Governance/Ethical Flashcards
Father is giving depot
- Professionalism
Autonomy - ?consent
Benefience/non mal:
-examine pt, rule out severe side effects such as parkinsonian
-check dose of med given
-depot prescription is a specialised treatment and involves specialist team
-unsupervised depot prescription can result in harm
Boundary violation - prescribing medication to family is outside scope of practice - Educator and collaborator
-psychoeducation about boundary violation
-clear advice to avoid further prescribing
-advice father to contact medicolegal
-inform about medicolegal obligations of mandatory reporting - Seek advice by medicolegal about mandatory reporting or hospital legal team
Complaint about doctor when unwell
If patient harm -> mandatory reporting obligations to AHPRA
Discuss with medicolegal insurance or hospital legal team, follow local service notification guidelines
Discuss with service clinical director
Dont discuss the patient’s details without the patient’s consent
Benefience - be sensitive about location of admission, preferably in private hospital distant of where the pt works
Return to work with gradual support - involvement of HR, OHS, peer support groups, addressing any stressors that are barriers
Causes for change in behaviour (parent)
Patient factors:
1. Acute stress reaction
2. Exacerbation of underlying psychotic illness due to stressors
3. Frustration and anger w treating team
4. Substance use related irritability and anger, being used as coping mechanism
Staff factors
1. Poorly broken bad news
2. Lack of time given to father to ask qs
3. Unable to vent anger and hostility
4. Lack of cultural sensitivity
System factors
1. Transference and countertransference issues
2. Lack of continuity of care
3. Regularly changing staff affecting therapeutic alliance
Principles of Informed Consent
- Presumed to have capacity regardless of their age or whether they are under MHA
- Adequate information
-proposed treatment, purpose, type and method and duration of tx
-advantages and disadvantages, risks
-answers to any relevant questions to influence their decision
-relevant statement of rights - Reasonable opportunity
-adequate time
-opportunity to discuss w doctor
-reasonable support
-opportunity to seek advice or assistance to make decision - Freedom from undue influence
-consent given freely, no coercion from any one else inc dr - Not withdrawn consent
-verbally or in writing
-behaviour indicating lack of consent
Patient complains about reg
Ask to read the complaint to hear what pt is complaining about. Get perspective of registrar
Use hospital protocols to respond to complaint e.g. medicolegal dept
Likely needs a written response from consultant or clinical director
Offer to assist written response
IIMS?
Reg well being
How is the patient feeling about the complaint
Offer to meet with registrar or liaise with supervisor for support
Consider discussing with DOT, director and peer supports respecting confidentiality
Advise reg to contact MDO
Consider QI processes as an outcome of the complaint to improve practice
Principles of supervision
Collaborative goal setting approach in a safe environment for issues to be raised, reflective practice and constructive learning
At least 4 hours, one on one clinical work for one hour per week
Assist with passing of exams, self guided learning
Monitor interaction with pts, peers and other medical staff
Discuss performance with DOT if needed
Strategies to overcome challenges
Availability to participate in WBAS and end of term reports
Formative and summative feedback
Principles of effective feedback
-Summative or formative
-Goal of formative to provide ongoing feedback to improve learning
-Goal of summative to evaluate learning at the end of a unit or rotation by comparing against standard or benchmark
-Feedback one on one or in group setting
-Flag that feedback is formative - on direct observation of behaviours
-Aim to develop a climate of trust
-Feedback not personally humiliating or in an angry, threatening or disrespectful manner
-Environment where the trainees can ask qs about how they can improve. Frank and direct but respectful and constructive
-Start with strengths then feedback. Finish on positive note with enhancing statement
-Give direction and invite for comments
Principles of using interpreter
Preinteraction info
-ensure interpreter is certified and registered
-obtain consent from pt
-ensure appropriate language
-ensure confidentiality (interpreter isnt from a small community that can breach)
-preinteraction info and briefing
-explain to interpreter about goal of interview
Interview
-speak slowly and clearly
-simple terms where possible
-speak to pt not interpreter
-clarify any confusing responses immediately
-ask for verbatim translation if translation is not clear. avoid taking notes
-concentrate on non verbal behaviours of the patient
Post interview discussion
-meet for feedback
-opinion on normality, speed of convo, any aspects not culturally appropriate or away from cultural norms
Explain what a RCA is
-analysis used to identify underlying causes of system failure
-clinical risk managers and other HCWs use to help find answers to qs posed by serious incidents
-ensure accountable, responsible and is underpinned by continuous quality improvement
-for high risk high impact events
-identify critical incident to be reviewed
-arrange a committee that involves clinical risk personnel to evaluate it, which consists of a consumer, possibly carer, team member directly or indirectly involved, consultant and clinical director
-focus on systems and processes, to avoid scapegoating
-problem solving methodology using analytic methods. TFEI (thoroughness, fair, efficient, independent rv)
-verify the incident, commission a RCA team, map a timeline, identify critical events, analyse cause and effect chart, identify root causes, support root causes with evidence, find solutions, provide recommendations
Teaching session for ECT
-evidence based therapy for a number of psychiatric conditions
-indications (RANZCP) are treatment resistant MDD (including melancholic), psychotic depression, peri partum onset, bipolar disorder (resistant mania and depression), depressed not responding to treatment, need for rapid clinical improvement, inadequate oral intake or suicide risk, high level of pt distress, some evidence in treatment resistant scz
Background
-efficacy and response rate: for unilateral with melancholic and psychotic depression who have failed >1 medication trials are as high as 48%
-psychotic depression: remission up to 95% and non psychotic depression up to 83%
-can reduce suicidal thoughts, actions or gestures up to 70% after 9 sessions
Administration and prescription
-Dosing: establish seizure threshold (lowest electrical dose that elixits seizure activity as on EEG or visible motor method. methods to establish: empirical dose titration, age related or half age method)
-Electrode placement (BT, BF, RUL)
-Pulse width (1.0ms) - ECT dosing up to 6x threshold for unilateral while 1.5-2x for bilateral. Ultrabrief: 0.25-0.3ms
-Session frequency - no of tx required is guided by progress and clinical improvement. courses consist of 6-12 treatments
-Concomitant meds
-Anesthetic approach: preECT evaluation by anaesthetist. Ensure threshold not excessively elaveted by drugs or dosage. Commonly used thiopentone and propofol.
Pre ECT ax and informed consent
-explanation of tx
-methodology and process
-adverse events and SEs
-risk of transient anterograde and retrograde cognitive impairment
-irreversible retrograde memory loss particularly if bitemporal
-what to be expected before during and after administration
-involve families and carers in process and take into account any advance directives
-make aware second opinion can be obtained
-can withdraw consent at any time during ECT
Monitoring
-MOCA or brief ECT cognitive screen + neuropsych if needed
Post ECT
-evaluation of EEG parameters e.g. adequate postictal suppression
-evaluation in suite for any delirium, cognitive impairment
-BL ultra brief to reduce cognitive side effects
Possible causes of stigma to psychiatry
Family related
-culturally alternative explanatory models of illness
-negative attitudes to western models of care
-belief in alternative or culturally alternative treatments - traditional healing
-religious beliefs
Treatment factors
-lack of trust in services
-previous negative experiences with MH services
-distrust of authority
-belief treatment will change personality or make the situation worse
Illness related
-belief that MI is a sign of wakness
-MI linked to pt’s own will
System related
Cost
Time
Lack of cultural or gender sensitivity
Quality improvement/audit
Steps in audit
-identify process to be reviewed
-establishing a gold standard e.g. literature review, speaking to colleagues, peer review groups, comparing with other services
-identifying the discrepancy (quantitative aspects) deviation from peers and how much?
-identifying causes for discrepancy:
-patient factors (higher presentation of __, greater awareness in community, good mental health literacy in community)/clinical factors (other psychiatrists, lack of training, attitudes) - /system factors (lack of psychiatrists, GPS, pharmaceutical marketing, conferences)
Self reflection
Implement solutions to manage the discrepancy
-independent peer review
-advice about appropriate training
-conferences, CPD
-grand round discussion or peer review group to obtain open and transparent understanding
Qualitative analysis
-why rather than statistics
Medicolegal insurance, good documentation, second opinions, working within guidelines
Reaudit in 6months - 1 year
Doctor Impairment
Legal considerations with confidentiality – doctor notification
o Clarify/reflect on your role – psychiatrist or colleague, friend – discuss with line manager
o It is the chief executives responsibility to make notification to AHPRA if its required
o Keep doctor informed, and suggest they seek legal advice from MDI
o Professional, legal and ethical obligations – statutory obligations that need to be followed
o Duty to warn – if safety concern is present then doctor should take leave immediately
o Maintaining privacy and confidentiality – of the doctor, and limits
o Clinical governance – corporate risk, documentation and referral processes
o Support from registration board
o Local and external help/advice
Causes for doctor impairment
o Personal causes
Language and cultural factors
Stressors at home
Finances
Relationships
Alcohol and drugs
Mental illness
Physical illness
o External causes
Exams
Bullying
Lack of debriefing
Lack of support
Nature of work
Lack of orientation
Unsupportive colleague
o System causes
Poor rostering
Long hours
Stressful job
Funding issues within the service
