Key issues and topics

Question 1

Harold Shipman

Answer 1

Was a practising GP convicted of the murder of 15 patients and forging a will, mostly by injecting opiates into their body

GMC did not trike him off the Medical Register when he was convicted of an opiate addiction, only fined £600

The shipman case led to a number of changes:

1. A move away from single-handed GP practices
2. Tighter regulations on the sue of controlled drugs
3. Tighter regulation of death certification
4. Review of the revalidation process

Question 2

MMR vaccination and the 2013 measles epidemic

Question 3

Clinical governance

Answer 3

A set of principles and behaviours that all doctors should adhere to in order to ensure that they offer their patients the best quality clinical care

1. Doctors should ensure that their practice is compliant with the latest evidence. They should keep up to date and should ensure that they constantly adjust their practice to match new guidelines and new evidence from research
2. Doctors should provide safe care to their patients and ensure they do not place their patients at risk (handwashing and check drugs). They should feel comfortable owning up to their mistakes and learning from them. They should report any incident so it can be investigated and lessons can be learnt
3. Doctors should ensure that they recognise when they have reached their limitations and should be willing to ask for help when necessary. Similarly, if doctors come across colleagues whose practice may endanger patients, they should act upon it and raise those issues with someone senior
4. Doctors should ensure they constantly develop their skills and should also train and educate others. All staff should be properly supported
5. Doctors should be attentive to patient needs and should take account of feedback they receive from members of the public to ensure they constantly improve their services

Question 4

The audit process

Answer 4

Audits are a systematic examination of current practice to assess how well an institution or a practitioner is performing against set standards. Reflecting on, reviewing and improving practice.

Why are audits important?

• The main purpose of an audit is to identify weaknesses in your practice and increase the quality of service provided to users
• Audits also help to identify inefficiencies and ultimately may lead to a better use of resources
• Audits are also used to provide information about quality of care to outside agencies
• Audits provide opportunities for training and education

Question 5

The four ethical principles

Answer 5

Autonomy:

Patients are entitled to their opinion and to make decisions for themselves.

In particular, patients have the right to choose the treatment that they feel is best for them and also have the right to refuse to be treated.

A key factor for this principle to apply is that the patient must be in a position to understand and process the information at his disposal to make an informed decision - patient competence

Patient, however, cannot demand a treatment, you can counter propose a treatment you know will not be effective with a treatment you think would be in the best interest of the patient; the patient can then decide whether to take it or leave it

Present options to patient for them to make an appropriate choice for themselves

Beneficence:

Doctors must do good and act in the best interest of their patients

Non-maleficence:

Doctors should act in such a way that he does not harm his patients

Justice:

Fairness across the population

Right to confidentiality - 5th:

Part of patient autonomy, their right to control the information that pertains to their own health

Can also be linked to non-maleficence in that you may harm the patient by revealing information about them

Question 6

Informed conent

Answer 6

Before patient can give their consent, doctors must explain:

• options for treatment or management of the condition, include option not to give treatment
• The aim of the planned procedure or treatment, including any consequences, common or serious side effects
• Details of the planned procedure or treatment, its benefits, chances of success, as well as common or serious risk and side effects, and how these might be managed
• Consequences of providing the treatment vs. not providing the treatment
• Details of any secondary intervention that may be required when undertaking the first one and for which the patient should provide consent before hand as they will be unable to do so should it be required in an emergency
• Details of who will be performing the procedure and whether doctors in training will be involved
• A reminder that the patient can change their mind and any time and that they can seek a second opinion
• Any costs that the patient may incur

Only competent patients can give consent

Implied consent only applies to simple tasks with no real consequences. Anything else requires explicit consent to be obtained

Question 7

Competence of a patient

Answer 7

Adults:

Adults (and children aged 16 and 17) are deemed competent unless proven otherwise

If an adult is not competent, e.g. serious mental disorder, no other party can give consent on their behalf. There are 2 options:

1. If the patient has issued an advance directive (living will) at an earlier date stating how they would wish to be treated if at some point they were no longer able to make decisions for themselves then doctors would then need to abide by the patient’s decision, even if such a decision was not necessarily in their best interest
2. If the patient has not indicated any particular wishes, the decision will rest with doctors to act in the best interest of the patient. However, doctors should involve relatives in order to ascertain what the patient would have wanted

Children below the age of 16 (Gillick competence/Fraser guidelines):

Children under the age of 16 are deemed competent to give consent if they are shown to be mature enough to understand the information given to them about the procedure and its consequences.

However, the doctor has a duty to discuss with the children the possible involvement of the parents or legal guardian in the discuss

Note that if the child refuses to involve the parents then the doctors have to respect their decision, as this would breach confidentiality

A doctor will only be able to involve the parents against the will of the child if the child is deemed not to be competent (in which case parental involvement is mandatory) or if the child is in danger (in which case you would involve social services or the police)

These principles are called Gillick competence or Fraser guidelines:

• The competence of a child is assessed in relation to the procedure concerned.
• Although a child can give consent for a procedure or treatment if competent, in England and Wales they cannot refuse consent for a procedure or treatment that is deemed in their best interest. I.e. if the child has cancer, surgical intervention refusal must be made by the parents
• If both the parents refused to give consent on behalf of their child for a life-saving procedure, doctors would need to act in the best interest of the child. If possible, they should get a court order to impose the treatment. If time is of the essence, they may need to impose the treatment first and justify that decision later in court if needed

Question 8

When can you breach confidentiality?

Answer 8

1) Implied consent has been given by the patient:

A patient will understand that you need to provide information about them to other members of your team in order to care for them, e.g., nurses or consultant if you are referring

If the patient visits you with a family member and openly discusses their situation with you however if you have to break bad news or deal with a sensitive issue you will need to check with a patient first

2) Information required by a court/judge:

Medical records in the course of an investigation, court order

3) In the public interest and to protect the patient or others:

• Where the interest to society or others of disclosing the information without the patient’s consent outweighs the benefit to the patient of keeping the information confidential
• Notification to the authorities of notifiable diseases (meningitis, tuberculosis, mumps, measles but not HIV and AIDS)
• Suspected cases of child abuse or of neglect, physical or emotional abuse, where the patient cannot give consent to disclosure
• Informing the DVLA if a patient’s condition may affect his diving
• When the information can help with the fight against terrorism or in identifying a driver who committed a road traffic offence

Question 9

Euthanasia & Assisted Suicide

Answer 9

Can not recommend assisted suicide as it breaches non-maleficence

Arguments for:

1. Patients should be allowed to choose what is best for them
2. Patients can avoid a lengthy and unnecessary suffering period
3. Patients can die with dignity at a time of their choosing
4. Allows for reallocation of resources utilised for these patients

Arguments against:

1. It goes against some religious principles, doctors or relatives playing God
2. Patients may change their mind later at a time when they may no longer be able to express their change of position
3. Possibility of recovery
4. Difficult to verbalise specific criteria for allowing or disallowing euthanasia/assisted suicide
5. If the case is not clear-cut or well documented, relatives may face murder charges
6. Relatives may abuse the situation to suit their own needs instead of the patient’s
7. Relatives may pressure a patient they do not actually wish