H & S Flashcards
1
Q
Beauchamp and Childress developed the Four Principles of Biomedical Ethics in 1978. They identified four principles that must be considered and balanced against each other in order to provide ethical healthcare.
A
Autonomy- patient should be provided with enough information and support to make their own informed decision about their healthcare, and this decision should be respected.
beneficence- care should always be “doing good”, i.e. acting in the patient’s best interests
non-maleficence - care should not cause a patient harm.
Justice- relates to the fair and equal distribution and access to healthcare resources.
2
Q
Health education
A
give people knowledge & skill to change potentially health damaging behaviours, e.g. advice from health professionals, mass media campaigns.
3
Q
Health protection
A
legislation to protect public health, e.g. not smoking inside, pollution, seat belts.
4
Q
Give approaches to health promotion
A
- Health persuasion e.g. campaigns, posters
- Legislative action e.g. smoking bans in public places, pollution regulation, car seat belts, fluoride in water
- Personal counselling e.g. opportunistic prevention in one-to-one setting, community settings with youth or community workers
- Community development e.g. food cooperatives
5
Q
Validity
A
assuming the premises are true, does the conclusion follow logically?
6
Q
Sound
A
are the premises of the argument actually true?
7
Q
BASIC REPRODUCTIVE NUMBER (R0) =
A
avg no. of individuals directly infected by an infectious case, in a totally susceptible population.
Determined by virulence factors, therefore specific to microorganism + population. Proportionate to:
- Length of time infectious case remains
- Number of contacts a case has with susceptible hosts, per unit time.
- Chance of transmission during one of these encounters (depends on pathogen’s innate virulence)
Doesn’t fluctuate in short term, not affected by vaccination, is a property of infectious agent. Can differ for same organism in different populations.
8
Q
EFFECTIVE REPRODUCTIVE NUMBER (R or RE) =
A
is the average number of secondary infections produced by a typical infective agent, if this number is greater than 1 then it is impossible to eradicate an infection. Since for every one eradicated a new one will appear.
Usually smaller than R0, and reflects impact of control measures and <100% susceptibility in a population.
R = R0 x S
9
Q
Requirements for eradication of a disease
A
- No other reservoirs of infectious agent (animals/environment)
- Scientific and political prioritisation of specific agent has to exist (money + time more available) - result of infection being serious and common
- Examples of eradicated diseases - polio and smallpox
10
Q
Herd Immunity =
A
large portion of a community (the herd) becomes immune to a disease (due to vaccination usually) such that it is difficult for the disease to spread (because there are not as many people who can be infected)
The formula for calculating the herd-immunity threshold is 1–1/R0
11
Q
Managing side effects of vaccines:
A
○ Prophylactic medication (i.e. paracetamol and ibuprofen)
○ Space out vaccines
○ Yellow cad system
○ Monitoring post vaccine
○ Ability to access healthcare if experience side effects
○ Make sure those with underlying conditions have advice (i.e. von Willerband Factor deficiency should take a dose of Transexamic Acid before the COVID vaccine)
12
Q
Primary disease prevention
A
prevent onset of disease; hard for some conditions as hard to know when onset of disease is (could be before symptoms come on ) = address cause of causes, e.g. cause of obesity that causes DM
Different types:
Universal (whole population)
Selective (risk group)
Individual (identify high risk individuals, e.g. genetic mutations)
13
Q
Secondary disease prevention
A
cure / identify disease earlier, e.g. screening
14
Q
Definition of screening
A
Application of a test to identify individuals at sufficient risk of a disorder to warrant investigation or direct preventative action, amongst persons who have not sought medical attention on account of symptoms
15
Q
Screening test requirements
A
- The condition being screened for should be an important health problem
- The natural history of the condition should be well understood
- There should be a detectable early stage (pre-clinical and/or risk factor, long enough so there is chance of detection)
- Treatment at an early stage should be of more benefit than at a later stage
- A suitable test should be devised for the early stage
- The test should be acceptable
- Intervals for repeating the test should be determined
- Adequate health service provision should be made for the extra clinical workload resulting from screening
- The risks, both physical and psychological, should be less than the benefits
- The costs should be balanced against the benefits
16
Q
Tertiary disease prevention
A
manage disease
17
Q
Breast screening
A
50 - 70
Mammography
Routine Repeat after 3 years
18
Q
Bowel screening
A
60 to 74 sent FIT test every 2 years
19
Q
term used to describe the phenomenon that only a proportion of symptoms experienced by patients lead to a consultation
A
‘Symptoms iceberg’
70% of symptoms are never reported.
20
Q
Triggers for seeking healthcare:
A
Interference with work / hobbies / house work
Interference with social relations
Interpersonal crisis = death of relative / friend, divorce, loss of child etc.
Putting a time limit on symptoms = will seek help if not resolved by certain time
Sanctioning = told to be someone else
21
Q
Black Report conclusions on inequalities in health care:
A
Statistical artefact (not genuine) Natural selection (less well become poorer) Materialistic exploitation of the lower socioeconomic classes Cultural / behavioral explanations
determinants of health inequalities
- Healthy people move up the classes
- Poverty causes ill health
- Life style differences
- Social selection
22
Q
Barriers influencing access to care
A
provision/availabilty of services cultural/family attitudes previous bad experience logistics risk perception
23
Q
Exercise guidelines
A
150 minutes of moderate intensity exercise OR 75 minutes of vigorous intensity per week = minimum of 30 mins each time
2x muscle strengthening activity per week
Limited time sat sedentary
Balance & co-ordination twice a week in elderly
24
Q
National Service Frameworks:
role
A
“Policies set by NHS to define care standards for major diseases (Cancer, CHD, COPD, DM etc.) or for specific patient groups (elderly, palliative care)”
1) Set formal quality requirements, based on best evidence for / against treatments and services
2) Offer strategies / support to help organisations attain these
25
Who is involved in National service frameworks
Department of Health = create the strategy, after identifying need for one
Strategic Health Authority = implement + manage it
Consultation with patients, carers, public, charities, healthcare professionals and industry
26
Epidemic:
Occurrence in a community / region of cases of an illness / health-related behaviour clearly in excess of normally expected
27
Endemic:
Persistent, usual, or expected level of disease in a given population
28
Pandemic:
Epidemic over a very wide area, crossing international boundaries
29
Adverse event
“An unintended event resulting from clinical care and causing patient harm (physical or psychological)”
very preventable and common
eg prescribing error
30
Near miss:
events or omissions arising during clinical care but not developing far enough to cause injury to a patient i.e. not an adverse event.
31
Never event:
serious patients safety incidents that should not occur if the available preventative measures have been implemented
e.g. wrong site surgery / retained instrument in surgery / wrong chemotherapy admin route / inpatient suicide using collapsible rails / postpartum haemorrhage = maternal death after elective C-section / IV administration of concentrated KCl
32
For successful negligence claim relating to treatment/diagnosis, 3 things need to be proven
Causation
Duty: a duty of care existed between doctor and patient
Breach: the doctor's practice fellow below the standard of care expected
33
Bolam v Bolitho
Bolam Test is used to see if the doctor's actions are supported by a responsible body of medical opinion.
If they are not, then there has been a breach in the duty of care.
If they are, then the Bolitho Test is applied.
Bolitho Test is used to scrutinise if the actions undertaken by the doctor and supported by the medical opinion are logical.
If they are not, then there has been a breach in the duty of care.
If they are, then the duty of care has not been breached.
34
Most common errors
Prescribing = wrong dose, drug, route of admission
Communication failure
Delay / failure in diagnosis
Obstetricians get sued the most (around 85% have been sued at some point)
35
Duty of Candour
1. Must tell patient when something has gone wrong
2. Must apologise & offer appropriate resolution
3. Must explain the potential short & long-term effects
36
Common complaints:
- Safety issues
- Poor / insufficient information
- Ineffective clinical practice, including poor coordination of discharge
- Poor handling of complaints ie failure acknowledge validity / to apologise / jargon in response / not explained what done
- Lack of dignity / respect / poor attitudes of staff
- Failure to follow consent procedure
- Poor environment including poor hygiene
37
What is standardised mortality ratio (SMR)?
Ratio between observed number of deaths in a study population to the number of expected deaths
38
Calman-Hine Report (1995)
Concluded unacceptable variation in quality of treatment between hospitals = services were disjointed & outcomes were poor
Highlighted need for strategic clinical cancer networks
- So would be better to centralize treatment to improve quality, with primary care at the center of this
- Should ensure all patient have equal access to care
- Public & professionals educated on recognizing early signs
- Services should be patient centered, given clear info on treatment options & outcomes
- Cancer registration & monitoring of outcomes is essential
- Psychosocial needs of carers & patient recognized
39
Cancer Networks (34 in total) – 3 levels of care:
```
Primary Care - prevention & early diagnosis
Cancer Unit (1 per 250,000) - treat common cancer, make diagnosis (non-complex chemo & surgery)
Cancer Center (1 per million) - treat rare cancers, radiotherapy, complex chemotherapy & surgery
```
40
Role of strategic cancer networks/what they do:
development of strategic plans for delivering better care
bring together those who use, provide and commission services to make improvements in outcomes for complex patient pathways using an integrated, whole system approach
Implementation of national policies
Deliver the improvements in care
Provide a channel for communication between groups across the network
Provide resources for audits and research
41
benefits of strategic cancer networks
Accurate studies on epidemiology of different cancers- useful for guiding future research
Commision care in a way to reduce inequalities in care throughout the SCN region , Reduces postcode lottery
Reduces incidence of cancer - through better screening programs and greater focus of cancer in primary care
Maximise survival of CA patients
Enhance quality of life of patients and families
Improve the patient experience of cancer services
42
Concentraing specialist care in cancer centres
pros- better case management of less common conditions
cons- increased geographical inequalities in cancer service provision, barriers to accessing care ( cost of travel, effort)
43
National Cancer Research Network:
Established in 2001
They support and promotes recruitment of patients into cancer trials and improves the speed of research into clinical practice to ensure patients receiving best possible and up to date care
Closely matched to cancer networks to improve patient numbers etc.
44
National Cancer Research Institute:
created to develop common plans for cancer research and to avoid unnecessary duplication of studies / effort
Established in 2001
Roles:
Invest in facilities + resources for research
Maintain cancer research database and analyze new research
Develop research initiatives
Coordinate clinical trials for new drugs
45
The audit cycle:
1. Identify the issue
2. Obtain or define standards Find the guideline which you are going to compare your data to
3. Collect data/measure current performance
4. Compare performance with standards and identify causes of non achievement
5. Implement change
6. Re-audit
46
Why audit?
Improves patient care by identifying shortcomings
Provides opportunities for clinical education.
Assess progress against national standards.guidelines are based on best evidence so important that they are closely followed on the front line in hospital
Financial benefits. Can check Services running efficiently and resources used appropriately
Fulfils contractual obligation
Encourages teamwork
47
Limitations audit
```
The only thing you are comparing to is current best practice
May not always help
Costs time, money and resources
If it doesn't change anything, resources have been wasted
‘Snapshot’ nature of information
Lack of generalisability
Accuracy of data collection
Size of results examined
```
48
Research ethics principles - Nuremberg Code
1. Voluntary consent is required
2. Should yield results beneficial to society that cannot be acquired by other means
3. Based on animal experimentation and a knowledge of natural history of the disease
4. Avoid all unnecessary physical and mental suffering
5. Should not be performed if there is a reason to believe the intervention is harmful
6. Risk should not exceed the benefits
7. Preparations and facilities should be provided to protect subjects and injury, disability, or death
8. Should be conducted by scientifically qualified people
9. Subjects should be able to leave whenever they wish
10. Scientists in charge must be prepared to end the experiment is there is evidence of harm (or likely to be)
49
Incidence:
Number of new cases over a period of time
New cases of disease within a period / number initially free of disease
50
Prevalence:
Number of cases present in a population at a given time
Number of people with disease at particular point in time / total population
Changes as people die/emigrate/are cured
51
10 legal requirements for a post-mortem:
Sudden / unexpected death
Unknown cause of death / unnatural death (accident / suicide / suspicious)
History of violence or substance abuse, alcoholism etc.
Death may be due to a medical procedure either invasive or not
Industrial disease death
Death from negligence
Death within 24 hours of admission
Not seen by doctor for 14 days
Patient detained under MHA
Receiving war pension / industrial disability pension unless death shown to be unconnected
52
For consent to be valid it must me
voluntary informed and patient must have capacity
to make consent informed the patient must be provided with basic overview of their condition, likely outcome of their decision, their treatment options including a second opinion
53
Name three statutes that oblige physicians to disclose information without the consent of the patient.
Public Health (Control of Diseases) Act 1984 (Notifiable diseases)
Abortion Act 1967
Birth and Deaths Registration Act 1953
Road Traffic Act 1988
Human Fertilization and Embryology Act 1990
NHS Venereal Diseases Regulations 1974
Prevention of Terrorism Act 1989/terrorism act 2000
Drug trafficking act 1986
54
Criteria to fulfil when breaching confidentiality under a public interest defence
A risk of harm needs to be identified
Patient consent should be gained if possible
You do not need to attempt to gain consent if doing so would put you at risk of serious harm, or would prejudice the prevention, detection or prosecution of crime.
The patient should be warned that disclosure will be made
Disclosure should be made on a need-to-know basis (i.e. only to the relevant people)
The disclosures made should be kept to a minimum (i.e. only disclosing relevant information)
The information should be anonymised, if possible.
55
Impairment
- Temporary or permanent loss or abnormality of body structure or function
- May be functional, physiological or psychological
eg amputated leg/ muscle pain
56
Disability
Restriction of normal activity from impairment
Lack of ability to perform an activity in the manner/within a range considered normal
eg walking
57
Handicap
Limits or prevents the fulfilment of a role that is normal for that individual
eg going to shop
58
Human Rights acts relevant to healthcare
- Article 2 = right to life
- Article 3 = prohibition of torture (or inhuman or degrading treatment of punishment)
- Article 5 = right to liberty and security
- Article 6 = right to a fair trial
- Article 8 = right to respect for private and family life
- Article 9 = freedom of thought, conscience and religion
- Article 10 = freedom of expression
- Article 12 = right to marry and found a family
- Article 14 = prohibition of discrimination
59
Chance of conception
People who are concerned about their fertility should be informed that over 80% of couples in the general population will conceive within 1 year if:
- the woman is aged under 40 years and
- they do not use contraception and have regular sexual intercourse.
Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate over 90%)
aginal sexual intercourse every 2 to 3 days optimises the chance of pregnancy.
60
causes of infertility
```
○ Male/ Sperm problems (30%)
○ Ovulation problems (25%)
○ Tubal problems (15%)
○ Uterine problems (10%)
○ Unexplained (20%)
```
61
Consider unstimulated intrauterine insemination as a treatment option in the following groups as an alternative to vaginal sexual intercourse:
people who are unable to, or would find it very difficult to, have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem who are using partner or donor sperm
people with conditions that require specific consideration in relation to methods of conception (for example, after sperm washing where the man is HIV positive)
people in same-sex relationships.
62
Intracytoplasmic sperm injection (ICSI)
Same as IVF but instead of allowing the insemination mixing, sperm are injected into oocytes.Indicated when quality of sperm is poor/low sperm count or when pregnancy has failed in the past
63
IVF criteria according to NICE if <40
In women aged under 40 years who have not conceived after 2 years of regular unprotected intercourse or 12 cycles of artificial insemination (where 6 or more are by intrauterine insemination), offer 3 full cycles of IVF, with or without ICSI. If the woman reaches the age of 40 during treatment, complete the current full cycle but do not offer further full cycles.
In women aged under 40 years any previous full IVF cycle, whether self- or NHS-funded, should count towards the total of 3 full cycles that should be offered by the NHS.
64
IVF criteria according to NICE if >40
In women aged 40–42 years who have not conceived after 2 years of regular unprotected intercourse or 12 cycles of artificial insemination (where 6 or more are by intrauterine insemination), offer 1 full cycle of IVF, with or without ICSI, provided the following 3 criteria are fulfilled:
1. they have never previously had IVF treatment
2. there is no evidence of low ovarian reserve
3. there has been a discussion of the additional implications of IVF and pregnancy at this age.
65
CCGs may have additional criteria you need to meet before you can have IVF on the NHS, such as:
not having any children already, from both your current and any previous relationships
being a healthy weight
not smoking
falling into a certain age range (for example, some CCGs only fund treatment for women under 35)
66
Human Fertilization & Embryology Act 1990
Established the Human Fertilisation and Embryology Authority = statutory body that regulates and inspects all clinics in the United Kingdom providing IVF, artificial insemination and the storage of human eggs, sperm or embryos. It also regulates human embryo research
“Women should not be provided with treatment unless account has been taken of welfare of any child who may be born as a result (including need for a father)”
2008 revision of father to supportive parenting
67
Ethical scenario IVF
FOR
- procreative autonomy: respect patient choices, minimalize state interference
- infertility can affect mental health
- welfare interest of future child
AGAINST
- embryos have moral status (destruction of embryos)
- harm to those conceive (OHSS, multiple, ectopics)
- Positive rights: no obligation to provide parents with means to have children
- Negative right: obligation not to interfere with peoples decision to have children
68
Abortion Act 1967 (amended 1990)
Must meet 1 of the following criteria:
1. Pregnancy not 24+ weeks, and continuation would involve risk (of injury to physical/mental health of woman/existing kids) greater than that of termination
2. Termination >24 weeks if necessary to prevent grave permanent injury (physical/mental), including saving mothers life
3. Substantial risk that child, when born, would suffer serious handicap (due to physical / mental abnormalities)
69
Anti-Abortion (“pro-life”):
1. Abortion ends life of foetus --> foetus has moral status of person --> wrong to end life of something with this moral status -->Abortion is morally wrong = justice
2. Abortion is doing harm = non-maleficence
3. Can lead to medical complications later in life both physical & psychological = non-maleficence
4. Many couples are looking to adopt & abortion is depriving them of this option = justice
5. Religious reasons
6. abortions for Down’s syndrome – suggest they have a lower moral status than other children
70
Pro-abortion:
1. Even if foetus is human, what about risk to mothers life? = non-maleficence
2. Foetus isn’t alive so doesn’t have the rights of a human --> especially as most take place at a stage where foetus wont survive =non maleficence
3. Banning will just encourage the use of unsafe & harmful methods = beneficence
4. Women should be able to avoid the emotional harm of bearing a child by rape = non-malificence
5. May be due to a contraceptive failure / mistake and pregnancy may reduce quality of life for mother and she may not be able to provide good quality of life for future child = beneficence
6. Will allow women in teenage years to achieve full potential = justice
7. women have right to decide what happens to their body/pregnnacy (autonomy)
71
Ethical scenario: Down’s syndrome screening
| FOR
- allows parents to prepare and plan
| - gives them an informed choice if they want to terminate
72
Ethical scenario: Down’s syndrome screening
| AGAINST
- risk of false positive and negatives
- spontaneous abortion with diagnostic testing (1%)
- suggesting Down’s syndrome life is less important
73
cervical screening programme
Ages 25-49 invited every 3 years
| Ages 50-64 invited every 5 years
74
most common sexually transmitted infection in the UK
Chlamydia
75
National Chlamydia Screening Programme
aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner. Everyone that tests positive should have a re-test three months after treatment. This re-testing is to ensure they have not contracted chlamydia again
76
Preventing HIV transmission:
- media campaigns
- education in school
- testing HIV and counselling
- ART
- condom use, Distribution of condom for free espiecally amongst high risk places, e.g. brothels
- contraception reduces the risk man to woman by 50%.
- treat chlamydia and gonorrhea as these facilitate HIV transmission during sex.
- IVDU and needle change
- Effective post-exposure prophylaxis
- HIV mothers not breastfeeding
- Limiting number of sexual partners
77
most common non-viral sexually transmitted infections worldwide
Trichomonas vaginalis- a protozoan, and is a single-celled organism with flagella.
78
female genital mutilation (FGM)
'all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons'.
Type 1
Partial or total removal of clitoris and/ prepuce (clitoridectomy)
Type 2
Removal of clitoris and labia minora (w/wo excision of labia majora)
Type 3
Narrowing of vaginal orifice creating a seal by cutting and appositioning the labia minora and/or labia majora with/ without excision of clitoris
Type 4
All other harmful procedures for non-medical purposes e.g. pricking, incising, scraping
79
Laws around FGM
ANY form of FGM is AGAINST the law in the UK INCLUDING REFIBULATION AFTER DELIVERY ( stitching up again) It carries a 14 year prison sentence
Law + child protection
Female Circumcision Act 1985 made it criminal to
Excise, infibulate or otherwise mutilate the whole or any part of the labia majora or labia minora or clitoris of another person
Aid, abet, counsel or procure a girl to mutilate her own genitalia
Law Updated
Female Genital Mutilation Act 2003 which added a further criminal offence
Aid, abet, counsel or procure another person who is not a UK national to mutilate a girl’s genitalia outside the UK
80
Most common gynae cancers
1. endometrial
2. ovarian
3. cervical
4. vulva
81
Complications of Domestic Abuse in obstetrics and gynaecology
```
higher rate of miscarriage
premature birth & LBW
fetal injury & death
premature labour & delivery
chorioamnionitis & maternal infections
poor weight gain
Violent pregnancies are high risk
```
82
Recommendations for domestic violence issues in obstetrics and gynaecology
Routine enquiry.
A named midwife should be responsible for and provide the majority of the antenatal care to a woman who has experienced domestic abuse.
Women should be given the opportunity to disclose domestic abuse in an environment in which they feel secure.
83
Alerts for domestic violence
```
Late booker/poor attender
Repeat minor injury attendance
Unexplained admissions
Depression/anxiety/self harm
Injuries of different ages (minimalisation)
STD/UTI/vaginal infections
Poor obstetric history
Domineering partner
```
84
Risk factors of significant harm or neglect to any child who may be born or to any existing child
1. Past or current circumstances that may lead to any child experiencing serious physical or psychological harm or neglect,
2. Previous convictions relating to harming children
3. Child protection measures taken regarding existing children, or violence or serious discord in the family environment
4. Past or current circumstances that are likely to lead to an inability to care throughout childhood for any child who may be born, or that are already seriously impairing the care of any existing child of the family, for example;
a. mental or physical conditions,
b. Drug or alcohol abuse.
c. Medical history, where the medical history indicates that any child who may be born is likely to suffer from a
serious medical condition,
d. Circumstances that the centre considers likely to cause serious harm to any child mentioned above.
85
Epidemiology non melanoma skin cancers
BCC is the commonest form of skin cancer. It is 4-5x more common than squamous cell carcinoma (SCC).
86
Epidemiology Melanoma
In the UK, it accounts for approximately 4% of all new cancers.represents the fifth most common cancer.
M>F
87
Premalignant lesions
actinic keratosis and Bowen’s disease
88
Counsel patients on appropriate sun protection behaviours
SMART ways to avoid excessive sun exposure
Spend time in the shade between 11am-3pm
Make sure you never burn
Aim to cover up with a t-shirt, wide-brimmed hat and sunglasses
Remember to take extra care with children
Then use Sun Protection Factor (SPF) 30+ sunscreen
89
Dx Hypertension
clinic blood pressure of 140/90 mmHg or higher and
| ABPM daytime average or HBPM average of 135/85 mmHg or higher.
90
<80 y HTN target
below 140/90 mmHg
| abpm/hbpm: below 135/85 mmHg
91
> 80y HTN target
below 150/90 mmHg
| abpm/hbpm: below 145/85 mmHg
92
diabetes HTN target
135/85 mmHg - type 1 diabetes.
| 130/80 mmHg - albuminuria or 2 or more features of metabolic syndrome
93
CKD and ACR ratio under 70 mg/mmol HTN target
aim for below 140 mmHg (target range 120 to 139 mmHg) and a clinic diastolic blood pressure below 90 mmHg.
94
CKD and an ACR ratio of 70 mg/mmol or more HTN target
aim for below 130 mmHg (target range 120 to 129 mmHg) and a clinic diastolic blood pressure below 80 mmHg
95
HTN target in pregnancy
135/85 mmHg.
96
services for patients with visual impairment and deafness impairment
organisations like royal institution of blind/deaf people , charity eg deafblind uk,vision aids, hearing aids ,braille
97
Tests for downs syndrome- more likely if ..
beta hcg - increased
papp-a - reduced
AFP- reduced
Inhibit A - increased
98
Stillbirth definition
is when a baby is born dead after 24 completed weeks of pregnancy/ 1000 births
99
Stillbirth epidemiology
1 in every 200 births in England.
| Findings Globally in 2019, an estimated 2·0 million babies were stillborn at 28 weeks or more of gestation
100
Perinatal mortality definition
perinatal mortality rate = number of stillbirths + early neonatal deaths per 1000 total births - WHO definition
the perinatal period commences at 22 completed weeks (154 days) of gestation, and ends seven completed days after birth"
101
Neonatal mortality:
Death of a live born infant --> 28 days
| Early neonatal = < 7 days
102
Maternal mortality
Includes up to 42 days post-pregnancy if is due to any cause related to or aggravated by the pregnancy
Doesn’t include incidental RTA etc.
103
Risk factors for still birth
```
Foetal growth restriction is biggest
Congenital anomaly
Multiple pregnancy
Age of extremes of maternity (<25/>40)
Obesity
Smoking
Obstetric complications APH/PPH
Geographical variation
Ethnicity Black or Asian have significantly higher rates
Lower socioeconomic status
```
104
Preventing still birth
not smoking
avoiding alcohol and drugs during pregnancy
not going to sleep on your back after 28 weeks
attending all your antenatal appointments
taking folic acid before pregnancy and having a flu vaccine during your pregnancy
limiting the amount of caffeine
Better supervision during labour/identifying women at risk in labour such as placental abruption/cord prolapse
Identifying babies not doing well eg infection and providing antibiotics quickly etc
105
Preterm definition
A premature infant is an infant born before 37 weeks' gestation.
Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm
106
Risk factors for prematurity
intra-uterine infection
preterm premature rupture of membranes (PPROM)
pre-eclampsia/pregnancy-induced hypertension
placental abruption/antepartum haemorrhage
abnormal amniotic fluid volume
severe bacterial vaginosis
multiple gestation
previous preterm birth/family history
foetal abnormality
cervical incompetence/uterine abnormality
gestational diabetes
maternal surgery during pregnancy
chronic maternal illness
maternal pregnancy body mass index <19 or >35
short interpregnancy time interval
drug use (tobacco, cocaine, heroin)
stress/depression
non-white race
107
Preterm complications
low oxygen levels at birth, hypothermia, trouble feeding and gaining weight, respiratory distress syndrome, infection and necrotising enterocolitis, brain injury IVH
108
Low birth weight definition
weight lower than 2.5 kg 5 pounds, 8 ounces.
| Normal range of weight for babies is around 3200 -3600g
109
Causes of low birth weight
born premature
IUGR-could be due to problems with the baby’s health, the mother’s health of the placenta. Often related to pregnancy associated hypertension
infection during pregnancy, smoking, alcohol or drug use.
Globally, malaria and malnutrition
110
Causes of low birth weight
born premature
IUGR-could be due to problems with the baby’s health, the mother’s health of the placenta. Often related to pregnancy associated hypertension
infection during pregnancy, smoking, alcohol or drug use.
Globally, malaria and malnutrition
111
Sudden infant death syndrome (SIDS) definition
sudden unexplained death in an infant. It is sometimes referred to as “cot death”. This usually occurs within the first six months of life. In the UK 230 babies die unexpectedly and suddenly.
112
SIDS risk factors
```
Prematurity
Low birth weight
Smoking during pregnancy
Parental smoking
Male baby (only slightly increased risk)
Co sleeping with adult
Sleeping on soft surface
Sleeping on stomach/front
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Measures to reduce the risk of SIDS
Put the baby on their back when not directly supervised
Keep their head uncovered
Place their feet at the foot of the bed to prevent them sliding down and under the blanket
Keep the cot clear of lots of toys and blankets
Maintain a comfortable room temperature (16 – 20 ºC)
Avoid smoking. Avoid handling the baby after smoking
Avoid co-sleeping, particularly on a sofa or chair
If co-sleeping avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers
The lullaby trust is a charity to help support families affected. Bereavement services and bereavement counselling should be available for affected families.
The Care of Next Infant (CONI) team supports parents with their next infant after a sudden infant death.
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congenital dysplasia of the hip
caused by abnormal development of the hip joint.In DDH, the socket of the hip is too shallow and the femoral head is not held tightly in place, so the hip joint is loose. In severe cases, the femur can come out of the socket
115
Risk Factors for DDH
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Female sex
First born
positive family history
breech presentation
postural deformity
can be associated with foot and spine abnormalities like talipes
restricted intrauterine space
incorrect lower-extremity swaddling
```
more common in the left hip
More common if European origin.
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DDH Screening
Checked in NIPE within 72h of birth
ultrasound scan of their hip between 4 and 6 weeks old if a doctor, midwife or nurse thinks their hip feels unstable.
US if childhood hip problems in first degree family,baby was in the breech position in the last month of pregnancy (at or after 36 weeks), or baby was born in the breech position after 28 weeks of pregnancy
in the case of multiple births with these risk factors, all babies in the pregnancy should have a hip ultrasound
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Living with a chronic condition, its effects on young person
Distress for patients and family
Chronic burneder of disease- never a break from regimen
Impairs spontaneity esp as its likely to be food related
How is emotional distress expressed eg parents might be anxious, can reinforce mentality for children
Time off school and difficulty completing coursework and exams
Feeling different to friends
Needing to plan day meals medications etc
Increased dependence on parents at at time of when independence is normally developing Impact on employment eg t1d and being a pilot,epilepsy and driving
Future fertility eg cf
Life expectancy eg cf
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Why might a young person miss their medications ?
Poorly developed abstract thinking and planning. They genuinely forget!
Difficulty in imagining the future self . Feels “Bullet proof”
Rejection of medical professional as part of NORMAL peer identification and separation from parents
Side effects of treatment unacceptable to young person eg weight gain with insulin, “spaced out” feeling of anticonvulsants
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legislation that sets out basic human rights of all children up to 18 years of age and responsibilities of countries to uphold these
United nations convention on the rights of the child 1989
Article19 Governments should ensure that children are properly cared for and protect them from violence, abuse and neglect by their parents, or anyone else who looks after them.
Children act 2004 is an updated version
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Children’s Act 2004 Section 17
places duty on local authorities to provide support and services for children in need. child is in need -> parents need to change their behaviour.
121
Children’s Act 2004 Section 47
places duty on local authorities to make enquiries in cases where there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. child is at risk of significant harm -> child needs to be removed from the household.
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if you are concerned that the young person might be at risk of significant harm
Make a note of your concerns and observations
Discuss with senior medical and nursing colleagues
Discuss what you are going to do and why with the child and their parent(s) or carer(s) - as long as this does not put them at increased risk
Notify and refer to children's social services by phone. In an emergency (e.g. the child absconds or parent tries to take the child), call the police
Participate in a strategy discussion with social services, police and other agencies (e.g. school)
If the strategy discussion concludes the young person is at risk of significant harm, a Section 47 Child Protection enquiry should be called
After completion of the enquiry, a case conference is held
The case conference decides whether or not the young person should be placed on the Child Protection Register and subject to a Child Protection Plan
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Burns and children
- children < 5 suffer 45% of all burns and scald accidents, usually in kitchen (hot water, irons, ovens)
- consider sunburn (sunscreen, hat, out of sun)
- get smoke alarms, don’t smoke near bed/sofa
- keep hot objects out of their reach
124
Types of childhood accidents
Babies = burns, scalds and being dropped
Toddlers = falls, burns, scalds, POISONING
Older children = falls
125
methods of prevention of childhood injury/accidents
road safety and use of cycle helmets, gates on stairs, safety in kitchen, smoke alarms, protection against fire hazards, covering electric sockets and keeping medicines/poisons out of reach
Choking: hold them when feeding, cut food into small bits, sit with child
Suffocation: no loose bedding, dispose of plastic bags safely
Falls: careful carrying baby, strap a child in high chair
Poisoning: CO alarms, medicines out of reach
Drowning: never leave baby in bath alone
Road accidents: correctly fitting rear seat every journey
126
Worrying NAI signs
- Explanation for injury absent or unsuitable
- Child is not independently mobile
- Injury on an area that wouldn’t come into contact with hot surface e.g. soles of feet, back, buttocks
- Injury in the shape of an object e.g. iron, belt etc. well demarcated
- Delayed presentation
- Evasive or changing history
- Inconsistency between age of injury and examination findings
- Signs of restraint on limbs
- Excessive multiple bruises of different ages
- spiral/ metaphysis fractures
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Risk factors child maltreatment
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Chronic disease
Disability
Social isolation
Poverty and poor housing.
Unplanned pregnant
Challenging behavioural needs
wrong gender
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toxic trio:
Parental mental health
Domestic violence and abuse
Parental substance misuse
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Sexual abuse in children
- recurrent GU symptoms (enuresis, constipation, soiling)
- abdo pain
- self harm
- alcohol/drug misuse
- pregnancy
- emotional/behavioural problems
- sexualized behavior
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Neglect:
- persistent failure to meet child’s basic physical and psychological needs
- poor interactions, poor growth, poor dental health, cleanliness, missed appointments
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Emotional abuse:
- persistent emotional maltreatment such as to cause severe and persistent adverse effects on a child or young persons emotional development.
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Definition safeguarding
“Action to promote the welfare of children and protect them from harm”
Protect from maltreatment
Prevent impairment of health and development
Ensure that children grow up in circumstances consistent with provision of safe and effective care
Take action to enable all children to have good outcomes
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Healthy child programme
all children receive a basic service with increased input according to a child or family's needs
Encouraging a strong bond between parents and child and helping parents enhance their parenting skills
Promoting children from serious diseases through immunisation and screening
Promoting healthy eating, physical activity and reducing obesity
Identifying problems in children's health and development ( such as learning difficulties) and safety ( such as parental neglect) and directing families for help
Making sure children are ready for school
Identifying and helping children with problems that may affect their changes in later life
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Health promotion in school
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Nutrition
Dental health
Physical activity
Reducing risk factors for obesity
Drugs and alcohol abuse
Contraception and safe sex
Sti
Smoking
Healthy relationships
Caring for young children
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Consequences of poor early health
Start life in poor health > LD + poor mental health, poor diet
Adolescents > leave school early, physically inactive
Adulthood: mortality risk, physical/mental health, social stigma
135
Children exposed to passive smoking are at increased risk of
sudden infant death syndrome, middle ear disease, lower respiratory tract illness and asthma.
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Conditions for valid consent
Under the Mental Capacity Act, there are a number of conditions that have to be met for valid consent to be obtained from a patient:
1. The patient must have capacity.
2. The consent must be freely given (i.e. uncoerced) and the patient must be suitably informed (i.e. have been given a suitable level of detail of the procedure, and expected outcomes and risks).
137
Mental Capacity Act (MCA) 2005 key principles
Capacity is assumed; it needs to be proven otherwise
Enabling people to make their own decisions
Unwise decisions
Best interests
Less restrictive option
138
Capacity
A person can consent to treatment provided he or she is competent to understand the nature, purpose and possible consequences of the treatment proposed
• understand its principal benefits, risks and alternatives;
• understand in broad terms what will be the consequences of not receiving the proposed treatment;
• retain the information for long enough to use it and weigh it in the balance in order to arrive at a decision.
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Fraser (Gillick) competence
A young person under 16 can consent to treatment provided he or she is competent to understand the nature, purpose and possible consequences of the treatment proposed . eg contraception or sexual health treatment
140
Competent for fraser if
- The young person understands the doctor’s advice.
- The doctor cannot persuade the young person to inform his or her parents
- The young person is very likely to begin or continue having sexual intercourse with or without contraception
- The young person’s physical or mental health or both are likely to deteriorate if he or she does not receive contraceptive treatment
- The young person's best interests require the doctor to give contraceptive advice or treatment or both without parental consent
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children and consent
People aged 16 or over are entitled to consent to their own treatment.
Children under the age of 16 can consent to their own treatment if they're believed to have enough intelligence, competence and understanding to fully appreciate what's involved in their treatment. This is known as being Gillick competent.Otherwise, someone with parental responsibility can consent for them.
If a young person refuses treatment, which may lead to their death or a severe permanent injury, their decision can be overruled by the Court of Protection.
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Transition of care definition
“a purposeful, planned process that addresses the medical, psychological and educational/ vocational needs of adolescents and young adults with chronic physical and medical conditions as they move from child centred to adult-oriented health care systems”
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Ingredients of a good programme
Discuss the matter during childhood and as the young person grows up
Acknowledge issues facing both the patient and his/her parents
Identify colleagues who have an interest in young adults who may supervise them
Select a health worker (family practitioner, nurse etc.) who may supervise the transfer
Organised common meetings with the new team
Secure some follow-up phone calls
Identify individuals (adults, peers) who can give support
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Primary prevention diabetic eye disease
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Glycaemic control
Blood pressure control
Lipid control
Healthy balanced diet and exercise
Smoking cessation
```
screening every year
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Optometrists:
Opthalmologist:
Orthoptists:
Optometrists: examine eyes for defect in visions and screening for diseases
Opthalmologist: operations on eye, work in eye hospitals/ departments
Orthoptists: work with ophthalmologist, concerned with eye movement and inability for eyes to work together e.g. strabismus, amblyopia, diplopia
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causes of squint
Refractive errors, especially hypermetropia.
Other causes of poor visual acuity (including occular malformations, optic neuropathy, amblyopia (lazy eye) congenital cataract, and retinoblastoma.
Neurodevelopmental conditions/ syndromes (cerebral palsy and downs syndrome)
Congenital abnormalities of the extra-ocular muscles or their innervation, such as Brown’s syndrome and Duane's syndrome.
Diseases that can affect one or more of the extra-ocular muscles or their innervation, such as brain tumours, other brain lesions, head injury, post-viral problems, hydrocephalus, and muscle disorders (for example myasthenia gravis).
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Blindness in children:
- high income: lesions of optic nerve, higher visual pathways
- lower income: measles, vitamin A deficiency, rubella, corneal scarring
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blindness epidemiology
● Causes worldwide: Cataracts > Glaucoma > ARMD > Corneal opacity > Trachoma > Childhood (vit A deficiency)
● Causes in developed world: ARMD > Congenital causes > Cataract > Glaucoma > Diabetes
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Routine screening for eyes
NIPE- 72h of birth
6 week check
At school entry (around 4 or 5 years of age), vision screening is offered
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Newborn hearing screening
automated otoacoustic emissions (AOAE). if test is abnormal they can do Automated auditory brainstem responses (AABR)
AABR is also used with AOAE for babies who have spent over 48 hours in the Special Care Baby Unit or Neonatal Intensive Care Unit
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Distraction test
6-9 months
Performed by a health visitor, requires two trained staff.Sounds are produced to the right or left of the baby out of their field of view and the loudness required until they react to these is assessed
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Recognition of familiar objects
18 months - 2.5 years
| Uses familiar objects e.g. teddy, cup. Ask child simple questions - e.g. 'where is the teddy?'
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> 2.5 years hearing tests
Performance testing
| Speech discrimination tests- ssess the child's ability to understand speech and differentiate it from background noise.
154
Pure tone audiometry
> 3 years
| Done at school entry in most areas of the UK
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Risk factors VTE
* Recent surgery, especially abdominal/pelvic or hip/knee replacement.
* Thrombophilia, eg antiphospholipid syndrome
* Leg fracture.
* Prolonged bed rest/reduced mobility eg travel
* Malignancy.
* Pregnancy/postpartum; combined contraceptive pill; HRT (lower risk).
* Previous PE.
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possibility of fractures as an indicator of non-accidental injury
rib fracture
multiple fractures
Injuries to the long bones were invariably spiral or oblique fractures or subperiosteal new bone formation--both "gripping or twisting" injuries eg Spiral fracture of the humeral shaft
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Signs of burn NAI
Delay in seeking medical attention.
The details of the mechanism of injury are implausible, change over time, or are inconsistent with the developmental stage of the child
Lack of concern by the person accompanying the child.
Abnormal behaviour or demeanour by the child e.g. withdrawn
Direct disclosure by the child that the injury was deliberately inflicted.
Lines of demarcation ( glove and stocking, donut sparing)
No splash marks
Sparing of flexor creases
Maybe circumferational
history form different carers slightly different
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health promotion with relation to burns and scald
Keep hot drinks away from kids
Keep toddler out of kitchen
Double check temperature of bath for child, don't leave kid <5 alone
Make sure hot items out of reach while they cool down
Hats and reapply sunscreen for kids, encourage them to play in shade
keep babies under the age of 6 months out of direct sunlight, especially around midday
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Paediatric palliative care conditions
Life-threatening for which curative treatment is feasible, e.g. malignancy
Premature death inevitable, where may be long periods of intensive treatment, e.g. CF
Progressive conditions without curative treatment options, e.g. DMD
Irreversible but non-progressive conditions causing severe disability leading to susceptibility to health complications & likelihood of premature death
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Hospices in paediatric palliative care
Can provide symptom control & respite stays, along with support at the home
Specialists in play, music & art therapists, chefs includes support to sibling
Most hospices have refrigerated bedrooms allowing time with child after death
Support for family & siblings, including for funeral & for months / years to come
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Level 0
Patients whose needs can be met through normal ward care in acute hospital
Majority of inpatient wards
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Level 1
Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team
Could be a part of the AMU or nurse enhanced unit
May have lower GCS
4 to 1
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Level 2
HDU areas
Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those stepping down from higher levels of care
2 to 1
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Level 3
ICU
Patients require advanced respiratory support alone ( if on a ventilator will be sedated) or basic respiratory support (e.g. nasal high flow) together with support of at least 2 organ systems. This level includes all complex patients requiring support for multiorgan failure.
1 to 1 nursing
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epilepsy driving restrictions
first unprovoked/isolated seizure: 6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met then this is increased to 12 months
for patients with established epilepsy or those with multiple unprovoked seizures:may qualify for a driving licence if they have been free from any seizure for 12 months
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Syncope driving restrictions
simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off
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stroke driving restrictions
single TIA: must not drive for 1 month but need not notify DVLA.
People who have multiple TIAs: must not drive for 3 months and must notify DVLA. Driving may resume after 3 months if there have been no further TIAs.
People who have had a stroke must not drive for 1 month but may not need to notify DVLA. Driving may resume after 1 month if there has been satisfactory clinical recovery. DVLA does not need to be notified unless there is residual neurological deficit 1 month after the episode and, in particular: visual field defects, cognitive defects, impaired limb function.
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social and medicolegal implications of a diagnosis of epilepsy
Education for patient, carers, family, friends colleague
Avoiding stimulants
Implications on jobs eg pilot
Safety: driving, heights, open water swimming- drowning risk
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impact of untreated inflammatory arthritis
severe damage to joints, lead to disability, and harm major organs.
cardiovascular disease
infection
also known to be associated with higher risks for lymphoma, anemia, osteoporosis, and depression.
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Back pain Red flags – associated with potentially serious secondary physical pathologies.
Age of onset <20 years (inflammatory spinal conditions) or >55 years (malignancy or vertebral fractures)
Recent trauma (sudden onset) important to exclude fractures
Nocturnal pain
Thoracic pain
Pain not relieved with rest (shows its not mechanical)
Past history of malignancy
Osteoporosis risk (increased risk of vertebral fractures)
Infection risk (immunosuppression, IVDU)
Systemic features (fever, weight loss) need to rule out malignancy and infection
Progressive neurological signs/bladder/bowel dysfunction (cauda equina, spinal cord compression)
Structural deformity ( ankylosing spondylitis, fractures)
Spinal (rather than paraspinal) tenderness.
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Back pain Yellow flags – potential psychosocial pathologies that may prolong recovery/influence outcome.
Belief that pain and activity are harmful
Abnormal sickness behaviour (extended rest)
Low/negative mood
Work environment (low support/dissatisfaction)
Seeking treatments that seem excessive/inappropriate
Ongoing litigation
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Complimentary therapy
Osteopathy-Tough physical manipulation, stretching and massage, goof for back pain, sports injuries
Chiropractor- dx, treat and prevent MSK – more manual treatments for back, neck, shoulder
evidence: small benefit after a year
recommend for lower back pain and osteoarthritis
Acupuncture- Release neurohumoral and endorphins.
NICE recommend for headache and migraine.
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end of life pain
Total Pain= Physical + Emotional + Social + Spiritual
•Physical- disease related, treatment related, debility, other health conditions e.g. arthritis
•Emotional- depression, anxiety, loneliness, guilt
•Social- financial worries, relationships with loved ones, loss of role
•Spiritual- religious uncertainty, feeling lost, uncertainty of the future
-Background Pain: pain that is consistently/ permanent
-Breakthrough/ Incidental Pain: transient, exacerbation of pain that occurs on movement or in relation to a trigger
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Euthanasia
an act of ending a patient’s life to relieve suffering
175
```
Types of euthanasia:
Active -
Passive -
Voluntary -
Non-voluntary -
Involuntary -
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Active - does the act of ending life
passive - withholds life-prolonging treatment = patient can consent to this & make advanced directives to refuse this
Voluntary - when person dying consent
Non-voluntary - when person dying can’t consent, so make decision for them, often based on statement of wishes
Involuntary - against persons wishes = murder
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Arguments for euthanasia
1. Allows patient autonomy to control own body & how one dies
2. Is already done in some sense --> DNACPR is passive & sedation to shorten life by ending suffering in palliative = as being carried out anyway may as well legalize
3. Acts in beneficence of patient
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Arguments against euthanasia
1. Religious --> only God has right to end human life
2. slippery slope- could change attitudes regarding human lives --> very ill may feel have to accept, may hinder research in cures to conditions, misdiagnosis could lead to euthanasia when death wasn’t imminent
3. Violates non-maleficence --> could lead to lack of respect for terminally ill / feel like doctor wants to kill them!
4. Detracts from instead improving end of life care = good quality should solve the suffering and thus the problem (does palliative care remove the need for euthanasia?)
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Situations where a patient and their loved one may request euthanasia
terminal diagnoses where cure is not possible (cancer, MND, Dementia, many), loss of function (e.g. C-spine injuries) or when a patient is in a coma (little brain activity, loved ones request)
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Physician Assisted Suicide:
“Suicide by a patient facilitated by means (as a drug prescription) or by information (as an indication of a lethal dosage) provided by a physician who is aware of the patient's intent”
Unlike euthanasia, it is not legally equivalent to murder because the final act is done by the patient themselves. However, it is still illegal in the UK under the Suicide Act 1961 and can result in a sentence of up to 14 years.
Assisted dying is legal in some countries (e.g. Switzerland), and so some people from the UK have been known to travel abroad to end their lives.
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How doctors should respond to requests for euthanasia / assisted suicide according to GMC:
Be prepared to listen and to discuss the reasons for the patient’s request
Limit any advice or information to:
- An explanation that it is a criminal offence for anyone to encourage or assist a person to commit or attempt suicide
- Objective advice about the lawful clinical options (e.g. sedation and other palliative care) which would be available if a patient were to reach a settled decision to kill them self.
Be respectful and compassionate and continue to provide appropriate care for the patient
Explore the patient’s understanding of their current condition and care plan
Assess whether the patient has any unmet palliative care needs, including pain and symptom management, psychological, social or spiritual support
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Principles of palliative care as outlined by WHO
The prevention and relief of suffering of adult and paediatric patients and their families facing the problems associated with life-threatening illness’
Enhances quality of life
Promotes dignity and comfort, positively influences course of illness
Early identification, assessment and treatment of issues
Supports bereaved family members after a patient’s death
Does not intentionally hasten death
Accessible at all levels and integrated into disease management
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Types of nurses:
- district nurse: community based, generic skills, hands on
- practice nurse: practice based, general palliative care
- marie curie: community based, district nurse for palliative care/ terminal illness
- macmillan: community/hospital, cancer.
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Definition of Advanced Decisions
An Advanced Decision, short for Advanced Decision to Refuse Treatment, is a legally binding document. Its purpose is to ensure that an individual can refuse a specific treatment(s) that they do not want to have in the future.
184
Advanced Decision Criteria
In order for an Advanced Decision to be legally binding, it must meet certain criteria:
It must be valid (this means it must have been made at a time when the individual had capacity to make that decision).
It must be applicable (this means the wording must be specific to the medical circumstances, and not vague or unclear).
It must have been made when the individual was over 18, and fully informed about their decision.
It must not have been made under the influence or duress of other people
It must be written down, be signed and witnessed (if it concerns a refusal of life-saving treatment)
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Definition of Advanced Statement
An Advance Statement is sometimes called a "Statement of Wishes and Care Preferences". It allows an individual to make general statements about their wishes, beliefs, feelings and values and how these influence their preferences for their future care and treatment.
An Advance Statement is not by itself legally binding, but legally must be taken into consideration when making a "best interests" decision on someone's behalf under the Mental Capacity Act (MCA), 2005. This is because one of the criteria of the MCA is that a patient's "wishes, feelings, beliefs and values" must be taken into consideration; an Advanced Statement provides evidence of this.
186
Information that can be included in an Advanced Statement can be anything that is important to the individual.
Religious or spiritual views, and those that might relate to care
Food preferences
Information about your daily routine
Where you would like to be cared for (in hospital, at home, in a care home etc.)
Any people who you would like to be consulted when best interests decisions are being made on your behalf (however this does not give the same legal power as creating a Lasting Power of Attorney)
187
End of Life Strategy 2008
promoting high quality care for all adults at the end of life
Framework for local services to use to deliver end of life care
188
gold standard framework
a practical systematic, evidence-based approach to optimising care for all people nearing the end of life.The motto of GSF is ‘right person, right care, right place, right time, every time’
189
When to consider making a DNAPCR decision.
- cardiac/respiratory arrest likely to be part of dying process and CPR will not be successful > advanced decision.
- last hours/ days spent in their preferred place of care
- CPR may be successful, clinical outcomes may still be bad – consider risk/benefit
of treatment.
- may want CPR even if unlikely to be successful.
190
Colin Murray Parkes’ four phases bereavement
numbness, yearning/anger, disorganization/despair, re-organization.
191
3 main types of moral theory in medical ethics
1. Consequentialism = the best overall outcome is achieved
2. Deontology = duty-based, according to moral rights/duties. May have more negative consequences
3. Virtue = the good and right thing to do, what a 'virtuous' person would do
192
Doctrine of ‘double effect’
explains how we can accept an action if the intention is to cause a 'good outcome' (e.g. pain relief), even if it may foreseeably lead to a 'bad outcome' (e.g. death).
193
Recognised stages of grief- Elisabeth Kubler-Ross
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Denial
Anger
Depression
Bargaining
Acceptance
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194
Colin Murray Parkes and psychologist John Bowlby stages of grief
Shock and Numbness:
Yearning and Searching:
Disorganization and Despair:
Reorganization and Recovery:
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assessment of suicide risk.
Can use SAD PERSONS assessment scale
- assess reasons for self-poisoning, suicidal intent, difficulties, psychiatric disorders, risk assessment in future, social support.
- SAD PERSONS: < 6 outpatient; 6-9 emergency psych evaluation; > 9 inpatient
- sex (male) (1)
- age (<19, > 45) (1)
- depression (1)
- previous attempts (1)
- excessive alcohol or drug use (1)
- rational thinking loss (2)
- single/ divorced (1)
- organized or serious suicidal attempt (2)
- no social support (1)
- stated future intent (2)
< 16y and self-poisoned admit to paeds ward.
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Types of accommodation:
- sheltered accommodation w warden control: live in own flat but communal areas, maybe pull cords with responder system
- residential homes: staffed by carers but not nurses, not suitable for complex behavior or mobility issues
- nursing homes: nurses and carers: dependent and higher care needs.
197
RF: Substance misuse in the elderly
physical mental health, long term prescription (painkillers, hypnotics, anti-anxiety), bereavement, retirement, boredom, loneliness, homelessness and depression.
198
Lasting Power of Attorney (LPA)
If an individual wants to legally appoint someone they trust to make decisions on their behalf in the future if they lose capacity, they can do this by making a lasting power of attorney (LPA). Usually an individual chooses a close relative or friend to be their "attorney", who is given legal power to make decisions about their health and care if they lose capacity at some point in the future.
An individual's attorney can make decisions about health and care decisions, including:
Where an individual should live, what care or treatment they should receive, decisions about their daily routine (food, activities, etc.). If special permission has been given, an attorney can also make decisions about life-saving treatment.
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Independent Mental Capacity Advocates (IMCAs)
IMCAs are used when an individual lacks the capacity to make a specific important decision, when there is no-one independent of services (e.g. a family member or friend) appropriate to represent the individual lacking capacity.
IMCAs support and represent the individual who lacks capacity, ensuring the Mental Capacity Act, 2005 is followed.
200
Court of Protection
The Court of Protection is a court that if applied to, can make decisions about an individual's health, welfare, finances and property under the Mental Capacity Act 2005.
The types of decisions the court can rule on include:
Whether an individual has capacity to make a decision, whether a decision is in an individual's best interests, removing an attorney under a lasting power of attorney.
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Legal requirements of post mortem examination
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Sudden death
Unknown cause of death
Unnatural death - accident/suicide/suspicious
Death from industrial disease
Death from negligence
Death during surgery/anesthesia
Death within 24hr admission
Not seen by a doctor for 14 days
Any patient detained under the MHA
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202
Benefits of post mortem examination
Gain deeper insight into pathological processes
Learn how to prevent patients death in future
Help with teaching or medical research ,particularly for rare or poorly understood diseases
Further understand long term effects of drug therapy eg effects on other organs, might inform future choices about drug therapy
Study and monitor uptake of levels of chemical and radioactive elements absorbed from the environment
203
The ‘high-risk’ strategy: targeting minority with high risk
Pros- appropriate interventions, cost-effective use of resources, favourable benefit: risk ratio
Cons- cost/difficulty of screening, limited potential for change in the population
204
The ‘population’ strategy: targets majority, low risk
Pros- large potential for change, radical
Cons- small benefit to the individual, little motivation for patients, questionable benefit: risk ratio
a preventative measure which brings great change to the population offers little to the participating individual.
205
What are the main approaches to preventing liver disease?
Diet – decrease fat intake
Moderate alcohol intake
Vaccinations – Hep B, yellow fever
Practice safe sex
Care with blood products – avoid contamination
Hygiene with IV drug use, tattoos, piercings
Safety and hygiene in areas of poor sanitation
Safe work environment – to avoid risk of things like leptospirosis
Safety/ care with prescribed drugs – paracetamol, statins, steroids, COCP
206
Types of transplant
* Deceased - anonymous, (usually brainstem deceased or sometimes cardiac arrest related)
* Living pooled/paired - when a donor wants to give a relative but their blood groups are mismatched then are paired with another couple in the same situation to get the best kidney for each party. Operations must happen at the same time.
* Living altruistic donation - when a patient donates to an unknown recipient.
* Illegal - payment, abduction & forced donation.
207
The Human Tissue Act 2004
• Regulates the donation by living people of
• Solid organs
• Bone marrow
• Stem cells
The Independent Assessor will discuss capacity to consent, duress, coercion and reward.
208
Transplant rationing
All patients needing a transplant are placed on the UK transplant national transplant database
This ensures fair rationing
Points system based on:
• Time on the waiting list (favouring patients who have waited longest).
• Tissue match and age combined (favouring well-matched transplants for younger patients).
• The age difference between donor and patient (favouring closer age matches).
• Location of patient relative to the donor (favouring patients who are closer in order to minimise the transportation time of the kidney).
• Three other factors relating to blood group match and rareness of the patient’s tissue type.
209
DCCT Diabetes Control and Complications Trial TRIAL
provided quantifiable justification to healthcare providers that the additional
expenses associated with intensive glycaemic control and close monitoring of diabetes are
cost effective.
reduces the development and progression of all diabetes micro-vascular, specific complications by as much as 76% (retinopathy), albuminuria (40%), neuropathy (60%)
Intensive therapy reduces measures of atherosclerosis over time, and probably reduces CVD events as well
Intensive intervention is most effective when implemented early in the course of diabetes; if intensive intervention is delayed, the momentum of complications is harder to slow, as shown by the results of the secondary intervention group
210
Diabetes Prevention Programme Trial (DPP) = 1996-2001
Found that early aggressive lifestyle interventions (58% reduction) in obese patient with impaired glucose tolerance was more effective at preventing the onset of DM in comparison to placebo or metformin (31% reduction)
Trial highlighted the importance of lifestyle interventions in preventing DM = better than pharmacology
211
tackling obesity
• Implementation of easy access exercise schemes and cheaper/free access to gyms and sports clubs.
• Establish regular meals and encourage healthier foods for long term weight management
• Reduce dietary fat, avoid fried foods, buy lean meats, use semi-skimmed milk and low fat alternatives.
• Educate about what constitutes a 'balanced diet' (including '5-a-day' fruit and veg).
• Encourage parents to observe food labeling and make healthier decisions when buying foods.
• Promote healthy eating in the young through school dinners and healthy packed-lunches
Eg sugar tax
212
Energy intake?
Energy expenditure?
Energy balance?
Energy intake? Calories consumed as food
Energy expenditure? A sum of internal heat produced and external work.
Energy balance? Energy balance is achieved when input (dietary energy intake) is equal to output (total energy expenditure) plus the energy cost of growth in childhood or pregnancy/ cost of milk production during lactation.
213
Person-level human factors
Emphasises the skills that allow the individual to apply their clinical expertise efficiently, effectively and safely. These are often referred to as non-technical skills.
214
System-level human factors
Emphasises analytical approaches for managing the human element within the healthcare system in support of activities such as incident investigation, assessment of new procedures, designing equipment, and maintaining a record of how human-related risks are managed.
215
Bipolar disorder epidemiology
M=F
216
Preventing falls
Home based strength and balance retaining programmes
daily cleaning of spectacles/vision checks
staff monitoring in nursing homes
home safety assessment/modifications
podiatry/chiropody services and walking aids
217
Psychological effects of falls
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loss of confidence
immobility
isolation
depression
increased dependence
long term care
effect on ADLS
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218
Releasing performance data
Advantages= focuses attention on improving patient care, public reassurance about effectiveness and safety, completion will boost performance
Disadvantages= Unmeasured performance will suffer, opportunity for data manipulation (choose healthier patients), some areas/ centres only receive patients with poor prognosis
219
Opportunity costs
represent the potential benefits that an individual, investor, or business misses out on when choosing one alternative over another.
220
two pieces of legislation that support carers.
Employment Act
Carers & Disability Act
Carers Act 2014
Equality Act 2010
221
financial support available for carers
Carer’s Allowance
Disability Living Allowance
Attendance Allowance
222
reasons why evidence based decision making is important
Deals with uncertainty
Medical knowledge is incomplete/shifting
Patients will receive most appropriate treatment
Constant need for innovation/improvement
Improving efficiency of healthcare services
Reduces practice variation
223
factors that influence rate of infection
Infectious agent – pathogenicity, ability to spread
Environment – animals, water, population
Mode of transmission – airborne, faecal-oral, droplet, aerosol
Portal of entry – mouth, nose, GI tract
Host factors- chronic illness, nutrition, age
