Ethics formative Flashcards
What are the 3 types of consent?
Implied
Verbal
Written
What act allows doctors to allow in the best interest of patients when they lack capacity?
Mental capacity act 2005 (england)
Adlts with incapacity act (scotland)
What are the key features of the mental capacity act 2005?
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
Who can consent?
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.
In the mental capacity act, who is described as lacking capacity?
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
When making decisions on behalf of someone, how can you peserve their freedom?
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
What is the definition of adult and unable according to the adults with incapacity act Scotland?
“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
What is the office of public guardians?
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.
What is the role of the mental welfare comission?
Protect people with an intervention or guardianship order
Visit the adult - bring matters of importance to health boards or local authorities
What does the continuing power of attorney relate to?
Finance and property
What does the welfare attorney relate to?
Personal welfare
What is the responsiblity of the solicitor when creating a power of attorney / welfare of attorney order?
- They must have interviewd the patient immediately before the granting
- He must take measures to ascertain that the patient knows the nature and the power of the order
- Makes sure there are no external factors / stressors
- 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!
When is research allowed on people with incapacity?
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
When might it not be possible to go through the consenting process?
- Patient unconscious?
- Patient does not have capacity?
- Expediency?
- Cannot communicate?
What is meant by Gillick Competency?
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
What is an advanced directive?
It is made when the person has capacity for the potential future where they lack capacity - preferred treatment/non-treatment is outlined
What steps must be taken to make the advanced directive valid?
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)
What predisposing factors might increase chances of making mistakes as a doctor?
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
What is the effects of alcohol and drugs in the workplace?
–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
What are the barriers to seeking help?
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
What are individal and organisational means to cope with stress/mental health at work?
•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)
What is meant by resilience?
•The ability to withstand and bounce back from adversity
What determines the capacity for resilience?
–Self-directedness
•strongest correlation with resilience
–Co-operativeness
–Harm avoidance
–Persistence
WHat are predictors of resilience?
•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
What people are most resilient?
Being female
Maintaining work life balance (relaxation, meditation, exercise, help-seeking)
Laughter/humour
Beliefs/ spirituality
Self-reflection/insight/mindfullness
Professinoal identity
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)
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
What resource is available for GPs who are struggling in England?
NHS GP Health Service
- Objectives:
- Retain in work
- Return to practice
- Reduce stigma
NOT Occupational health and it does not replace the NHS
What treatments are available in the GP health service?
- 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)
What is the practical application of using the GMC guidance?
- 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
What are the 4 domains of good medical practice?
Knowledge, skills and performance
Safety and quality
Communication, partnership and teamwork
Maintaining trust
What is personal data?
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’
What is the guidance regarding keeping personal information?
- 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.
What does the equality act 2010 define protected characteristics as?
- age;
- disability;
- gender reassignment;
- marriage and civil partnership;
- pregnancy and maternity;
- race;
- religion or belief;
- sex;
- sexual orientation.
What are the limbs of a successful megligence claim?
- Failure in Ones Duty of Care
(Falling below the standard)
- ‘Foreseeable’ damage must result
‘Causation’
Wilsher v Essex Health Authority
What are ethics?
•The body of moral principles or values governing or distinctive of a particular culture or group
What are the duties of a doctor?
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.
What is meant by the duty of candour?
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
When is it okay to breach confidentiality?
“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
What is the effect of malicious unfounded criticism of colleagues on social media?
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.)
Take home messages on social media guidance?
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
Does your behaviour outside the clinic affect fitness to practice?
Yes
‘your conduct at all times should justify your patients trust in you and the publics trust in the profession’
If you do something unprofessional of a serious degree what will the GMC find you guilty of?
Infamous conduct in a professional respect
What is the role of the GMC?
- 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
What behaviours of a medical student might the GMC investigate?
- 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.
What are potential reasons for a complaint?
Error
Grief
Poor understanding/poor explanation
Unrealistic expectations
Failure to appreciate needs/wishes of patient
Why do patients sue?
Predisposing factors;
Rudeness, inattentiveness, miscommunication
Precipitating events
Adverse outcome, iatrogenic injury, incorrect care, system errors
What is the majority of litigation a result of?
Poor communication between doctor and patient
What are the types of criminal allegations made against doctors?
Indecent assault
Prescription fraud
Manslaughter
Murder
Deception offences
What is the time restraint for an informal complaint?
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
What is the time restraint for a formal complaint?
Must acknowledge within 3 working days
When is a response required from a formal complaint procedure?
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.
What can a patient do if they are unsatissfied with the response given from their complaint?
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
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.
What are possible systems of quality assurance and quality improvement?
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.
To keep patients safe you must:
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.
Are you obliged to help in the community?
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.
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)
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
If you have a conscientious objection, what steps would you need to take?
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.
If a patient under your care has suffered harm or distress as a result of something going wrong, what should you do?
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.
When should you end a professional relationship with a patient?
When the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient
When is it not acceptable to accept a gift from a patient?
If it affects or is seen to affect the way you prescribe for, treat or refer patients or commision services for patients
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.
Who can you raise concerns with?
The consultant in charge of the team, the clinical or medical director or a practice partner
When might you raise a concern directly to the GMC?
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.
What is meant by the duty of candour?
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.
Are euthanasia and phsycian assisted suicide legal?
Not in the UK
What is meant by the doctrine of double effect?
Doctors must not intend to hastnen death, but may in certain circumstances administer treatment that will hasten death
When does the patient not get the treatment they desire?
If the doctor does not consider the particular medicine to be indicated - they can however ask for a second opinion
When is family allowed to make decisions on behalf of the patient?
If they ahve been legally appointed proxy decision maker AND the patient lacks capacity
When are patients deemed to be incapable?
–Patients can be presumed to have capacity
–They are only ‘incapable’ if they are incapable of:
- acting; or
- making decisions; or
- communicating decisions; or
- understanding decisions; or
- retaining the memory of decisions
If the patient lacks capacity, what should the intervention take into consideratin?
Their past and present wishes
The views of relevant others
When might refusal of treatment be invalid?
(advanced directive/advanced refusal of treatment)
–Refusal may be invalid if:
- The patient is not capable at time of writing or is or has been duress (forced to do it)
- There is reason to doubt authenticity
•Does not apply if:
- Treatment options have changed
- 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
Main points in social media guidance
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
Defence organisations
MPS
MDU
What should you do if a patient tries to add you on social media?
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
Who can get punished for defamation?
The original defamer but also the persons who repeat the statement
What is a vulnerable adult according to the department of health?
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
Who has the responsibility of safeguarding?
Everyone
What are risk factors for abuse?
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
What are the main types of abuse?
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
The Department of Health for England and Wales states six principles of good safeguarding practice….
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.
What is the definition of an adult at risk?
- unable to safeguard their own well-being, property, rights or other interests;
- at risk of harm; and
- 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.
What might the appearance be of someone who is being abused?
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.
Managing the conversation with an individual when abuse is suspected
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
When would you be required to pone 999/112/911 regarding the care of someone who is you suspect is being abused?
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
What are the local services responsible for safeguarding in england and Wales?
The local safeguarding investigating team
Where are safeguarding roles set out for all organisations commissioning NHS health and social care?
The Accountability and Assurance Framework (AAF) sets out the safeguarding roles, duties and responsibilities of all organisations commissioning NHS health and social care
What can the long-term effects of chid abuse be?
Lack of trust and relationship difficulties
Feelings of being worthless or damaged
Trouble regulting emotions
What can the consequences of sexual abuse be?
Self-loathing
Sexual problems as they grow older - often either excessive promiscuity or an inability to have intimate relations
What are warning signs for emotional abuse in children?
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).
What are warning signs for physical abuse as a child?
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.
What are warning signs of child abuse and neglect?
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.
What are risk factors for child abuse and neglect?
Untreated mental illness
Lack of parenting skills
Stress and lack of support
Act assocaited with child abuse
Children Act 1995?
When is it okay to disclose information to a person who has close contact with a patient who has a serious communicable disease?
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
