pbl lobs Flashcards
clinical abnormalities of refeeding syndrome
hypomagnesiaemia, hypophosphataemia, hypokalaemia, and abnormal fluid balance
what are the higher risks of refeeding syndrome:
lower BMI than 18.5
higher BMI than 18.5
chemotherapy
little nutritional intake for more than 10 days
unintentional weight loss more than 10% in 3-6 months
high risk:
BMI lower than 16, unintentional weight loss 15% in 3-6 months, little nutritional intake more than 10 days.
low risk:
BMI lower than 18.5, unintentional weight loss 10% in 3-6 months, little nutritional intake in more than 5 days, alcohol abuse, chemotherapy, insulin, diuretics
What is the management for refeeding syndrome
if the patient has not been eating for more 5 ore more days, aim to re-feed at no more than 50% of daily requirements for the first two days
What layers do you cut through during a tracheostomy
skin, subcutaneous fat, platysma muscle, thyroid, trachea
What is the location of a emergency cricothyroidotomy
cricothyroid membrane
What is the location of a tracheostomy
1-2cm inferior to the cricoid cartilage, between the 1st and 2nd tracheal ring
What are the indications for a tracheostomy
cannot intubate or ventilate, laryngeal cancer or upper airway obstruction, pulmonary lung disease.
What are the precautions for a tracheostomy
generally suctioning of secretions in the airway, humid airway and maybe a damp gauze in the hole
two differences between cricothyroidotomy and a tracheostomy
1) one is in the cricothyroid membrane and other between the 1-2nd ring. 2) tracheostomy needs general/full anaesthesia
What are the clinical features of upper airway obstruction
dysphagia, marked rep distress, inspiratory stridor, voice change, reduced breath sounds and tachycardia
complications of tracheostomy
infection, collapsed lung, blocked tracheostomy tube
what is a stridor
an high pitched inspiratory stridor suggestive of a tracheal or main bronchi obstruction
presentation of oral cancer
recurrent mouth ulcers that do not heal, lumps in the neck or mouth that do not go away, dysphagia, unintentional weight loss,
what is the needle and fluid is inserted into the neck for in a tracheostomy
needle is inserted into the space, apply negative pressure on the syringe and if air is found you are in a trachea
risk factors for laryngeal carcinoma
smoking tobacco, drinking above the alcohol limit, unhealthy diet with low fruits and vegetables, exposure to asbestos and coal dust and stong family history
Describe the social and historical developments that
have brought about changes in the meanings
associated with death and dying in contemporary
society
In many of the more traditional societies that continue
to exist around the world, the social processes
associated with dying and death remain culturally‘well
scripted’.
This generally involves a distinct set of funeral rites
and mourning customs which serve to facilitate
the‘social death’ of a person following their ‘biological
death’.
However, in modern high-income societies, this
intimate link between the biological and social death
of individuals has over time become more tenuous.
In the past, death typically came suddenly, resulting
from traumatic injuries or acute infectious disease.
However, with rising standards of living in the UK, with
improvements in public health infrastructures, and
more effective biomedical therapies, people began to
enjoy longer lives.
As a consequence, the meanings and practices
associated with many traditional death rites in the UK
gradually lost much of their power.
Death now typically comes after the prolonged
deterioration associated with chronic diseases in latter
life.
This epidemiological shift has reversed the
traditional sequence: now social death typically
precedes biological death.
The “work” of separating the dying from society
within hospitals and nursing homes, now routinely
occurs well before an individual’s definitive
biological death.
Without what anthropologist’s term the ‘sheltering
canopy’ of cultural customs associated with death
and dying, the individual and their family can find it
difficult to achieve a satisfactory separation before
and after biological death.
In such circumstances the lack of a cultural
script for dying, results in what has been
termed ‘disorderly deaths’, that is made all the
more painful because they typically occur in our
temples of hope - the modern hospital
(Joralemon:2002).Since the pre-modern period, much more rigid corporeal
boundaries now exist, both symbolic and actual, between
the dead and the living.
This in part reflects the decline in the importance of the
sacred within modern secular societies, where death is
generally perceived as separated from life.
It also reflects the decline in personal exposure to death
and dying associated with the ‘epidemiological transition’
(death occurring predominantly in later life and from chronic
disease).
This decline in the culture of mourning in modern societies
has had important personal and social consequences for
the process of grieving for the death of a loved one.
Describe the social and organisational processes that
are associated with the ‘medicalisation of death’
construct.
One of the major outcomes of this process of medicalisation
is termed iatrogenesis.
‘Clinical iatrogenesis’ refers to the potentially detrimental
consequences of medical interventions, but the process of
iatrogenesis goes beyond clinical interventions, and
involves the broader social and cultural spheres of life.
The latter process is termed ‘cultural iatrogenesis’, and
refers to the way in which biomedical accounts serve to
undermine people’s ability to manage their own health, as
well as their autonomy in coping with pain, suffering, and
death. Leading to an ever greater reliance on medical
intervention to solve these issues.
Related critical constructs such as ‘over-treatment’ and
‘heroic medicine’ also reflect this position that the
institutional focus on clinical intervention and treatment has,
until the recent past, too often blinded the medical
profession to attending to the needs of the dying patient.
That is, dying has too often been confused with illness
within the hospital environment.
Hospitals seen as the institutional expression of the
modern desire to remove evidence of sickness and
death away from the public gaze (Mellor and
Shilling:1993).
Bauman (1992) has argued that the nosologies
(classification of diseases i.e ICD-10) of biomedicine,
have inadvertently reduced death to nothing more than
a series of pathological anatomical and physiological
processes.
This perspective sees the biomedical model as
inadvertently generating the illusion that death can
somehow be controlled.
Outline the meaning of the concept of the ‘good death’.
(1) Awareness of Dying: A personal and social process
of greater openness about the prognosis of an illness
where it known that there is a high probability of death.
(2) Personal preparations and social adjustments: An
enablement of the settling of‘emotional accounts’.
(3) Public preparations: sorting out wills, putting practical
affairs in order.
(4) The relinquishing, where appropriate of formal work
roles. Too often it is automatically assumed that dying
individuals are beyond the age of retirement. This is
not the case with AIDS and forms of CHD and Cancer.
(5) A Good death involves formal and informal farewells.
However, because a ‘Good Death’ involves the
gradual withdrawal from an individual’s social roles
and responsibilities, it requires the involvement of
other’s, family, friends, as well as appropriate
professional support.
In doing so, it shifts death and dying from the
private to the collective sphere, thereby promoting
the social role of death in all our lives
However, because a ‘Good Death’ involves the
gradual withdrawal from an individual’s social roles
and responsibilities, it requires the involvement of
other’s, family, friends, as well as appropriate
professional support.
In doing so, it shifts death and dying from the
private to the collective sphere, thereby promoting
the social role of death in all our lives.
Outline the distinction that is drawn between ‘social’
and biological’ death.
In many ways, the origins of what was to become the
ideology of the ‘good death’ go back to the1960s and
the beginning of what became known as the ‘hospice
movement’.
It was charitable organisations that first established
hospices as institutions for effective end of life care,
outside of the organisation of the NHS.
Hospices sought to give more autonomy to the dying.
This involved proactive symptom management, and
attention to the religious, social and psychological
needs of the dying to achieve the normative goal of
accepting impending death.
The hospice movement sought to ‘de-medicalise’ the
dying process and challenge the practices of clinical
professionals which frequently led to the isolation of
the dying patient within hospital.
Whereas, hospice care was once on the periphery of health
care practice in the UK, it now constitutes part of a the much
wider shift in attitudes towards death and dying (discussed
above).
The success of hospices led directly to the development of the
palliative care medicine specialism, and an associated shift in
professional practice.
Professional attitudes have changed, with much greater
emphasis now placed on the emotional and psychological
dimensions of the experience of dying.
The ‘medicalisation’ of death approach has become much less
pervasive in health care systems (Timmermans:2005).
To the extent that the debate about the rights of individuals to
‘Assisted dying’ (voluntary active euthanasia and physician-
assisted death) has now opened up across European health
care systems
define CPR
This is an emergency procedure for people
in cardio-respiratory arrest.in cardio-respiratory arrest.
define DNACPR
Do Not Attempt Cardio Pulmonary
Resuscitation document states
resuscitation should not be attempted if a person suffers cardio-respiratory arrest..
It is not legally binding if only a DNACPR document is
present
An advance refusal of treatment (a legally binding advance decision) can give DNACPR legal grounding
Outline the need for a DNACPR
CPR is unlikely to be successful (“futility”)
The patient is mentally competent and does not want
to be resuscitated
Patient lacks capacity but has a legally valid advance
directive stating that they do not want CPR
Resuscitation is not in the best interests of the patient because the quantity and/or quality of life of the
patient following CPR is likely to be short/poor
DNACPR & Competent Patients
It has long been recognised that competent adultsIt has long been recognised that competent adults
have the legal & ethical right to refuse treatment.have the legal & ethical right to refuse treatment.
This right includes theThis right includes the right to refuse life savingright to refuse life saving
treatment.treatment. Thus competent adult patients have theThus competent adult patients have the
legal & moral right to refuse CPR and demand alegal & moral right to refuse CPR and demand a
DNACPR order.DNACPR order.
This right to refuse consent to treatment is vital toThis right to refuse consent to treatment is vital to
protect patientsprotect patients autonomyautonomy..
DNACPR & Incompetent patients
Where patients are incompetent, physicians must
Where patients are incompetent, physicians must
decide whether to issue a DNACPR order on the
decide whether to issue a DNACPR order on the
basis ofbasis of best interestsbest interests - MCA (2005)- MCA (2005)
Questions:Questions:
Can it ever be in a patient’s best interests not toCan it ever be in a patient’s best interests not to
be resuscitated?be resuscitated?
Is this the same as saying that it is in theIs this the same as saying that it is in the
patient’s best interests to die?patient’s best interests to die?
DNACPR & Advance Decisions
Competent patients, as we will learn shortly, can
issueissue advanceadvance decisions giving directives as todecisions giving directives as to
which treatments they do not wish to receive ifwhich treatments they do not wish to receive if
they become incompetent at a later datethey become incompetent at a later date
AnAn advance decisionadvance decision can include acan include a communicationcommunication
to the effect that resuscitation should NOT beto the effect that resuscitation should NOT be
attemptedattempted
This decision is legally binding (subject to someThis decision is legally binding (subject to some
caveats)
define advanced decision
An advanced decisions is an oral or writtenoral or written
statementstatement, made by a, made by a competentcompetent individual, aboutindividual, about
how they would like to be treated in the futurehow they would like to be treated in the future ifif
they happen to fall ill and are no longer competentthey happen to fall ill and are no longer competent
to make decisions about their health care.to make decisions about their health care.
Advanced decisions = advanced statements =Advanced decisions = advanced statements =
advanced directives = living willsadvanced directives = living wills
DNAPCR orders
Effective recording of DNACPR decisions in a form
that is recognized by all those involved in giving carethat is recognized by all those involved in giving care
Effective communication & explanation of DNACPREffective communication & explanation of DNACPR
decisions (where appropriate) with the patientdecisions (where appropriate) with the patient
Effective communication & explanation of DNACPREffective communication & explanation of DNACPR
decisions (where appropriate & with due respect fordecisions (where appropriate & with due respect for
confidentiality) with patient’s family, friends etc.confidentiality) with patient’s family, friends etc.
Effective communication of DNACPR decisionsEffective communication of DNACPR decisions
between all healthcare workers & organizationsbetween all healthcare workers & organizations
involved with the patientinvolved with the patient
discuss the risks and benefits of cpr
he primary benefit of CPR is that it gives a
chance of extending life. However, the survivalchance of extending life. However, the survival
rates are low.rates are low.
CPR is also invasive & includes the followingCPR is also invasive & includes the following
risks:risks:
Rib/sternal fracturesRib/sternal fractures
Hepatic/splenic ruptureHepatic/splenic rupture
Prolonged ITU care (inc. ventilation & dialysis)Prolonged ITU care (inc. ventilation & dialysis)
Brain damage following hypoxiaBrain damage following hypoxia
“Traumatic” death“Traumatic” death
Ethics of advanced decisions
Advanced decisions are advocated from an
ethical perspective because:
Extend patient autonomyExtend patient autonomy
It relies on a notion of precedent autonomy which recognises ourIt relies on a notion of precedent autonomy which recognises our
interests in making decisions about important matters in ourinterests in making decisions about important matters in our
futurefuture
Improve patient welfare because patients will be less anxious aboutImprove patient welfare because patients will be less anxious about
the possibility of unwanted treatmentsthe possibility of unwanted treatments
Advanced decisions are opposed from an ethicalAdvanced decisions are opposed from an ethical
perspective because:perspective because:
What reasonably healthy patientsWhat reasonably healthy patients thinkthink they want when they arethey want when they are
very ill is often not what they want when they are very illvery ill is often not what they want when they are very ill
The advanced decision may not be specific enoughThe advanced decision may not be specific enough
People may change their mind, but fail to communicate this factPeople may change their mind, but fail to communicate this fact
The legality of advanced decisions
he Mental Capacity Act 2005Mental Capacity Act 2005 clearly states thatclearly states that
advanced decisions are legally binding and mustadvanced decisions are legally binding and must
be respected (subject to important caveats)be respected (subject to important caveats)
Failure to adhere to the patients wishes asFailure to adhere to the patients wishes as
expressed in a valid advanced decision may lead toexpressed in a valid advanced decision may lead to
a charge ofa charge of assault or batteryassault or battery
Discuss when a advanced decision is not valid
Before losing capacity the individual annuls the
advanced directiveadvanced directive
There is evidence that the patient has changed his mindThere is evidence that the patient has changed his mind
regarding the advanced directive.regarding the advanced directive.
The advanced directive does not refer specifically to theThe advanced directive does not refer specifically to the
situation at handsituation at hand
There are reasonable grounds for thinking thatThere are reasonable grounds for thinking that
circumstances now exist, which the patient did notcircumstances now exist, which the patient did not
anticipate, & which would have affected the patientsanticipate, & which would have affected the patients
decisions had he anticipated them.decisions had he anticipated them.
The patient has created a lasting power of attorneyThe patient has created a lasting power of attorney
since the advanced directive was writtensince the advanced directive was written
outline the PICOS framework; An Answerable Question
In randomised controlled trials, which
include children who have acute otitis
media treated in primary care, does a
course of antibiotics, in comparison to
a matching placebo, make a difference
to pain duration, side effects, time out
of nursery, long term hearing
problems or mastoiditis.
*Patient characteristics
*Intervention
*Comparison
*Outcome
*Study Design
who is legally responsible for a prescription and what is the four fold duty
Four-fold duty
correct patient name & drug name
no contraindications
correct dose and directions are
given
provision for appropriate
monitoring & follow up
norwell’s 10 commandments
Notes to be legible
Date and Time of Consultation
Signed by name and printed underneath
signature
Use only approved/unambiguous abbreviations
Never alter or disguise entries
No insulting or ‘humorous’ comments
Check everything written in your name
See and evaluate notes thoroughly before filing
Do not dispose of notes
A nurse practitioner saw a newly registered
patient with a healthcare student in the room.patient with a healthcare student in the room.
During the consultation the nurse referred toDuring the consultation the nurse referred to
the patient’s HIV+ status. This wasthe patient’s HIV+ status. This was
mentioned in his transferred [electronic]mentioned in his transferred [electronic]
records. The patient was horrified and saidrecords. The patient was horrified and said
that he only wanted his GP and consultant tothat he only wanted his GP and consultant to
know about this diagnosis.know about this diagnosis.
Does the patient have the moral/legal rightDoes the patient have the moral/legal right
to deny access to some health careto deny access to some health care
professionals and/or healthcare students?professionals and/or healthcare students?
a patient objects to particular personal information being shared for their own care, you should not disclose the information unless it would be justified in the public interest,12 or is of overall benefit to a patient who lacks the capacity to make the decision. You can find further guidance on disclosures of information about adults who lack capacity to consent in paragraphs 41 - 49.
31
You should explain to the patient the potential consequences of a decision not to allow personal information to be shared with others who are providing their care. You should also consider with the patient whether any compromise can be reached. If, after discussion, a patient who has capacity to make the decision still objects to the disclosure of personal information that you are convinced is essential to provide safe care, you should explain that you cannot refer them or otherwise arrange for their treatment without also disclosing that information
difference between enteral and parenteral nutrition
enteral: through the gastrointestinal tract, parenteral: through the circulation- IV
which type of shock has hypotension and bradycardia
neurogenic
which types of shock have decreased CO and decreased TPR
septic and anaphylactic
define inotropic, dromotropic and chromotropic
ino: contractility(force of contraction), dromo: conduction chromo: heart rate
what are the alpha and beta receptors on the heart and their effect
beta1: contractility and heart rate, alpha1: contractility
what are the alpha and beta receptors on the blood vessels and their effect
alpha 1 and2: constriction beta2: dilatation
cholinergic receptor on heart and what does it do
m2 bradycardia
draw out the clotting cascade
https://www.youtube.com/shorts/rY0dpkSxcOo
sizes of small, medium and large sized AAA and management
If small AAA (3-4.4cm) – offered yearly repeat ultrasound
If medium AAA (4.5-5.4cm) – offered repeat ultrasound every 3 months
If large AAA (>5.5cm) – surgery generally recommended.The two main surgical options are open repair or Endovascular Aneurysm repair (EVAR).
The indications for repair are size >5.5cm or rapid expansion.
worse prognostic factor for ALL:
WBC more than 10,000
more than 10 years
white ethnicity
testicular filtration
WBC more than 500,000
male, WBC more than 200,000, black, splenomegaly, testicular infiltration, CNS involvement, less than 1 or more than 10 years, hypoploidy
different myeloid haematological malignancies
AML, myeloproliferative disorders: CML, myelofibrosis, essential thrombocytosis and polycythaemia
different lymphoid haematological malignancies
CLL, ALL, lymphoma and myeloma
which what are the four stages of ALL treatment. Which leukaemia is linked to downs syndrome
induction, consolidation, CNS prophylaxis and maintainence. AML is associated with downs
which leukaemia develops into high grade non-hodgkins lymphoma and which ones are sudden onset
CLL (richter’s syndrome) , sudden: ALL and AML
philadelphia chromosome, tyrosine kinase inhibitor, most common, BCR ABL
CML
pruritis, plethora, JAK2 mutation
polycythaemia
JAK2 mutation, digital ischaemia, recurrent abortions, budd-chiari
essential thrombocythaemia
gout, platelet derived growth factor, teardrop and dry tap, extramedullary haematopoesis, megakaryocyte proliferation
primary myelofibrosis
lytic lesions on the skull and plasma cell infiltration in bone marrow aspirate
multiple myeloma
8 types of childhood cancers
leukaemia, bone cancer, brain cancer, lymphoma, neuroblastoma, wilms, rhabdomyosarcoma, retinosarcoma
causes of petechial rash in adults and children
adults: ITP, DIC, bone marrow failure, drugs and nutritional deficiencies
children: meningiococcal sepsis, ITP, ALL, Henoch-Schonlein purpura
6months landmark for gross motor, fine motor, language, social
sits up unassisted, palmar grasp, lalalalal, puts food in thier mouth
when do they smile, crawl, runs, pincer grip
6 weeks, 9 months, 2-5 years, 10 months
when do they walk and on tiptoes, tower of 3, 6, 8
walk from 12-18 months
when can they draw a line, circle, square and triangle
2 years, 3 years, 4 years and 5 years
what promotes a secure attachment style
Parents aware of infants signals
Parent’s accurately interpreting signals
Parent responsiveness of signals.
Parent responding appropriately.
More broadly, parents should be able to mentalize- appreciate the
child’s perspective and see the child as a separate person, not just
something that has to have its needs met.
If no capacity MHU(CT) Regulations 2004 requires
that consent must be obtained from a “legal
representative” (e.g. an adult’s close relative)
that research must be likely to benefit the patient or other people who suffer from the same condition
that efforts are made to gain consent and that any consent and that any
sign of dissent should be taken seriously
Is research always in the best interests of the participant? (cf. MCA 2005)
equipose
In order for research (especially
interventional research) to be
justified it if often argued that
there must be genuine uncertainty
over whether or not the treatment will be beneficial. This is knows as
equipoise.
Once there is sufficient evidence
the research is usually stopped
since clinical equipoise is not met
when do we use placebos
Placebo controlled trials can be empirically and ethically acceptable especially where there is no alternative treatment available or if the research is non-therapeutic (e.g. phase non-therapeutic (e.g. phase 1 trial).
what are REC’s
are local (LREC) or multi-centre (MREC)
have 12-18 members (the membership must be balanced and must include lay people)
offer ethical review but do not give legal advice.
what do publication ethics involve
The pressures of “publish or perish” culture
Biased trials and biased publications
Potentially problematic pharmaceutical
involvement and perverse incentives
facts and figures of drug testing
All drugs licensed for use in Britain have been
tested on animals.
The number of experiments had been declining (1970s-1990s) but increasing again now.
280 institutions currently carry out regulated procedures in the UK:
Universities 40%
Commercial companies 37%
Charities 6%
Government departments 5%
100 million animals are used in testing worldwideworldwide
2.66million animals used in UK:
52% for medical or veterinary research
34% for fundamental scientific research
66% for cosmetic research
Rodents (e.g. rats) most commonly used (84%)
Research with great apes - gorillas, chimpanzees,
orangutans and bonobos - was banned in 1998.
What is the criterion which distinguishes animals from humans?
Criteria:
Sentience / Ability to feel (esp. pain)?
Reason/Rationality/Consciousness?
Capacity for Moral Agency?
Being human?
The 3Rs of Ethical
Animal Experimentation
Replacement: Non-animal methods to be used where possible
Reduction: The number of animals used should be kept to a minimum
Refinement: The smallest amount of pain & distress should be caused to animals& should be caused only for a justifiable purpose.
The Animals (Scientific Procedures) Act
1986:
regulates the use of all “protected” laboratory
animals where the research procedures might “cause “pain, suffering, distress or lasting harm”
provides for special protection for primates, cats, dogs and horses
requires that there be an ethics committee in institutions
what should registered medical professionals do for notifiable diseases
- A RMP has “reasonable grounds for suspecting” that a patient
has a ND (or a disease which risks serious harm) - The RMP has a statutory duty to notify a “Proper Officer” of the local authority (e.g. CCDC)
- Notifications of infectious diseases prompts local investigation and action to control the diseases. Proper officers are required to inform PHE of anonymised details of each case of each disease that has been notified.
- PHE collates the weekly returns from proper officers and publishes analyses of local and national trends
RMPs should NOT wait for laboratory confirmation.
They should report if they have clinical suspicion.
There are clear time limits for reporting:
3 days max to report a case (in writing)
24 hours max for urgent cases (by phone) and then asap in writing
[The prime purpose of the notifications system is timely response to cases, clusters and epidemics of infectious diseases and incidents on non-infectious health hazard, in order to prevent further transmission or spread of disease.]
notifiable disease
Acute encephalitis
Acute poliomyelitis Acute infectious hepatitis Anthrax Botulism
BrucellosisDiphtheria
Enteric fever Cholera
Food poisoning
Haemolytic Uraemic Syndrome
Leprosy
Infectious bloody diarrhoea Legionnaires’ Disease
Malaria Measles Invasive group A streptococcal disease Plague Rabies
Rubella SARS
Smallpox Tetanus
Tuberculosis Typhus
Viral haemorrhagic fever Whooping cough
Yellow fever SARS-Cov-2 Meningococcal septicaemia Mumps
coronavirus act 2020
Signed by SoS 6.50am 10th feb 2020
Can hold in isolation
Police can return to isolation
Can enforce 14d period
Requires DPH to declare a risk, with travel
from infected area
References Public Health [Control of Disease
] Act 1984
Superseded by Coronavirus Act 202
difference between reportable and notifiable disease
In addition to notifiable diseases there are also certain
categories of reportable diseases where employers must be reported to HSE if a doctor believes disease to be employment related
Powers of Detention I
An application can be made by a local authority under
s37of the 1984 Act to a JP for a Part 2A Order to Order to detain a patient when
precautions to contain a ND are not being taken
there is a serious risk of harm to others
suitable NHS accommodation is available
limitations of detention III for having a notifiable disease
Neither s37 nor s38 of the 1984 Act, even as
amended, provides specifically for treatment (or vaccination) of a patient with a ND once the patient has been detained.
S 40 allows for the compulsory examination and detention of a patient found in a common lodging
house with a view to ascertaining whether he is suffering/has suffered from a ND – but again no treatment can be required
The HRA 1998
The HRA 1998 applies to public (e.g. NHS)
Articles Art 5 (liberty) & Art 8 (privacy) have a bearing on the detention of non-adherent patients
ss 37 & 38 may not be compatible with HRA –
although recent amendments may help
An automatic review system has been proposed & more rigorous requirements of proof of serious risk
Giving HIV+ result
Be prepared
Give immediately
Allow space
Don’t make assumptions
Clarify understanding
Avoid information overload
Assess self-harm risk
Arrange follow-up support
the kubler ross model
https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=-tklqDo1JcjBjM&tbnid=krY6ejLrZ0H8ZM:&ved=0CAUQjRw&url=https://www.lucidchart.com/community/examples/view/4d41e4e1-4754-4c38-8c81-19b20ac17bf0&ei=NzZOU-TuIMmtO6S4gJAN&bvm=bv.64764171,d.ZWU&psig=AFQjCNEw2NzKfS3qen1BXAqZmRDqkVCcuw&ust=1397720968345115
PROBLEMS OF COMPARING SCREEN
DETECTED VS NON-DETECTED DISEASE
(non-randomized comparison)
LEAD TIME BIAS
Earlier diagnosis leads to spurious improvement
in prognosis
* LENGTH BIAS
Screening more likely to detect slow-growing disease
SELECTION (REFERRAL) BIAS
Better prognosis among people who attend
screening vs those who do not
This emphasizes the need for really good randomized
controlled trials to evaluate screening programmes
HTA 2004 deceased donations
No need for HTA approval
If patient consents this is sufficient
If patient refuses to consent (‘opts out’) this must be respected
If patient has nominated a person to make the decision then the nominee can give proxy consent
If patient has not expressed any wishes either way people the donation is on the basis of ‘deemed consent’ with consultation with family
excluded groups of HTA act
Those under the age of 18
People who lack the mental capacity to understand the new arrangements and take the necessary action Visitors to England, and those not living here voluntarily
People who have lived in England for less than 12 months before their death
Pros and cons of ‘deemed consent
PROS
Beneficence – could save lives
Maximizing utility(?)
Autonomy - consistent with a
view of a majority so
presumably better for autonomy
Autonomy – neutral for
autonomy as replaces asking relatives for consent
Alleviates some burned on family members
CONS
Autonomy: Potential
violation of donors
autonomy/nonsensical
Is the organ no longer a)gift or donation(?)
Psychological harm to
family members (?)
Misses the point
Public trust/consequences
Difference between quality planning, quality control, quality assurance and quality improvement
- A surge in obesity in the local population has led to an increase in type
II diabetes, hospital services are swamped and there is a need to review
how care for diabetics is provided. Quality Planning - A GP practice reviews diabetic patients each year with a target that
90% of diabetics will be seen for a foot check with a nylon thread of the
correct diameter Quality Control - An intermediate diabetes service decides to survey all users of the
service in the last three months to review the quality of care with respect
to access, advice provided and any unmet health needs. Quality
Assurance - A diabetes unit discovers that there are a significant number of type 1
diabetics are never seen, and control is poor for this cohort. Quality
Improvement
methods and sources to collect data
Patient notes / records
* Staff / patient surveys (e.g. electronic)
* Interviews / focus groups
* Complaints / incident reports
* Clinical assessment
* Direct observation
* Pre-existing statistics: primary & secondary
care databases/morbidity/mortality/process
outcomes
different types of outcomes
Outcome measures e.g. DVT Eg: Aim to reduce incidence of DVTs
Outcome = no. of patients presenting to GP/hospital with DVTs postop.
* Process measures e.g. Prescription Measures the changes you have made
* Easier to measure
* Show whether the process is working
* Balancing measures e.g. bleeds/cost: Measure other consequences
associated with the changes (side
effects- like a medication)
* Help show overall impact
* Not always necessary
* Structural measures e.g. availability: Structural measures look at the
environment in which healthcare is
being provided
* Including material resources (e.g.
electronic records), human
resources (e.g. staff expertise), and
organizational structure
* Not always necessary
What is a chronic disease?
Long duration (3 months or more)
* Generally slow progression (though not always)
* May include periods of remission and relapse
* Current medical interventions can usually only control, not cure
* The life of a person with a chronic illness is forever altered – there
is no return to “normal”
* Impact on quality of life
Crisis Theory of Chronic Illness
https://canvas.sgul.ac.uk/courses/4149/pages/pps-lecture-psychology-of-chronic-illness-dr-linda-perkins-porras
coping strategies
Denying / avoiding
* Blaming self or others
* Guilt &/or shame
* Seeking information
* Acceptance
* Gaining a manageable perspective
* Adherence to treatment – medication, physio, diet etc
* Self management - Learning to provide own medical care
* Setting concrete, achievable goals
* Recruiting practical & emotional support from family & friends
* Considering possible future events and planning
Perceptual-Practical Model of Adherence
Unintentional
non-adherence
Capacity &
Resources
Practical barriers
Motivational
beliefs/preferences
Intentional
non-adherence
Perceptual barriers
Motivational
beliefs/preferences
Intentional
non-adherence
(Horne, 2009)
The Necessity-Concerns Framework
Operationalisation of the perceptual factors involved in intentional
non-adherence
Reflects a balance between personal beliefs about:
* The necessity of taking treatment/medication
* The concerns about taking the treatment/medication
Psychological interventions for chronic
conditions
Educational, social support & behavioural approaches: Helpful to both
patient & family/carers
Information provision
Support groups, respite provision
Training for self-care procedures
Behavioural approaches to improve compliance (reminders, rewards)
* Relaxation & biofeedback
Management of stress, anxiety
Cognitive methods: Helpful in changing feelings & thought processes
Challenge & change incorrect and unhelpful beliefs
Think more constructively & realistically
Treat depression
* Insight & family therapy
Deal with anxiety, changed self-concept
Understand needs of family & friends
Acceptance & Commitment Therapy
three phases of habit formation
Habit formation process: Three
phases
1. Initiation phase – define the new behaviour and context in which it
will be practiced
2. Learning phase – behaviour is repeated in chosen context to
strengthen the context-behaviour association
3. Stability phase – the habit has formed and its strength has plateaued,
habits persists over time with minimal effor
COM-B model for taking medication
Capability
·Comprehension of disease and treatment
·Cognitive functioning—memory
·Dexterity to take medication
·Convinced that the treatment is beneficial
Opportunity
.Access (availability of medication)
.Cost (prescription £)
.Social support – approval, encouragement
.Religious and cultural beliefs
Motivation
.Perception of illness (chronic/acute)
.Beliefs about treatment
.Self-efficacy
.Associated with benefit
Target behaviour =
Take medication regularly
Motivational Interviewing Principles
R: olling with resistance
Avoid telling the patient what to do, persuasion or
argument. Instead reflect & re-frame
U:nderstand motivations Understand values, needs, abilities, motivations and
barriers to change behaviours.
L: isten with empathy Seek to understand from the patients perspective
Respect decisions and choices
E: mpower Help patient to explore how they can make changes
Encourage patient to come up with own solutions
1. Open questions
2. Affirmation
3. Reflection
4. Summarising
“A 55 year old male music teacher,
presents to his GP. He is overweight and
sedentary. He knows he needs to be
physically active but discusses his failed
attempts to make physical activity
habitual. He wants to become healthier
but does not know where to start”
How might the GP help this patient get into
the habit of regular, planned physical
activity?
Supporting change behaviour
Define new behaviour – patient chooses
Understand barriers to behaviour change
Increase motivation – motivational interviewing
approach
Choose an appropriate context to perform action ‘cue’
Action planning & goal setting
Goal setting needs to be SMART (Specific, Measurable,
Achievable, Realistic, Timely)
Repetition!
Review
Patient
example
Set small manageable goals
2. Focus on selecting a new habit
3. Disrupt the unwanted habit
4. Identify cues
5. Focus on long-term outcomes/reward
The law states that the existence of a mental disorder
does not equate to a lack of mental capacity
Statutory Homelessness
Unintentionally homeless and in priority need
* Intentionally homeless in priority need
* Homeless but not in priority need
* Local connection
* Hidden Homelessness
The social structuring of dependency in
older age
The assumption of retirement policies such as exists in the UK,
is the idea that older age brings with it a reduction in
productivity and long-term health problems which affects the
ability to fully participate in the labour market beyond the age
of 66.
These are ageist assumptions and reflect a normative set of
social and cultural expectations about the age at which people
should ‘transition’ to from the world of work to enforced
retirement (and for many, dependence on the limited state
pension).
With the ‘transition’ in role status post-retirement come another
set of normative assumptions. This involves the assessment of
an individuals relative ‘success’ in maintaining their
independence in the activities of daily life.
Those who are seen to require support are frequently
stigmatised as ‘dependent’
If older age is socially constructed as a period of
dependency in the life course, this belief can act as a
barrier to older people maintaining their pre-existing
interactions and activities ( ‘active ageing’).
A reciprocal relationship has been found to exist
between social participation and health, such that low
levels of social participation lead directly to poorer
health outcomes.
A system of social care should in principle be focused
on supporting initial care needs in order to reduce the
risk of dependency further down the line.
However, in the UK, the social care system has
historically been underfunded, and so has focused
limited resources on what is known as ‘firefighting’,
managing problems as they arise rather than
developing long-term strategies of prevention.
The 2014 Care Act
- Managing and maintaining nutrition
- Maintaining personal hygiene
- Managing toilet needs
- Being appropriately clothed
- Being able to make use of the home safely
- Maintaining a habitable home environment
- Developing and maintaining personal relationships
- Accessing and engaging in work, education or volunteering
- Making use of facilities in the local community
- Carrying out any caring responsibilities
difference between DSM and ICD criteria
ICD was developed by the world health organisations and covers all disorders into 11 groups
DSM was developed by the american psychological association, it only covers mental health disorders in 18 groups
advantages and diasadcantages for mental health disorders
advantages: * Diagnosis
* Shorthand communication
* Frames the problem
* Guidance for treatment
* Indication of prognosis
* Offers the patient an explanation
* Demystification of mental illness
disadvantages:
Labelling and stigmatization
* Illusion of understanding
* Limited information
* Some categories contentious & unreliable
* Difficulties if >1 condition
diagnostic pyramid for disorders
personality disorders, neurotic disorders, affective disorders, psychotic disorders and organic
biopsychosocial model of mental health illness
Biological
Physical disorders and insults
Genetic factors
Changes in brain structure and functioning
Psychological: Body of knowledge concerned with the emotional bonds
and affective interactions between human beings and the
psychological and psychopathological consequences
which arise when these process go awry
Temperament and personality
Psychodynamic and attachment theory
Self-esteem
Cognitive (IQ)
Social / environmental
Families
Cultural
Religion
Social networks; neighbourhoods; work and school
Life events (trauma)
Socio-political factors; war and conflict; socio-economic
disadvantage
CHILD SAFEGUARDING PRINCIPLES- GMC 2018
All children and young people have a right to be protected from abuse and neglect.
All clinicians must consider the needs and well-being of children and young people.
Decisions about child protection are best made with others.
Clinicians must be competent to deal with child protection issues
INDICATORS OF NON-ACCIDENTAL INJURY
INDICATORS OF NON-ACCIDENTAL INJURY
Inconsistent history/information presented that does not fit with clinical signs
Delay between injury and presentation
Bruises- shape suggestive of hand/ligature marks, location not in keeping with level of mobility, multiple bruises
of varying ages on non-bony prominences
Bite marks
Watchful/subdued child
Burns- clearly delineated lines (?immersion), shape (eg. Cigarette burns), location (buttocks/soles of feet)
Fractures- different ages, spiral fractures, occult rib fractures.
Intracranial injuries.
STRATEGIES FOR MANAGING MEDICAL UNCERTAINTY
Empower yourself with relevant knowledge- be aware of the guidelines and their limitations, practice risk communication
Consider your clinical and communication skills and how best to reduce patient uncertainty
Be honest with patients where information is unclear or unknown
Approach management as a shared-decision making process
Don’t be afraid to ask for help- involve colleagues who can help you where needed
Make provision for safety-netting +/- follow-up to ensure your shared plan has had the desired outcome
Five Factor Model of
Personality
Introversion – extroversion
Neuroticism
Agreeableness
Conscientiousness
Openness
n detail - people high in extraversion and low in
neuroticism tend to see events and situations in
a more positive light, and tend to discount
opportunities that are not available to them.
Differences in conscientiousness,
agreeableness, and openness to experience
are less strongly and consistently associated
with SWB
Depression Diagnostic
Criteria DSM IV
5 or more of the following at least one is
either 1 or 2. Most of the day, nearly
every day:
1. Depressed mood
2. Markedly diminished
interest/pleasure in all activities
3. Sig weight loss/wt gain
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness/ excessive
or inappropriate guilt
8. Decreased ability to think/concentrate
9. Recurrent thoughts of death,
recurrent suicidal ideation
MENTAL CAPACITY ACT 2005
Every adult has the right to make his/her own
decisions and must be assumed to have capacity to
do so unless it is proved otherwise
Everyone should be encouraged and enabled to
make his/her own decisions, or to participate as fully
as possible in decision-making, by being given the help
and support s/he needs to make and express a choice
Individuals must retain the right to make what might
be seen as eccentric or unwise decisions
Decisions made on behalf of people without
capacity should be made in their best interests,
giving priority to achieving what they themselves would
have wanted
Decisions made on behalf of someone else should be
those which are least restrictive of their basic rights
and freedoms.
THE CRITERIA FOR CAPACITY IN
MCA 2005
For the purposes of the Act, a person is unable to make
a decision for himself if he is unable to:
(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, or
(d) communicate his decision (whether by talking, using sign
language or any other means).
The fact that a person is able to retain the information
relevant to a decision for a short period only does not
prevent him from being regarded as able to make the
decision.
Note ‘belief’ has been removed from the test
BMA/Law Society guidelines suggest that
individuals should be able to:-
understand in simple language what the medical treatment
is, its nature and purpose and why it is being proposed;
* understand its principal (note not all!) benefits, risks and
alternatives;
* understand in broad terms the consequences of not
receiving the proposed treatment;
* retain the information for long enough to make an
effective decision; and
* make a free choice
HOW TO MAXIMISE
CAPACITY
appropriate timing and location
treating inhibiting conditions
diagrams
educational models
videos and audio
translators and interpreters
time
WHERE A PATIENT IS NOT
CAPACITOUS
s there a valid Lasting Powers of Attorney [LPA] or advance
decision?
Treat in patient’s best interests (construed holistically and not
limited to best medical interests) on the basis of ‘necessity’
Is there anyone who can advocate the patient? (Note the role of
the Independent Mental Capacity Advocate [IMCA] Service)
Document all assessments and rationale for
conclusion/decisions
best interests of a patient
The legal concept of best interests (S.4 in MCA) puts weight
on patients’
1) past and present wishes and feelings (including any
written statements)
2) beliefs and values that would be likely to influence
his/her decisions
3) other factors that the patient would be likely to consider
* including the views of proxy decision makers
it is important to not make assumptions
consider all relevant circumstances relating to the patient
consider if the patient was to regain capacity, the decision maker must involve the person as much as possible, for life-sustaining treatment the patient must not be desired by the patients death
ABSMTPCI
a ppearance, behaviour, speech, mood, thoughts, perception, cognition and insight
Qualitative work has a role in health research
Qualitative work has a role in health research for
example, in addressing the ‘gap’ between evidence-
based approaches based on the findings of RCT`s, as
a population-orientated investigation, and the practice
of clinical decision-making in individual cases.
The more individualised the clinical intervention, the
greater the role for qualitative work in the evaluation
of outcomes.
Qualitative research can also help us to understand
why for example promising clinical interventions do
not always work in the real world; how patients
experience care; and practitioners reflections on their
engagement in patient care
Qualitative Research Evaluation Criteria
Qualitative research cannot be judged by the same
measures of validity ( whether the research instrument
measures what it aims to measure) and reliability (the
reproducibility and consistency of the instrument
used), as applied to quantitative research.
In terms of generalisability, evaluation of qualitative
research focuses on the potential for transferability. Of
the ‘situated’ or contextual findings using small
samples
Qualitative research analysis should be able to
incorporate all observations and not leave out any
unexplained variance (‘confounding variables’) ordeviant cases’ (there are no normal distribution
curves for qualitative material).
That is, it should seek to embrace social complexity
rather than seeking to ‘reduce’ the data by eliminating
‘outliers’ / deviation from the mean.
Qualitative research should not be confined to an
exploratory’ research role, but aim to achieve an
analytical depth rooted so offering the possibility of
generating formal hypothesis (that may then be tested
by the use of quantitative surveys).
Qualitative research should not be producing lists of
interpretative categories (applied to
interview/observation data) based purely on
`common-sense’ knowledge.
The Social Causation /
Social Determinants Model
Mental illness is an objective, measurable ‘social fact’.
The aetiology of mental illness can be explained
largely in social epidemiological terms.
There are identifiable social factors correlated with a
predicable incidence of mental illness; depression in
particular.
Social class is identified as key correlate of `social-
stress’.
The impact of Neuroscience
The influence of the neurosciences represents a further
paradigm shift in the conceptualisation of mental illness as
a disorder of brain functioning.
If the brain is perceived to be a material and self-contained
physiological system that can be known and therefore
predicted, then (in theory) it opens up mental illness to
effective interventions.
Over the past two decades, developments in molecular
biology and in brain imaging have enabled neuroscientists,
to develop new ways of identifying neurophysiological
mechanisms, and psychopharmacologists to develop new
drugs to effect mood, behaviour, and to seemingly enhance
cognition.
Social constructionism
Labelling theory focuses on the societal reaction to,
and categorisation of, behaviour that does not
conform to social roles and norms.
The more socially visible the ‘deviant’ behaviour,
then usually the greater the chance of being labelled
as having a mental health problem.
In acquiring the power to define ‘madness’, the
profession is seen as having taken on the (social)
authority to control and manage individuals now
defined as ‘insane’.
As such, the designation of madness as psychiatric
illness was, ‘not a discovery of an objective truth but a
result of the convergence of internment and medicine’
(Cousins and Hussain:1984;139).
Or as Foucault himself describes it, the imposition of
the new psychiatric ‘gaze’ meant that, ‘the victim of
mental illness is entirely alienated in the real person of
his doctor, the doctor dissipates the reality of the
mental illness in the critical concept of madness’
(Foucault:1967/1989;86).
Insanity was now increasingly came to be seen as
curable, and patients urged in the direction of self-
restraint and self-control – an approach that became
known as the “Moral Treatment”
Mental Health Act; functions
Enable the state to enforce hospital admission for the
assessment/treatment of patients with mental disorder
* For the protection of the patient
* For the protection of others
* Provide mechanisms (including appeal) to ensure such
powers are not misused
* English law suggests it is right to override a patient’s
refusal to treatment on the grounds of
* Best interests
* Mental disorder
When the MHA is not needed
The majority of patients with mental disorders are
assessed and treated in circumstances where the
MHA 1983 (2007) does not (usually) apply:
* Competent patients who voluntarily consent to
assessment and treatment [common law]
* Incompetent patients where treatment is in their best
interests [Mental Capacity Act 2005]
Non voluntary admission
* The key forms of mandatory admission are:
- S 2: admission for assessment
- S 3: admission for treatment
- S 4: emergency admission
- S 5(2): detention of patient already in hospital
- S 5(4): detention by a nurse
Section 2: admission for
assessment
- 28 day detention
- Application made by nearest relative or AMHP and
supported by 2 Drs (1 a specialist) - Patient must be suffering from a “mental disorder of a
nature or degree” warranting admission for assessment and
this must be in the “interests of his own health or safety or
the protection of others” - Appeal via MHRT
Section 3: admission for
treatment
Up to 6 month detention period (renewable and reviewable at 6
months and then every 12 months)
* Application made by nearest relative or AMHP and supported by
2 Drs (1 a specialist)
* Patient must be suffering from mental disorder for which they
need Rx in hospital and it is necessary for health or safety of
patient or others that Rx be given and appropriate medical
treatment is available
* Appeal via MHRT
Up to 6 month detention period (renewable and reviewable at 6
months and then every 12 months)
* Application made by nearest relative or AMHP and supported by
2 Drs (1 a specialist)
* Patient must be suffering from mental disorder for which they
need Rx in hospital and it is necessary for health or safety of
patient or others that Rx be given and appropriate medical
treatment is available
* Appeal via MHRT
Section 4 - emergency admission
Up to 72 hours detention period
* Admitted on the recommendation of 1 doctor (who need not be
specialist but (ideally) knows the patient) if there is “urgent
necessity”
* Patient must be suffering from a mental disorder
* Time spent in hospital under s4 counts towards compulsory
periods of detention
Section 5
S 5 (2)
* Detention of a patient who is already in hospital
voluntarily (usually psychiatric hospital) who then
changes his/her mind and wants to leave
* 72 hours detention (maximum)
* Can be done quickly without a second medical opinion
* S 5 (4)
* Detention by a nurse
* 6 hours detention (maximum)
Non Voluntary Treatment
Once admitted competent patients who refuse treatment can be
treated against their will under Part IV of the MHA 1983 (2007)
* Exceptions
* Part IV (Section 63) permits treatment for mental disorder but not
for physical conditions unrelated to the mental disorder
* But this distinction is not easy to define…
Discharge
f a patient is discharged after being detained under the MHA
1983 (2007) certain forms of after-care / support must be
provided
* The 2007 amendment also now allows for a “Community
Treatment Order” which is a form of “conditional discharge”
CTO
Community Treatment Order: for patients who are sufficiently
well to be conditionally discharged (after detention under MHA)
but require on-going treatment – Section 17a
* Patients permitted to remain in the community if “compliant”
with treatment
* If non-adherent patients will be returned to hospital
* Compulsory treatment can only take place in community if it is
an emergency
IMHA
Qualifying patients (e.g. those admitted under Section 3) are
legally entitled to access an Independent Mental Health
Advocates (IMHA)
* IMHAs will help qualifying patients understand the legal
provisions to which they are subject under the MHA, and the
rights and safeguards to which they are entitled
The Unconscious Patient
Where unconscious, doctrine of necessity used to allow
emergency treatment
* Emergency to be interpreted conservatively (to avert
immediate danger/risks)
* Treatment must be in the patient’s best interests
* Covers treatment after self-harm
* Law allows emergency treatment but consider ethical
implications
