when someone’s life is in immediate danger or there is significant risk of serious harm Doctors assessing risk should also think about any risk posed to adults at risk other than the patient, to members of the public, or to children

Question 86

What are the local services responsible for safeguarding in england and Wales?

Answer 86

The local safeguarding investigating team

Question 87

Where are safeguarding roles set out for all organisations commissioning NHS health and social care?

Answer 87

The Accountability and Assurance Framework (AAF) sets out the safeguarding roles, duties and responsibilities of all organisations commissioning NHS health and social care

Question 88

What can the long-term effects of chid abuse be?

Answer 88

Lack of trust and relationship difficulties Feelings of being worthless or damaged Trouble regulting emotions

Question 89

What can the consequences of sexual abuse be?

Answer 89

Self-loathing Sexual problems as they grow older - often either excessive promiscuity or an inability to have intimate relations

Question 90

What are warning signs for emotional abuse in children?

Answer 90

Excessively withdrawn, fearful, or anxious about doing something wrong. Shows extremes in behaviour (extremely compliant or extremely demanding; extremely passive or extremely aggressive). Doesn’t seem to be attached to the parent or caregiver. Acts either inappropriately adult (taking care of other children) or inappropriately infantile (rocking, thumb-sucking, throwing tantrums).

Question 91

What are warning signs for physical abuse as a child?

Answer 91

Frequent injuries or unexplained bruises, welts, or cuts. The child is always watchful and “on alert,” as if waiting for something bad to happen. Injuries appear to have a pattern such as marks from a hand or belt. The child shies away from touch, flinches at sudden movements, or seems afraid to go home. The child wears inappropriate clothing to cover up injuries, such as long-sleeved shirts on hot days.

Question 92

What are warning signs of child abuse and neglect?

Answer 92

Clothes are ill-fitting, filthy, or inappropriate for the weather. Hygiene is consistently bad (un-bathed, matted and unwashed hair, noticeable body odour). Untreated illnesses and physical injuries. The child is frequently unsupervised or left alone or allowed to play in unsafe situations and environments. The child is frequently late or missing from school.

Question 93

What are risk factors for child abuse and neglect?

Answer 93

Untreated mental illness Lack of parenting skills Stress and lack of support

Question 94

Act assocaited with child abuse

Answer 94

Children Act 1995?

Question 95

When is it okay to disclose information to a person who has close contact with a patient who has a serious communicable disease?

Answer 95

If you have reason to think that - The person is at risk of infection that is likely to result in serious harm - The patient has not informed them and cannot be persuaded to do so The identity of the inected person doesn't have to be disclosed to the person they are contacting