Medical Law and Ethics Assessment

Question 1

A 68 year old man is brought to A&E with a significant haemoptysis (coughing up blood from the respiratory tract). He has lung cancer which has progressed through a course of chemotherapy, with secondaries in his liver and oesophagus. Tests indicate that he is probably close to death: his lungs are now failing and he will die within hours. He is semi-conscious. Given the irreversibility of his underlying breathing difficulties, admission to intensive care is not considered appropriate due to lack of medical benefit. This is explained to his family but they refuse to accept the diagnosis, saying they want all life saving treatment administered. What should you do?

Answer 1

Explain that no treatment will prevent his imminent death but that you will provide medication and nursing care to relieve his breathlessness and anxiety, with a focus on comfort care.

Explanation:
Treatment that is futile should not be provided, even at the insistence of family. Treatment should only ever be provided in the patient’s best interests. But you should sensitively explain the situation to the family and try to relieve the patient’s suffering.

Question 2

You are the senior doctor in A&E and are asked to see a patient who has been brought in by his brothers. He is confused and delirious with a high temperature. On investigation it is discovered that he has a gangrenous foot that requires amputation to prevent septicaemia spreading. Meanwhile medical treatment is available that may stabilise his condition for a short time. You explain this to his brothers but they insist his foot not be amputated because, in their culture, it means he will be unable to find a bride. They say that this would be his view too. You try to talk to the patient but it is clear that he speaks little English. The brothers explain that he has been here only a few months. What should you do?

Answer 2

Prescribe drugs to stabilise the patient in the hope that he will regain sufficient capacity to discuss what he wants, through an interpreter.

Explanation:
If treatment can be delayed and there is a possibility that the patient can regain capacity then you should wait and provide all reasonable help for the patient to make the decision themselves. An interpreter would be needed to ensure that the patient had accurate information, which cannot be guaranteed with the family interpreting. But as the patient is delirious on admission there is no point in engaging an interpreter at that stage. Delaying in order to involve the patient in the decision is also the least restrictive option, given that amputation is being recommended.

Question 3

A man of 72 has been admitted to hospital with a fever and mild delirium. He needs blood tests to identify the problem. This is explained to him. He appears to understand and when asked “Is that okay?” says yes. When you return 10 minutes later with a needle he becomes very distressed, thrashing around and screaming “Leave me alone. No! No!” What would be the best course of action?

Answer 3

Talk to the patient to calm him and try to gain consent. But if this is not possible, have the patient restrained and take blood in his best interests.

Explanation:
It appears as though the patient has fluctuating capacity or even lacked capacity at the time when he appeared to give consent, as he is unable to recall that decision a short while later. So he should be reassessed and care taken to maximise his capacity. He is ill and blood tests are needed in order to treat him effectively. So if you are unable to gain consent then you should restrain him in order to take blood, in his best interests.

Question 4

Which one of the following is not an advance decision enforceable by the Mental Capacity Act?

a) I do not want to be given artificial feeding if my MND has reached the stage where I’m unable to swallow.
b) I do not want to be given blood transfusions in any circumstances.
c) I do not want to have any treatment if I develop dementia.
d) I do not want to be given antibiotics if I am in a permanent vegetative state.

Answer 4

c) I do not want to have any treatment if I develop dementia

Explanation:
This is too general as it doesn’t specify any particular stage of dementia or any specific treatment.

Question 5

What do legally valid and applicable advance decisions require healthcare professionals to do?

Answer 5

Withhold any treatment specified in the decision.

Explanation:
Legally valid and applicable advance decisions apply to refusals, and not provision, of treatment. They are binding and so no permission is required from next of kin.

Question 6

Cerys Jones is a 66 year old woman with terminal bowel cancer who has been admitted to hospital with pain that is becoming difficult to control. She is increasingly distressed and repeatedly expresses her wish, in front of nursing staff, of wanting to die as she can no longer tolerate the pain. The hospital palliative care team reviewed her and advised the team to increase her pain medication. But when this is explained to her family (with her permission) they object because they have heard that such medication hastens death. The patient, however, is aware of this possible consequence and wants to take the medication. She is assessed to have capacity for this decision. It is Saturday and the FY2 doctor is called to mediate and make a decision. How should you advise the doctor?

Answer 6

Administering the medication is lawful provided the intention is not to hasten death but to relieve pain

Explanation:
The patient has consented and the reason the medication has been offered is to relieve symptoms rather than end the patient’s life. So there is a clinical justification and an ethical one.

Question 7

According to the Mental Capacity Act, which one of the following would invalidate an advance decision to refuse treatment?

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Answer 7

The patient gave someone Lasting Power of Attorney to make the said decision after writing their advance decision.

Explanation:
A later Power of Attorney overrides a previous advance decision. It is not a legal requirement that a doctor attest to a patient’s capacity at the time they make an advance decision. But if there is reason to doubt their capacity at the time they made their decision then it can be overridden.

Question 8

Mr Allen is 82 years old and has coronary heart disease. He has recently been admitted to hospital with pneumonia. His condition has deteriorated and he is now in the ICU. He has an advance decision to refuse treatment for pneumonia. Under what circumstances may you treat his pneumonia?

Answer 8

If the next of kin tell you that he had recently been considering whether to withdraw this advance decision.

Explanation:
A valid advance decision is binding, even if the patient’s condition is treatable. The next of kin have no right to make decisions on his behalf. A doctor with a conscientious objection can only pass the patient’s care to another doctor; they cannot refuse to comply with a valid advance decision if they are the only doctor available to care for the patient.

Question 9

Alan Sharma requested an HIV test at his GP practice following a business trip to South Africa 8 months previously where he had unprotected sexual intercourse with a sex worker. His partner Elise shares the same GP and they are expecting their first child in two months. The GP tells Mr Sharma that the test is positive and explains that it is important that he informs Elise so that she can be tested and, if necessary, receive treatment. Mr Sharma is adamant that Elise is not told the result. How should you advise the GP regarding disclosure of the HIV test result to Elise?

Answer 9

The GP can disclose the information against Mr Sharma’s wishes if he cannot be persuaded to do it himself and is informed about the disclosure

Explanation:
His wife is at risk of serious harm if she is not tested, as is her unborn child. This justifies disclosure against the wishes of the patient. But the patient must be informed that disclosure will occur against his will.

Question 10

A 71 year old man with end stage lung disease is admitted to hospital with confusion and pneumonia. Despite aggressive antibiotic treatment, he develops multi-organ failure and requires ventilation. He is not expected to survive overnight. The ICU consultant and the respiratory consultant agree that the patient should not be resuscitated if his heart stops. This is explained to the patient’s wife. His wife says that she and her husband are religious. She is adamant that everything possible should be done, including cardiac resuscitation. How would you advise the doctors?

Answer 10

Resuscitation can be lawfully withheld if it is not in the patient’s best interests

Explanation:
It is likely that CPR would not be successful given the patient’s condition and prognosis, and doctors are not obligated to provide treatment that they think is clinically inappropriate.

Question 11

A 44 year old man who is terminally ill with pancreatic cancer is receiving palliative care. He has been prescribed an opiate for the pain. His GP, Dr Hayley Langley, visits him and reviews his opiate prescription. He tells her that he nursed his father when he was dying of lung cancer and he is terrified of dying in the same way - ‘bedridden, helpless and in agony’. The patient asks Dr Langley how much of his opiate medication he would need to take to end his life. He assures Dr Langley that he has no intention at the moment of ending his life but may want to do so in the future if his suffering becomes unbearable, and it would be reassuring to know that he would be able to take his own life peacefully and painlessly. How should you advise Dr Langley?

Answer 11

Dr Langley should explain that the law does not allow her to answer his question

Explanation:
The GMC advises that a doctor should ‘limit any advice or information [they give to a patient] to…an explanation that it is a criminal offence to encourage or assist a person to commit or attempt suicide’. This does not preclude prescribing suitable medication at appropriate doses.

Question 12

Susan is a 35 year-old woman with two children under five years of age. She has been diagnosed with lymphoma which is curable with a course of cytotoxic chemotherapy. The diagnosis and recommended treatment plan are discussed with Sarah and her husband by the oncologist in the outpatient clinic. Susan refuses chemotherapy because she does not believe that it offers a greater chance of cure than the treatment offered by her homeopath, even though it is explained to her that there is no evidence that homeopathy has any curative effects. The oncologist must accept Susan’s refusal of treatment only if she has capacity. How would you advise the oncologist about Susan’s capacity?

Answer 12

Susan has capacity because she understands that the oncologist believes that there is no curative power in homeopathy but has formed a different view about the efficacy of homeopathy.

Explanation:
Patients are entitled to disagree with doctors, even about clinical or scientific evidence. Belief, for example, in the efficacy of homeopathy is not evidence that the patient lacks capacity or that there is an impairment or disturbance in the functioning of the mind or brain. It is evidence of disagreement. Even if it is irrational, this is not in itself evidence of lack of capacity. A judgment of lack of capacity must identify an impairment or disturbance in the functioning of the mind or brain which is causing the failure to understand, retain or weigh information.

Question 13

Angela Watkins is 74 and lives with her daughter. She has been diagnosed with cancer. There are a number of treatment options available, including surgery. This is explained to Mrs Watkins but she refuses to engage in any discussion and says that you should do what you think is best as her doctor. How should you proceed?

Answer 13

Explain that treatment requires her informed consent and so the options must be discussed with her.

She doesn’t lack capacity, and neither you nor her daughter has authority to act in her best interests and so consent on her behalf.

Question 14

A 54 year old woman with advanced multiple sclerosis gave Lasting Power of Attorney (LPA) for Health and Wellbeing to her daughter. Her condition has deteriorated: she is no longer able to swallow and has been in hospital for over a month with recurrent chest infections. In hospital she suffers a major stroke and, as a result, is not able to communicate or respond in a meaningful way. The stroke specialist informs her daughter that any meaningful recovery is extremely unlikely. She then develops respiratory failure and will require artificial ventilation to be kept alive. The ICU consultant thinks that in view of her multiple medical problems it is very unlikely that she will recover sufficiently to leave the ICU. The daughter shows the consultant her mother’s LPA and insists that his mother is ventilated as this is what she would have wanted. What advice would you give the consultant?

Answer 14

This is not a valid advance decision and so ventilation may be withheld if it is in the patient’s best interests

Explanation:
The law recognises only advance refusals of treatment as legally binding (if they are applicable to the circumstances). So this is not a valid advance decision for it requests treatment. Doctors are not obligated to provide treatment that they think is clinically inappropriate.

Question 15

A 55 year old female with advanced multiple sclerosis is in hospital with a urinary tract infection. She initially responds to antibiotics but her long term Percutaneous Endoscopic Gastrostomy (PEG) feeding tube becomes blocked. The enteral feeding team are unable to unblock the PEG feeding tube. She then develops a severe chest infection which is not responding to antibiotics and intensive chest physiotherapy. The medical team feel she is at the end of her life and the multi-disciplinary team decide that a nasogastric tube would not be in her best interests. This is explained to the patient’s sister when she visits. The patient’s sister strongly objects to the decision, insisting that they insert a nasogastric tube as nutrition and hydration is basic care, and removing this will result in her death. What would you advise the treatment team to do?

Answer 15

Nasogastric feeding is clinically assisted nutrition and may be withheld if it is not in the best interests of the patient

Explanation:
CANH is classed as treatment rather than basis care and so can be administered only if it is in the patient’s best interests. It is not always in a patient’s best interests to provide life-prolonging treatment.

Question 16

A 58 year old woman has rheumatoid arthritis which causes her severe pain. She has been admitted with wrist fractures following a fall. She has been struggling at home for some time and the occupational therapist has recommended transfer to a nursing home. The patient also has Type 1 diabetes and has been admitted in the past with diabetic ketoacidosis. With non-opioid analgesia the patient’s pain remains difficult to control and she expresses the wish to die. Over the next few weeks she makes repeated requests that her insulin be stopped so that she drifts into a coma and die. She is assessed by a psychiatrist and is found not to be suffering from depression or other mental illness, and there is no other underlying disorder that could be affecting her capacity. How would you advise the consultant rheumatologist regarding this request?

Answer 16

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Question 17

Dr Mallya is a GP who is managing Mr Ed Rosenthal, an 84 year old man who is entering the terminal phase of COPD. Over the past few days Mr Rosenthal has become increasingly agitated and confused due to hypoxia, despite maximum medical therapy and 24-hour home oxygen. The GP’s treatment plan, which was agreed with Mr Rosenthal prior to this episode of confusion, was that he should be managed at home with treatment aimed at relieving symptoms rather than prolonging his life. Mr Rosenthal’s son asks Dr Mallya whether she can administer sedating medication to help with his father’s agitation. Dr Mallya explains that sedating medication could cause respiratory depression. What is the legal position with respect to the GP administering sedating medication in this situation?

Answer 17

Sedation can be administered if the intention is to treat Mr Rosenthal’s agitation and it is in his best interests

Explanation:
So long as the intention is to relieve symptoms, sedation can be administered even in the knowledge that it may shorten the patient’s life. The patient had previously agreed to treatment aimed at relieving symptoms rather than prolonging life and so this treatment would be in his best interests.

Question 18

Thelma Thomas is 12 weeks pregnant and comes to see her GP seeking an abortion. She tells her GP that her husband, Anton, must not know about the abortion. Anton Thomas is also a patient of the GP and visits the GP a week later. He says he feels depressed and is not coping at work. He says that his wife has been acting strangely over the past few months and in recent weeks she has been eating very poorly. He is aware that his wife has had several visits to the doctor recently and is convinced she has a serious illness and is afraid to tell him. May the GP disclose the information about Thelma’s abortion request to her husband?

Answer 18

Information cannot lawfully be disclosed as Thelma does not pose a risk of serious harm to her husband

Explanation:
The third party/public interest justification for breaching confidentiality requires that the patient poses a risk of serious harm to others, which Thelma does not.

Question 19

A woman of 72 is admitted to A&E after her husband called an ambulance. She had chest pains and difficulty breathing. In the ambulance her condition deteriorated and she is barely conscious on arrival. The ECG indicates that she has had the most serious type of heart attack (myocardial infarction). She has DNR tattooed on her chest. How should you proceed?

Answer 19

Provide treatment to stabilise her condition but also speak to her husband to find out what her view about resuscitation might be in this situation.

Explanation:
A tattoo is not a valid and applicable advance decision to refuse treatment. Nor is it a clear indication of her wishes. You do not know when she had it done. So you should consult her husband as to her likely wishes about treatment in this situation but, given the emergency, also act to to stabilise the patient.

Question 20

A 45 year old woman has been diagnosed with malignant melanoma with metastatic lesions in her brain. She is being looked after by her husband at home, with the support of 24-hour private nurses. Three months ago, as her condition deteriorated but while she still had capacity, she informed her GP that under no circumstances did she ever want to have an indwelling urinary catheter, since she remembers her mother having had one after she suffered a stroke, and felt that this would lead to an unacceptable loss of dignity. Her GP discussed the possible consequences of such a refusal but the patient persisted in her request. This was recorded in her notes. As a result of the brain metastases she is now always confused, semi-conscious and incontinent. The nurses request that she be treated with a catheter as they think she would be more comfortable if they did not have to change her incontinence pads every few hours. Her husband agrees with them. How should you advise the GP?

Answer 20

The patient has made a valid advance decision which must be respected

Explanation:
A valid and applicable advance decision overrides any requests from family or any further clinical judgement about best interests.

Question 21

A 24-year-old woman has been in a Permanent Vegetative State since she was hit by a car 2 years previously. Neurological tests have demonstrated normal brain stem functions but there is no evidence of any higher cortical function and, therefore, it is likely that she has no conscious awareness. Her neurologist and her parents are in agreement that artificial nutrition is no longer in her best interests and would like to withdraw her percutaneous entero-gastrostomy (PEG) feeding, which will result in her death. What does the law permit in these cases?

Answer 21

Artificial feeding can be withdrawn, without Court approval, if the family and medical team agree that it is not in the patient’s best interests

Explanation:
The law changed in 2018, the result of which is that if the family and treatment team agree that continuation of treatment is not in the patient’s best interests, there is no need for court sanction of the decision.

Question 22

Nazneen , aged 37, is 29 weeks pregnant and has been admitted to hospital after going into early labour. An ultrasound shows that the baby is in a breech position and the placenta is low-lying. The consultant explains that a vaginal delivery would pose a serious risk to her life and that of the baby. But Nazneen refuses a C-section. She also refuses to have any friends or relatives contacted because she thinks they will try to get her to change her mind. She is assessed to have capacity for this decision. What should the consultant do?

Answer 22

Accept the patient’s refusal and proceed with a vaginal delivery

Explanation:
An adult with capacity can refuse any treatment for any reason, even if that places her life or the life of her unborn child at risk.

Question 23

Alice Fowler is a frail 92 year old woman with osteoarthritis who is mainly confined to bed with pain. Her son Arthur, who is her full time carer, calls the GP since following her lunch she has not been able to swallow anything. All food and fluids are getting stuck when she swallows, causing her to gag. The GP examines Alice and advises her that she needs to be admitted to hospital for an endoscopy. Alice appears to have full understanding of the situation, and implications of treatment or its refusal, but is reluctant to be admitted. Arthur is against her being admitted to hospital. He says this will be distressing for her, and that the obstruction may pass. How would you advise the GP?

Answer 23

Explore the reasons for her refusal but Alice cannot be admitted without her consent

Explanation:
There is no reason to doubt the patient’s capacity but the GP should try to ascertain her reasons for refusal to check that this is a true reflection of what she wants rather than what her son wants. Without evidence that she is making a decision under duress, her refusal must be accepted.

Question 24

Amy is an 89 year-old woman admitted to hospital with a urinary tract infection. She is usually fit and well but is currently extremely confused and agitated. When Tom, her son, comes to visit he asks you to write in her notes that if her heart stops she should not be resuscitated because she always said that if she was ever admitted to hospital she did not want any heroic treatment. What should you do?

Answer 24

Explain to Tom that an advance decision to refuse life-sustaining treatment must be written prior to the loss of capacity and be specific about the circumstances in which it is to apply. However her wishes will be taken into consideration if a best interests decision is required.

Explanation:
An advance decision to refuse life-sustaining treatment must be written prior to the loss of capacity and be specific about the circumstances in which it is to apply, and specify that the refusal applies even if life is at risk. Amy’s wishes, as conveyed by her son, are not very specific (what does ‘heroic’ mean?) and probably do not apply as she has not been admitted with a life threatening condition. However, if her condition were to deteriorate to become life threatening, her known wishes should be taken into consideration to inform a best interests decision.

Question 25

A 54 year old woman with advanced multiple sclerosis has written a living will which has been signed and witnessed by a neighbour. She is deeply religious and in the document she says that she believes life is sacred and wishes to be kept alive by all possible means should she become unable to make decisions for herself. Her condition deteriorates so that she is no longer able to swallow. On admission to hospital she suffers recurrent chest infections, then a major stroke and is not able to communicate or respond in a meaningful way. She then develops respiratory failure and will require artificial ventilation to be kept alive. The ICU consultant thinks that ventilation is not in her best interests as, given her multiple medical problems, it is very unlikely that she will recover sufficiently to leave ICU. The son shows the consultant his mother’s living will and insists that his mother is ventilated. What would you advise the consultant to do?

Answer 25

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Question 26

A 17 year old male has a moderately aggressive brain tumour. Following an acute deterioration, he is unconscious and requires an urgent neurosurgical procedure to survive. His family produce a signed and witnessed advance decision which clearly states that he wants no surgical intervention even if his life is at risk. Should the neurosurgical team comply with the advance decision?

Answer 26

They should not comply with it because the patient is 17 and, therefore, the advance decision is not valid

Explanation:
Patients must be at least 18 before they have the legal authority to write an advance decision. This is because under 18s have no legal right to refuse treatment.

Question 27

Amanda is 23 and has Down’s syndrome. She is estimated to have intellectual capacities equivalent to a child of 12 or 13. She had an operation to address a heart defect while a baby. She now needs a further heart operation. Her parents, who are her carers, want her to have the operation. You are her consultant. How should you proceed?

Answer 27

Assess her capacity to consent to the procedure, using language appropriate to her intellectual ability

Explanation:
You should always assess capacity and attempt to maximise the patient’s ability to understand the relevant information through use of appropriate language. Capacity is decision specific and so a patient with learning difficulties may have capacity for some decisions and not others. Only if the patient cannot demonstrate capacity, after all reasonable efforts to maximise their capacity, may you make a decision in their best interests. Her parents have no legal authority to make decisions on her behalf as she is over 18 years of age. They could have that authority only if Amanda has granted them Lasting Power of Attorney.