Pass Med

Question 1

How is capacity assessed?

Answer 1

Mental health act - The Act sets out a clear test for assessing whether a person lacks capacity. It is a ‘decision-specific’ and ‘time-specific’ test. An adult can only be considered unable to make a particular decision if:

1. He or she has an ‘impairment of, or disturbance in, the functioning of the mind or
   brain’ whether permanent or temporary AND
2. He or she is unable to undertake any of the following
   a. understand the information relevant to the decision
   b. retain that information
   c. use or weigh that information as part of the process of making the decision
   d. communicate the decision made by talking, sign language or other means

Question 2

What should be considered as part of a best interests decision?

Answer 2

1. Whether the person is likely to regain capacity and can the decision wait.
2. How to encourage and optimise the participation of the person in the decision.
3. The past and present wishes, feelings, beliefs, values of the person and any other relevant factors
4. Views of other relevant people

Question 3

What is Lasting powers of attorney?

Answer 3

The Act allows a person to appoint an attorney to act on their behalf if they should lose capacity in the future, replacing the current Enduring Power of Attorney (EPA). In addition to property and financial affairs the Act also allows people to empower an attorney make health and welfare decisions. The attorney only has the authority to make decisions about life-sustaining treatment if the LPA specifies that. Before it can be used an LPA must be registered with the Office of the Public Guardian

Question 4

What does an advanced decision entail?

Answer 4

Advance decisions can be drawn up by anybody with capacity to specify treatments they would not want if they lost capacity. They may be made verbally unless they specify refusing life-sustaining treatment (e.g. Ventilation) in which case they need to be written, signed and witnessed to be valid. Advance decisions cannot demand treatment

Question 5

What are the 4 consent forms used?

Answer 5

Form 1 - For competent adults who are able to consent for themselves where consciousness may be impaired (e.g. GA)

Form 2 - For an adult consenting on behalf of a child where consciousness is impaired

Form 3 - For an adult or child where consciousness is not impaired

Form 4 - For adults who lack capacity to provide informed consent

Question 6

Who can consent for minors who are not Gillick competent?

Answer 6

Young children and older children who are not Gillick competent cannot consent for themselves. In British law the patient’s biological mother can always provide consent. The childs father can consent if the parents are married (and the father is the biological father), or if the father is named on the birth certificate (irrespective of marital status). If parents are not married and the father is not named on the birth certificate then the father cannot consent.

Question 7

What is duty of candour?

Answer 7

All healthcare professionals must be honest when something has gone wrong. They must:
Tell the patient when something has gone wrong
Apologise to the patient (or carer or family member where appropriate)
Offer an appropriate resolution
Explain the potential short and long-term effects of the error

Question 8

What are notifiable deaths?

Answer 8

The following deaths should be reported to the coroner
unexpected or sudden deaths
when the doctor attending the deceased did not see them within 14 days before death
if a death occurs within 24 hours of hospital admission
accidents and injuries
suicide
industrial injury or disease (e.g. asbestosis)
deaths occurring as a result of ill treatment, starvation or neglect
the death occurred during an operation or before recovery from the effect of an anaesthetic
poisoning, including taking illicit drugs
stillbirths - if there is doubt as to whether the child was born alive
prisoner or people in police custody
service disability pensioners

Question 9

when can you end a professional relationship with a patient?

Answer 9

You must only end a professional relationship with a patient when the breakdown of trust means you cannot provide good clinical care. This includes the patient being violent, threatening you or being abusive or the patient having stolen from you or the premises. It also includes the patient persistently acted inconsiderately or unreasonably or if they have made a sexual advance to you.

Question 10

when can you break confidentiality regarding STDs?

Answer 10

‘You may disclose information to a known sexual contact of a patient with a sexually transmitted serious communicable disease if you have reason to think that they are at risk of infection and that the patient has not informed them and cannot be persuaded to do so. In such circumstances, you should tell the patient before you make the disclosure, if it is practicable and safe to do so. You must be prepared to justify a decision to disclose personal information without consent.’

Question 11

What is DNACPR - can a patient ask for CPR even if the team have made a DNACPR order?

Answer 11

‘If cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful, making and recording an advance decision not to attempt CPR will help to ensure that the patient dies in a dignified and peaceful manner. It may also help to ensure that the patients last hours or days are spent in their preferred place of care by, for example, avoiding emergency admission from a community setting to hospital. These management plans are called Do Not Attempt CPR (DNACPR) orders, or Do Not Attempt Resuscitation or Allow Natural Death decisions.’

‘If a patient is at foreseeable risk of cardiac or respiratory arrest and you judge that CPR should not be attempted, because it will not be successful in restarting the patients heart and breathing and restoring circulation, you must carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made. You should not make assumptions about a patients wishes, but should explore in a sensitive way how willing they might be to know about a DNACPR decision. While some patients may want to be told, others may find discussion about Treatment and care towards the end of life: good practice in decision making interventions that would not be clinically appropriate burdensome and of little or no value. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team.’

Where a patient has not appointed a welfare attorney or made an advance decision, the treatment decision rests with the most senior clinician responsible for the patients care. Where CPR may re-start the patients heart and breathing for a sustained period, the decision as to whether CPR is appropriate must be made on the basis of the patients best interests (or benefit in Scotland). In order to assess best interests, where possible the views of those close to the patient must be sought, to determine any previously expressed wishes and what level or chance of recovery the patient would be likely to consider of benefit, given the inherent risks and adverse effects of CPR

Question 12

Which law governs the emergency management of patients who refuse treatment?

Answer 12

Common law is the framework that governs the emergency management of patients who refuse treatment

note that if the situation was less urgent a formal capacity assessment could be performed and the patient treated under the Mental Capacity Act.

Question 13

What is DoLS (deprivation of liberty safeguard)?

Answer 13

DoLS is an amendment to the Mental Capacity Act which is used if extra safeguards are needed if the restrictions and restraint used will deprive a person of their liberty. For example, one safeguard states that the patient should have someone appointed with legal powers to represent them.

Question 14

What is the difference between the mental capacity and the mental health act?

Answer 14

The Mental Capacity Act allows patients to be treated for physical disorders which affect their brain function if they refuse treatment.

The Mental Health Act allows patients to be treated for established mental health disorders if they refuse treatment.

Question 15

What laws underpin patients who refuse treatment?

Answer 15

Many patients who are admitted to hospital, or treated in the community, lack capacity. In the vast majority of cases, these patients do not refuse treatment that is given that is deemed to be in their best interest. The problem arises when patients who lack (or are suspected of lacking) capacity refuse treatment.

There are 3 main frameworks that are used in this scenario:

1. common law: used to treat patients in emergency scenarios
2. Mental Capacity Act: (MCA) used in patients who require treatment for physical disorders that affect brain function. Remember this may be delirium secondary to sepsis or a primary brain disorder such as dementia
3. Mental Health Act (MHA): used in patients who require treatment for mental disorders. For patients already admitted to hospital, a section 5(2) is used if there is not the time for a more formal section 2 or 3. A typical scenario would be a patient who has a mental health disorder attempting to discharge themselves, when it is thought this may result in harm

Question 16

What criminal activity needs to be reported to the GMC (regarding oneself)?

Answer 16

The GMC have produced guidelines on reporting criminal and regulatory proceedings within and outside the UK. This states that you must tell the GMC, without delay, if anywhere in the world, you:
Are found guilty of a criminal offence
Are charged with a criminal offence
Formally admit to committing a criminal offence (for example, by accepting a caution)
Accept the option of paying a penalty notice for an ASBO
Receive a cannabis warning
Have had your registration restricted, or have been found guilty of an offence, by another medical or other professional regulatory body.
Your conduct (including as part of a management team) has directly contributed to an organisation that has entered into a deferred prosecution agreement.

Question 17

When can confidentiality be broken?

Answer 17

1. Required by law - notifiable diseases, certain regulatory bodies, judges order
2. with consent - within healthcare team, for research, to ensurers/benefit claims
3. in the public interest - to protect again serious communicable diseases, crime or risk of serious harm
4. protect others - protect from death or serious harm

Question 18

What details regarding a chaperone must be recorded?

Answer 18

You should record any discussion about chaperones and the outcome in the patients medical record. If a chaperone is present, you should record that fact and make a note of their identity. If the patient does not want a chaperone, you should record that the offer was made and declined.’

Chaperones are essential during intimate examinations for self- and patient-protection purposes. During less invasive examinations they are also always very useful for these purposes, however are hugely less sought.

Just recording that a chaperone was present is not enough, and it is important to identify the chaperone so they can be identified if any future discussion occurs surrounding the examination.

By recordinging their professional license number you are recording their identity but to use name and job is more efficient in the clinical environment.

Question 19

Who can be a chaperone?

Answer 19

Chaperones:
A chaperone is an impartial person who is present during the examination to both offer support to the patient and act as an observer to ensure the examination is carried out in a professional manner
They should be a healthcare worker who has no relation to the patient or doctor. Patients may also wish to have family members present for support but they cannot be relied upon as chaperones as they are not impartial
The full name and role of the chaperone should be documented in the medical records with the examination findings
In the event of the patient making any allegations against the doctor with regards to the examination, the chaperone can be called on as a witness
The chaperone should also be able to safely announce whether they feel any behaviours are inappropriate during the examination
It is not mandatory to have a chaperone and many patients may wish to be examined without another individual present. In these cases, the offer and refusal should be documented in the medical records
A doctor should not feel pressured to perform an examination without a chaperone if they do not wish. However, they should ensure the patient is referred to a colleague who is comfortable doing so and that they would not wait unnecessarily for treatment because of this

Question 20

Who has to gain consent for cosmetic procedures?

Answer 20

If you offer cosmetic interventions, you must:

seek your patient’s consent to the procedure yourself rather than delegate

Question 21

DVLA visual disorders rules

Answer 21

DVLA: visual disorders

The guidelines below relate to car/motorcycle use unless specifically stated. For obvious reasons, the rules relating to drivers of heavy goods vehicles tend to be much stricter

Visual field defects
driving must cease unless confirmed able to meet recommended national guidelines for visual field

Monocular vision
must notify DVLA
may drive if acuity and visual field is normal in the remaining eye

Blepharospasm
consultant opinion is required

Question 22

Advanced directives

Answer 22

Advance directives may be defined as a document written at a time when a person is of sound mind, of that individual’s preferences with respect to medical treatment, should they later become unable to express those wishes directly.

It is important that any directive refers to a specific treatment in a specific circumstance rather than a general statement.

The Mental Capacity Act 2005 makes clear that such advance directives are binding, unless the following exceptions apply:
The decision has been subsequently withdrawn
Power to make such decisions has been conferred to another person by creating a Lasting Power of Attorney
Since making the will the patient has acted in a way that is clearly inconsistent with the advance decision remaining their fixed decision
The person is not incapacitated and can decide for themselves
The treatment in question is not that specified in the advance decision
Any of the circumstances specified in the advance decision do not exist
There ‘are reasonable grounds for believing that circumstances exist which the person did not anticipate at the time of the advance decision and which would have affected his decision at the time of the advance decision.’

Of note is the responsibility of the patient to ensure health care professionals are informed of their wishes. Some patients carry ‘organ donor’ style cards with them. It is clearly a good idea if copies are stored by their GP and hospital specialists.

According to the Mental Capacity Act the perspective of any Lasting Power of Attorney has precedence over the written advance decision.

It is good practice that advance directives have a limited time frame so that they are reviewed at regular intervals (e.g. 2 yearly) to ensure they are still applicable.

Question 23

Death Certification

Answer 23

There is no legal definition of death in the UK although guidelines exist. Current guidance states ‘death should be verified by a doctor, or other suitably qualified personnel’ which means staff such as nurse practitioners may verify (but not certify) death.

After a patient has died a doctor needs to complete a medical certificate of cause of death (MCCD). There is a list of circumstances in which a doctor should notify the Coroner prior to completing the MCCD.

Some specific points on completing the MCCD:
‘old age’ as 1a is only acceptable if the patient was at least 80 years of age . It can be used if certain conditions are met but is discouraged
‘natural causes’ is not acceptable
organ failure (e.g. ‘liver failure’) can only be used if you specify the disease or condition that led to the organ failure (e.g. 1b: Hepatitis C)
abbreviations should be avoided (except HIV and AIDS*)

The family then take the MCCD to the local Registrar of Births, Deaths, and Marriages office to register the death. If the Registrar decides that the death does not need reporting to the Coroner he/she will issue:
certificate for Burial or Cremation
certificate of Registration of Death (for Social Security purposes)
if requested. Copies of the Death Register (banks and insurance companies expect to see them)

Question 24

Social media

Answer 24

The General medical council (GMC) state that when communicating publicly, including speaking to or writing in the media, you must maintain patient confidentiality.

They also state:

You should remember when using social media that communications intended for friends or family may become more widely available.

Although individual pieces of information may not breach confidentiality on their own, the sum of published information online could be enough to identify a patient or someone close to them.

It is good practice to state your real name if you are commenting on healthcare practice online. If you state that you are a doctor and comment on healthcare, it is not acceptable to not identify yourself.
The general public trust doctors opinions, weighting them with high creditability. Doctors behaviour must not undermine public trust in the profession. Therefore, the GMC think that doctors who want to express views, as doctors, should say who they are.

Question 25

DVLA psychiatric disorders

Answer 25

DVLA: psychiatric disorders

The below rules apply to group 1 vehicles (car and motorcycle), the group 2 (bus and lorry) rules are stricter.

Specific rules
Severe anxiety or depression with any of the following: significant memory problems, significant concentration problems, agitation, behavioural disturbance or suicidal thoughts: must not drive and must notify the DVLA
Acute psychotic disorder: must not drive during acute illness and must notify the DVLA
Hypomania or mania: must not drive during acute illness and must notify the DVLA
Schizophrenia: must not drive during acute illness and must notify the DVLA
Pervasive developmental disorders and ADHD: may be able to drive but must inform the DVLA
Mild cognitive impairment: may drive and need not inform the DVLA
Dementia: may be able to drive but must inform the DVLA
Mild learning disability: may be able to drive but must inform the DVLA
Severe disability: must not drive and must notify the DVLA
Personality disorders: may be able to drive but must inform the DVLA

Question 26

Carers allowance

Answer 26

Carer’s allowance

Carer’s allowance is payable if you fulfill the following eligibility requirements:
You’re 16 or over
You spend at least 35 hours a week caring for someone
Have been in England, Scotland or Wales for at least 2 of the last 3 years
You normally live in England, Scotland or Wales, or you live abroad as a member of the armed forces
You’re not in full time education or studying for 21 hours a week or more
You earn no more than £110 a week (after taxes, care costs while youre at work and 50% of what you pay into your pension)

The restrictions on earnings therefore defines this benefit as ‘means tested’.

Carer’s credit, Attendance Allowance, Personal Independence Payment and Disability Living Allowance (now converted to PIP) are all NOT means tested.