Pink Flashcards
1
Q
What is housing?
A
Physical structure of dwelling
Home: psychosocial, economic and cultural construction created by household
Immediate environment: physical neighbourhood infrastructure
Community: social environment, population and services
2
Q
Define decent home
A
Meets current statutory minimum standard for housing
Reasonable state of repair
Reasonably modern facilities and services
Provides a reasonable degree of thermal comfort
3
Q
What are the main health hazards related to housing?
A
Cold homes: poor energy efficiency in homes and rising fuel cost, level of excess winter deaths
Overcrowding: Lack of affordable homes, lack of larger homes, respiratory problems, stress, poor mental health, children’s poor educational attainment, sleep problems, difficulty managing children’s behaviour
Damp and mould: Caused by cold and poor ventilated homes, Associated with respiratory infections, allergies and asthma
Structural defects: Caused by poor design and repair – poor lighting, lack of stair rails, steep stairs increases risk of accidents
4
Q
Groups most at risk of living in unhealthy home environments are those most at risk of poverty. Who are these groups?
A
Disabled people and those with long-term conditions
Older adults
Families with young children, particularly if lone parent households
Black and minority groups
Young single people
5
Q
Describe the health service perspective on the benefits of good housing
A
Improving housing quality and quantity can reduce pressures on NHS
Healthier adults and children, lower rates of disability and long-term conditions
Enables people to manage their health and care needs
Reduces demands for emergency health services
Enables timely discharge
6
Q
What is a rough sleeper?
A
People sleeping, about to bed down or actually bedded down in open air (streets, in tents, doorways, parks, bus shelters or encampments)
People in buildings or other places not designed for habitation (stairwells, barns, sheds, car parks, cars, derelict boats, stations, or ‘bashes’)
Not people in hostels or shelters, campsites or other sites used for recreational purposes or organised protest, squatters or travellers
7
Q
When do rough sleeper counts happen?
A
Given that rough sleepers often move between local authority areas (particularly in urban areas) it is strongly recommended that neighbouring authorities count on the same night whenever possible
Formal rough sleeper counts should take place between 1 October and 30 November. Local authorities may chooseto count more often than this but CLG will collate figures from autumn counts
8
Q
What areas of life are affected by being a sofa surfer?
A
Relationships
Benefits
Council tax reduction (if tenant claiming as a single person)
Tenancy
Status as homeless if for more than a few nights
9
Q
What criteria make someone statutory homeless?
A
You are eligible for public funds
Have a local connection
Are unintentionally homeless (ie it’s not your fault)
Have a priority need
10
Q
What categories are covered under the term priority need?
A
Household with dependent children
Household with a pregnant woman
Vulnerable because of physical or mental health
Aged 16 or 17 or aged 18-20 and previously in care
Vulnerable as a result of time spent in care, custody or HM Forces
Vulnerable as a result of having to flee their home because of violence or threat of violence
11
Q
IF MAIN HOMELESSNESS DUTY ACCEPTED, what needs to happen?
A
Authority must ensure that suitable accommodation is
available for applicant and his or her household
Duty continues until a settled housing solution becomes available for them, or some other circumstance brings duty to an end
12
Q
IF MAIN HOMELESSNESS DUTY NOT ACCEPTED, what needs to happen?
A
Local authority must provide advice and assistance to help applicant to find accommodation for themselves
13
Q
How many homeless people are there in England?
A
Across England 9% of adults say that they have experienced homelessness at some time
8% of under-25s say this happened in the last five years
These new data imply that around 185,000 adults experience homelessness each year in England
14
Q
What are some causes of homelessness?
A
Welfare changes
Lack of affordable housing
Effects of Government plans for “Right to Buy” for housing association tenants
Unemployment
Closure of long-term psychiatric hospitals
15
Q
List some routes into homelessness
A
Relationship breakdown Being asked to leave family home Drug and alcohol problems Leaving prison Mental health problems Other: eviction, problems with benefits payments
16
Q
What are barriers to the health of homeless people?
A
How to register with a GP if you don’t have an address
Safe discharge
High emergency readmission rates within 28 days of discharge
17
Q
What risk factors for longstanding health problems are often present in homeless people?
A
Mental health issues Drugs or recovering from a drug problem Have or are recovering from an alcohol problem Physical health problems Regular smokers
18
Q
WHERE DO HOMELESS PEOPLE GET HEALTHCARE?
A
A and E GPs Hospital Opticians Dentist
19
Q
Name some leading causes of death in homeless people
A
Drugs Alcohol Cardiovascular disease Suicide Respiratory problems
20
Q
What is the average age of death of homeless people in the uk?
A
47 years old
21
Q
How much more likely is a homeless person to commit suicide than the average person in the UK?
A
9x more likely
22
Q
What partnership working is being done to help homeless people?
A
Inclusion of housing and housing circumstances: Health and
Wellbeing Strategy and local commissioning
Local commissioning: range of housing to meet local needs, intervention to protect and improve health in the private sector, to prevent homelessness and enable people to remain living in their ownhome should their needs change
Housing providers’ local knowledge inform plans to develop new homes and manage their existing homes to best meet needs, include working with NHS providers to re-design care pathways and develop new preventative support services in community
Provision of specialist housing, wide range of services: enable people to re-establish their lives after a crisis and to remain in their own homes as their needs change. Home improvement agencies and
handyperson services to deliver adaptations and a wide range of other home improvements
Voluntary and community: wide range of services, day centres for homeless people to information and advice to housing support services
23
Q
What are key features of a healthy home?
A
Warm and affordable Free from hazards, safe form harm Enables movement around the home and is accessible for residents and visitors Promotes a sense of security Support available if needed
24
Q
What is meant by the term sexuality?
A
Umbrella term: private dimension in which people live out their sexual, intimate and/or emotional desires
25
What factors can influence a persons sexuality?
Historical, social, cultural and political aspects of society
Relationships with ourselves, those around us, and society
26
What is the naturalist approach to sexuality?
Sexuality is biologically determined with minimal influence from societal structures
Traits are fixed and there is no variation
Uses anatomical differences between males and females to claim biological basis to sexuality
Heterosexuality is normal expression and identity of sexuality
Heterosexuality has no cause as it is viewed as natural
27
What is the nurture approach to sexuality?
Sexuality is constructed and influenced by societal structures
Gives us a potential for choice, change and diversity
Complex; reasons for engaging in sexual behaviour are varied
Sexuality is made; people are experts in own lives and therefore ‘make’ their identities, including their sexual selves
Acknowledges biological anatomical differences between men and women, but recognises that a person’s sexuality is also influenced by society’s structures
28
What is sexual identity/ orientation?
Focus of a person’s sexual attractions and desires
Heterosexual, lesbian, gay, bisexual and transgender
Presented as essentialist categories with fixed assumptions about sexual orientation
People’s experiences and choices not necessarily so certain; e.g. men
in relationships with women who define themselves as heterosexual
who also have sexual encounters with men
‘Men who have sex with men’ (MSM): ‘Women who have sex with
women’ (WSW) and ‘Same sex attraction’ (SSA)
29
Define heterosexual
Where people are exclusively or almost exclusively sexually attracted to people of the opposite sex/gender identity
30
Define lesbian
Woman whose primary sexual attraction is to other women
31
What does gay mean?
Most often used in relation to men whose primary sexual attraction is to other men
32
Define bisexual
Person who is sexually and/or emotionally attracted to both men and women
33
What is transgender?
Includes those who do not consider themselves to fit into the traditional female/male, sex/gender constructs
34
What is homophobia?
Intolerance, fear, hatred that people have of lesbians, gay men and bisexuals
35
What is internalised homophobia?
Self-loathing that lesbians, gay men and bisexuals may develop as a response to homophobia
36
What is a problem with the term homophobia?
Phobia implies that it is only located within individual concerned
Ignores fact that much anti-gay prejudice is perpetrated quite consciously through society’s cultural and structural institutions and values
37
What is heterosexism?
Set of assumptions and practices which promote
| heterosexuality as only normal, acceptable and viable way to live our lives
38
What act changed legislation to reduce the age of consent for gay men to sixteen years?
Sexual offences act 2000
39
Which act allowed lesbian and gay couples to adopt?
Adoption and Children Act 2002
40
Which act protects against direct and indirect discrimination, victimisation and harassment in employment?
Employment Equality Act (Sexual Orientation)
41
Which act provided lesbian and gay partners with the option of a civil ceremony?
Civil Partnership Act
42
Which idealogical beliefs tend to be associated with hostility towards gay men and lesbians?
Authoritarianism
| Religious fundamentalism
43
Why do LGBT people often report low expectations of medical services?
Prejudice, stereotyping and invisibility
44
Describe some best practice guidelines for dealing with issues around LGBT discrimination in medical practice
Be aware and challenge discrimination around sexuality
Do not to make any assumptions about a person’s sexuality
Ensure that history taking and assessments are conducted in such a way as to facilitate disclosure: e.g. asking open questions
Develop a language of sexual expression and be able to talk about sexuality comfortably and explicitly
45
What characteristics are babies born to teenage mothers more likely to have?
Low birth weight
Born prematurely
Higher risk of dying during infancy
46
What social factors are associated with teenage pregnancy?
Social disadvantage
Poor educational outcome
Lack of aspiration
47
What is the most commonly diagnosed STI?
Chlamydia
48
Which groups of sexual orientation are at most risk of contracting HIV?
Gay, bisexual men and men who have sex with men (MSM)
49
Why are STI diagnoses increasing?
```
Increased sexual activity particularly amongst younger people
People more aware of STIs
Easier to access services
Better diagnostic tests e.g. Chlamydia
Artefact
```
50
Give some examples of STIs which can be asymptomatic
Chlamydia, Genital Warts, Genital Herpes, Hepatitis, Syphilis, Trichomonas, HIV
51
What clinical problems can arise from a chlamydia infection?
Complete occlusion of fallopian tube
Pelvic inflammatory disease
Risk factor for cervical cancer
52
Which STIs are highly protected against with correct condom use?
Chlamydia, Gonorrhoea, Hepatitis B/C, HIV, Syphilis, Trichomonas
53
Which STIs are slightly protected against with correct condom use?
Herpes Simplex Virus (HSV), Human Papilloma Virus (HPV)
54
Which STIs are not protected against at all with correct condom use?
Hepatitis A, Pubic Lice
55
Why is partner notification important for STIs?
Protect the patient from re-infection
Offer sexual partners tests for STIs
Offer sexual partners treatment
Inhibit further spread into the community
56
Give examples of STIs which don't require partner notification as they have no effective treatment?
Herpes and genital warts
57
Give some main differences regarding sexual health care in primary care and GUM clinics
GUM attenders tend to perceive themselves at risk
GUM attenders expect questions about sex
Primary care attenders do not necessarily perceive themselves at risk or expect questions about sex
Testing in GUM clinics can be anonymous
In General Practice all tests appear in the patients notes
58
Give some advantages of providing sexual healthcare services within general practice
People who are asymptomatic are unlikely to present at a GUM clinic/ they may not know they have an STI
GP practice may be more accessible
Patient may prefer to talk about sexual health with someone they know
Patient may feel uncomfortable about attending a GUM clinic
Patients may feel that they would be better supported in GP practice
Possible to test for STIs at the same time as providing other care e.g. cervical smears
59
How might you introduce the topic of sex into a consultation?
Ask pt what they think
Make it routine
Introduce by making a statement
Followed by one or two questions which asks person for permission to go on to talk about persons sexual health
60
How can you establish that someone is at no apparent risk of STI?
Not sexually active
Monogomy: not had sex with anyone else
Condom use
Been tested and not had sex since then
61
What is a DNAR order?
A do not attempt resuscitate order
Medical order instructing health care providers not to do cardiopulmonary resuscitation (CPR) if breathing stops or if the heart stops beating
62
What is an advance care plan?
Structured discussion with patients and their families or carers about their wishes and thoughts for the future
Processes which enable individuals to be involved in decisions
regarding future care. It is a voluntary process of discussion and review. Identifies a person’s preferences in the context of an anticipated deterioration in their condition
63
What needs to be done with regards to an advanced care plan when it is put in place?
Documented
Regularly reviewed
Communicated to key persons involved in their care
64
What issues should you discuss with a patient when determining their advance care plan?
What they want to happen
What they don’t want to happen
Who will speak for them
65
What are triggers to people seeking medical help?
Interpersonal crisis
Interference with social or personal relations
Sanctioning by others
Interference with vocational or physical activity
Temporalizing of symptomatology
66
What is the prognosis for someone with bronchiectasis?
Depends on the cause:
Ciliary dysfunction- progressive damage and respiratory failure
Not related to ciliary dysfunction- relatively good if physiotherapy is performed regularly and antibiotics are used aggressively
10% of adults with non-CF bronchiectasis die within 5-8 years of diagnosis, with the cause of death being respiratory in over half of those
67
In a community acquired pneumonia in a child, what are the likely causative organisms?
Strep pneumonia is the most likely bacterial pathogen
| Viruses must also be considered. e.g. rhinovirus
68
In children with recurrent chest infections, what factors might you want to explore in the home and with the family?
```
Condition of housing
Smokers in the house
Family history of chest problems
Prematurity
Immunisation records
```
69
What are some long term effects of recurrent childhood chest infections?
Some pneumonias are destructive (eg, adenovirus) and can cause permanent changes, most childhood pneumonias have complete radiologic clearing. If a significant abnormality persists,
consideration of an anatomic abnormality e.g. abnormally narrowed airways or muscular problems, is appropriate and appropriate radiological investigations should be performed
70
Define immigrant
Anyone who moves to another country for at least a year
71
Define asylum seeker
Person who claims asylum in the UK due to persecution in their country of origin
72
Define refugee
Person fleeing their country due to conflict
| Also a person who has been granted asylum
73
Asylum seekers can apply for basic housing and monthly subsistence payments. Who provides this?
National Asylum Support Service (NASS), dept. within the UK Border Agency
74
Discuss GP services for asylum seekers
May be no special service in their area: difficult to access GP – language, can’t register
In dispersal areas usually specialised provision for asylum seekers - either: A service which screens, then registers asylum seekers with local GPs, or a service which screens and keeps them as registered patients
75
What are some migrant health issues?
Infectious diseases: hepatitis B, hepatitis C, HIV, syphilis, TB, leprosy
Malnutrition, anaemia, parasitic infestation
Untreated major and minor conditions
Female genital mutilation
Trafficking and modern slavery
Effects of detention and torture, physical and mental
Effects of exposure to conflict
76
Describe the meridian practice in Coventry
Asylum seekers from Iran, Iraq, Afghan, Syria
Mostly aged 20–40 years old
After registering, detailed nursing assessment, which includes asking why they seek asylum
Two GPs, need to understand asylum process
Professional interpreters for over 50% of appointments
77
What happens at a nursing assessment for asylum seekers?
Lasts 60-90 minutes
Current and past medical history
TB screen/mental health screen/sexual health
Women are asked about history of FGM, relates to own health and safeguarding daughters
Asked in outline why they are seeking asylum
Referral to GP re any issues identified
78
What are some TB screening questions?
```
Persistent cough?
Coughing blood?
Significant weight loss?
Night sweats?
In contact with TB?
```
79
What screening tests are done for asylum seekers?
Blood tests for: HIV, hepatitis B, hepatitis C, syphilis, haemoglobinopathies (sickle cell, thalassaemia)
Interferon gamma assay test for TB – T-spot
Chlamydia (under-25s) – national policy
FBC
Other blood tests as indicated eg HbA1c
80
What annual things should be put into place for HIV positive patients?
Cervical smears for female HIV +ve patients
| Annual flu vaccs, and pneumococcal vaccination
81
What are problems with illegal immigrants in relation to health care?
No access to health care, no NHS number, can’t register with GP. Use A and E
82
What is being done to eradicate female genital mutilation in the local area?
Regular multi-agency group meeting to research, raise awareness, plan strategy
Community groups and men groups crucial
All GPs must now document FGM and safeguard girls at risk
Reporting to Health Service
83
What medical malpractice may lead to a criminal prosecution?
Gross negligence
Manslaughter
Criminal battery
84
What medical malpractice may lead to a civil action?
Civil battery
Negligence
Breach of contract
85
What is the aim of a legal course of action in battery?
Compensate a person for uninvited invasion of bodily integrity
86
What is the aim of a legal course of action in negligence?
Compensate a patient for harm caused by negligent conduct of the doctor
87
What are the elements of battery?
Non-consensual physical contact
Patient must prove lack of consent
No need to prove damage
Defendant may be liable for all damage flowing from the battery
88
What are the elements of negligence?
Duty of Care: Whenever one can reasonably foresee that one’s conduct may cause harm to another
Breach of duty: claimant must show that defendant fell below required standard of care
Causation: claimant must establish that his condition was worsened or unimproved condition was caused by doctor’s negligence
All 3 required to prove negligence
89
What is duty of care?
You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour
90
Describe the scope of duty in relation to duty of care
In order for a duty of care to arise, a sufficiently proximate relationship must exist to make imposition of such a duty fair
In medical context, duty arises when doctor assumes responsibility for the patient, e.g. undertakes the task of treating the patient
91
How is it decided what the standard of care is in relation to a negligence claim?
Doctor cannot be found liable in negligence if she can find a responsible body of medical opinion that might have done as she did in those circumstances
If other reasonable doctors might have done as the defendant doctor did then doctor is not negligent
92
What are criticisms of Bolam in terms of how negligence is determined?
Makes doctors themselves the final arbiters of what is or is not negligent
Prevents judges from having any right of oversight, not allowed to assess expert evidence themselves, only check whether or not it existed
This is different to the way standard of care operates for all other professions
93
What was the outcome of the Bolitho case in relation to medical negligence?
House of Lords held that it was open to the courts to find negligence even where defendant doctor could provide some expert evidence on her own behalf
However, only in rare case that evidence provided by defendant’s experts was unable to withstand logical analysis
94
Describe what measures are in place to protect patients from medical negligence
Requirement of peer support: If doctors can find other doctors to testify on their behalf, then that is strong evidence that they are acting responsibly (Bolam)
Possibility of court oversight: judge can review evidence and assess whether it is logical. In the very rare case that it isn’t, the judge can
intervene and find negligence anyway (Bolitho)
95
Which legal case lead to a change in the requirements for risk disclosure and consent to protect against negligence?
Montgomery v Lanarkshire Health Board
Woman with diabetes, had severely disabled child due to mechanical complications arising during delivery due to shoulder dystocia. She was not warned about the risk
96
Describe how causation has to be shown in a negligence claim
Breach of duty is not in itself actionable. Claimant must also demonstrate that defendant’s negligence caused his injuries
Traditional ‘but for’ test is appropriate where it can be simply applied
97
What are the rules on failure to examine in relation to negligence?
Where a defendant fails to attend a patient, and patient suffers injury, it must be demonstrated that defendant had she attended would have made a Bolam-compliant decision
House of Lords held that two doctors who negligently failed to examine a patient with severe respiratory problems did not ‘cause’ patient’s injuries and death because they claimed they would not have intubated and thus acted in accordance with requirements of Bolam
98
What is different in negligence if there are multiple causes?
Breach of duty sounds in negligence if, on the ‘balance of probabilities’, it causes, or ‘materially contributes’ to the injury
99
What is lost chance in relation to negligence?
Doctor does not ‘cause’ the injury per se but removes chances of a patient recovering from a pre-existing condition
100
How does lost autonomy relate to negligence claims?
Courts have held that a claim can be established if a medical professional negligently fails to warn of a risk as a result of which the claimant agrees to undergo an operation, and the risk materialises, even when if properly advised, she would have undergone the operation eventually, but not at that time
101
What happened in the Simms vs Simms case?
Court considered an application that two persons suffering
from variant Creutzfeld Jakob disease should be given innovative treatment which was new and untested on humans. Court decided that first question was whether the doctors would be acting in accordance with a responsible and competent body of relevant
professional opinion as per Bolam, and the court held that there was a responsible body of professional opinion that supported the innovative treatment
102
What is the GMC guidance on prescribing unlicensed medications?
Commonly used in some areas of medicine such as in paediatrics, psychiatry and palliative care
Should usually prescribe licensed medicines in accordance with terms of their licence. However, you may prescribe unlicensed medicines where, on the basis of an assessment of the individual patient, you conclude, for medical reasons, that it is necessary to
do so to meet the specific needs of the patient
103
What is the medical innovation bill?
Purpose of this Act is to encourage responsible innovation in medical treatment
Not negligent for a doctor to depart from existing range of accepted medical treatments for a condition if decision to do so is taken responsibly
Responsible innovation will not be negligent, even in circumstances where no responsible body of medical opinion would support that departure, provided he takes that decision responsibly
104
What is procedural responsibility in relation to medical innovation?
Obtain views of one or more qualified doctors with a view to ascertaining whether treatment would have support of a responsible body of medical opinion
Take full account of views obtained and do so in a way in which any responsible doctor would be expected to
Obtain any consents required by law to carrying out of proposed treatment
Consider any opinions or requests expressed by the patient
Consider risks and benefits that are associated with proposed treatment, treatments that fall within the existing range of accepted medical treatments for condition, and not carrying out any of those treatments
Take such other steps as are necessary to secure that decision is made in a way which is accountable and transparent
105
What sources of organs for transplantation are available?
Xenotransplantation
Living donation: Directed donation (To a specified person, Paired donation, Pooled donation). Altruistic (non directed) donation
Cadaveric donation: Donation after circulatory death, Donation after brain death
106
What are the circumstances under which solid organ donation can occur?
Ventilated and cared for on Intensive Care or in Accident and Emergency
When death has been confirmed by Brain Stem Death Tests
When death is the expected outcome
107
Describe the organ donation referral process
Potential Organ Donors can be referred by anyone to on call Specialist Nurse for Organ Donation who will check Organ Donor Register
108
What proportion of the population are organ donors?
30%
109
Who can register to be an organ donor?
Self registration: No age restriction for self registration or withdrawal from Register
Third Party Registration: Person aged under 16 years of age, parent can register their child or a child for whom they have parental responsibility
Person with Capacity aged 16 years and over, no-one can register another person on ODR
Person without Capacity aged 16 years and over, Mental Capacity Act, an authorised person can send a copy of Lasting Power of Attorney then they can register the person
110
Registration on ODR register is considered as Consent to Organ Donation under which act?
Human tissue act 2004
111
What makes a consent valid?
Given voluntarily by an appropriately informed person who has capacity to consent to intervention in question (patient, someone with parental responsibility for a patient under 18,
someone authorised to do so under an LPA or someone who has authority to make treatment decisions as a court appointed deputy)
Acquiescence where person does not know what the intervention entails is not consent
112
What is the time scale on a valid consent?
When a person gives valid consent to an intervention, in general that consent remains valid for an indefinite duration, unless it is
withdrawn by the person
113
What is the difference between donation after brain stem death and donation after cardiac death?
Donation after Brain-stem Death (Heart Beating Donation), retrieval of organs and eye tissue for purposes of transplantation after death confirmed using neurological criteria
Donation after Cardiac Death, retrieval of organs and eye tissue for purposes of transplantation after death is confirmed using traditional cardio-respiratory criteria. This refers exclusively to ‘controlled’ DCD – donation which follows a cardiac death that is result of withdrawal or non-escalation of cardio-respiratory support therapies that are considered to be no longer in a patient’s best interests
114
What does the human tissue act do in relation to organ donation?
Regulates storage and use of human organs and tissue from living individuals, and removal, storage and use of human organs and tissues from deceased
Lists purposes for which consent is required (Scheduled Purposes)
Specifies who may give consent for Scheduled Purposes
Makes it lawful to take minimum steps to preserve organs of a deceased person for use in transplantation while steps are taken to determine wishes of deceased, or, in absence of their known wishes,
obtaining consent from someone in an appropriate relationship
115
Describe the process of organ donation
```
Entering electronic donor information
Obtaining bloods tissue typing virology
Donor management
Patient assessment
Contact GP
Coroners consent
Transport of Organs
Perfusion, removal and packing of organs
Transfer to theatres
Liaising with theatres
Placing organs
```
116
What support is available for the family of organ donors?
Offer Keepsakes
Letter of thanks & information about recipients
Donor Family Network
Liaison between donor and recipient families
Offer formal bereavement care
117
What are the different types of living organ donation?
Directed donation: To a specified person, Paired donation, Pooled donation
Altruistic (non directed) donation
118
What is paired or pooled organ donation?
Through national living kidney sharing scheme
Donor and recipient are incompatible or mismatched
Pair may be matched to another couple in similar situation so that both people in need of transplant can get one
Pooled is where more than two pairs are involved in swap
119
What are ethical problems with living organ donation?
Concerns about undue pressure on donor
| Risk to donor of process of donation
120
What is brain stem death?
Irreversible loss of the integrative function of brain stem
Irreversible loss of consciousness
Requires mechanical ventilation to breathe
Loss of integrated biological function inevitably leads to organ deterioration and necrosis within a short period of time
121
What is cardiac death?
Irreversible cessation of cardiorespiratory function
Irreversible neurological sequaele (confirmed by absence of pupillary reflex)
Simultaneous and irreversible onset of apnoea and unconsciousness in absence of the circulation
122
Why do we need criteria for confirming death in organ donation?
To avoid distressing delay in confirmation for relatives
To allow withdrawal of ventilation prior to organ necrosis (avoid distress for families and allow a dignified death for patient)
To allow retrieval of viable organs for transplantation
123
What factors can be assessed to determine brain stem death?
Fixed dilated pupils
Absence of corneal reflex
Absence of oculo vestibular reflex
No motor response to supra orbital pressure
No gag or cough reflex in response to bronchial stimulation
Apnoea test (respiratory response to hypercarbia): observe off ventilator for 5 minutes
124
What criteria need to have been fulfilled for cardiac death to be confirmed?
Full and extensive attempts at reversal of any contributing
cause to cardiorespiratory arrest have been made (temperature, endocrine, metabolic and biochemical abnormalities)
Individual meets the criteria for not attempting CPR
Attempts at cardiopulmonary resuscitation have failed
Treatment aimed at sustaining life has been withdrawn because it has been decided to be of no further benefit to patient and/or is in respect of the patient’s wishes via an advance decision to refuse treatment
125
How is cardiac death confirmed?
Individual should be observed by person responsible for certifying death for 5 minutes
Absence of a pulse
Absence of heart sounds
After 5 minutes of cardiorespiratory arrest, irreversible neurological sequaele confirmed by absence of pupillary response, corneal reflex, and motor response to supra orbital pressure
126
What makes a valid consent for a living organ donor?
In a person 18 or over, consent must be explicit, given by the adult, and comply with the requirements of a valid consent
127
What is appropriate consent for a deceased adult to be an organ donor or for public display?
For anatomical examination or public display, only explicit consent in writing and witnessed of deceased person prior to their death
For other purposes: consent of deceased before her death, Her nominated representative(s), or someone in a qualifying relationship with her immediately before she died
128
What is appropriate consent for a living child?
Consent of child if he or she has given valid consent
Without this, consent should be by someone with parental
responsibility for the child
129
What is appropriate consent for a deceased child?
Removal, storage or use of body parts for public display or
anatomical examination: consent of child (witnessed and in writing) when alive is required
For other Scheduled Purposes: consent of child prior to death, if valid
Without this, then consent from someone with parental responsibility
If no such person, then someone in a qualifying relationship with child
130
What is the hierarchy of consent?
```
Spouse or partner
Parent or child
Brother or sister
Grandparent or grandchild
Child of a brother or sister
Stepfather or stepmother
Half brother or half sister
Friend of longstanding
```
131
What ethical principles underly organ donation?
Respect for autonomy (donor)
Benefit to potential recipients (maximising benefit across population)
Duty of care (to donors and recipients)
Justice (fair allocation of organs)
Relationship of trust between: patients and doctors, public and NHS
132
What are advantages of opt in systems for organ donation?
Values autonomy – as long as family cannot override decision
Allows for religious and other objections
Inadequate supply for present needs
133
What are advantages and disadvantages to family decision making in organ donation?
May enable them to feel something good comes out of death
Enables families feelings to be valued
Families are source of information about deceased’s wishes
Recipients like to know family are happy with decision
Difficult time to approach families and may increase distress
134
What are advantages and disadvantages to an opt out system to organ donation?
May increase supply
Still allows for autonomy – again if not overridden by family
Raises worries about State ownership of bodies
May reduce trust between doctors and patients
Raises conflicts of interest for treating doctors (Best Interests decision)
Does not recognise value of a gift relationship
135
What are advantages and disadvantages to sale of organs for donation?
Assumption that it will increase supply
Respect for donor (seller) autonomy
Concerns about exploitation, commodification and fairness of distribution
136
What aspects of life can be impacted by chronic illness?
Daily living activities
Social relationships
Identity (view that others hold of them)
Sense of self (private view of themselves)
137
What type of strategy do parents of ill children with possible innocent explanations tend to adopt?
Adopt wait and see approach: temporalising of symptomology
Consult if symptoms persist or if feeling that child ‘not right’
doesn’t go away
138
What type of strategy do parents of ill children with unusual or frightening symptoms or events tend to adopt?
Tend to interpret these as needing prompt attention
| Seek attention promptly
139
Why might diagnosis be delayed in children?
Temporalising: Place a time limit on signs/symptoms before taking action or making a referral
Discrediting strategies: see parent as lacking creditability
140
What strategies do parents use to avoid delayed diagnosis in their children?
Returning repeatedly, seeing different GPs, using private health care, visiting Emergency Department
141
Which is reported as the most distressing symptom by parents when children are ill?
Pain
142
What threats to their identity might children face when they have a chronic illness?
Changes to appearance: hair loss, effects of steroids, scarring, Hickman lines, portable ventilator
Perceived to be different or treated differently by others
Changes to roles and relationships
Forms of care associated with infancy: bathing, help with toilet and feeding
143
What normalisation strategies might be adopted in children with a chronic illness?
Passing as normal: try to maintain pre-condition state/identify by concealing illness, reluctance to give up activities
Re-designation of normal life: new ‘normal’ develops
144
What biographical disruption can occur when a child has a chronic illness?
Threats to identity: Changes to appearance, Perceived to be different or treated differently by others, Changes to roles and relationships, Forms of care associated with infancy
Adopt normalisation strategies: Passing as normal, concealing illness, reluctance to give up activities
Difficulty maintaining a socially acceptable identify among peers: exclusion by healthy friends, friends don’t know how to behaviour around them, feel outcast
145
Give examples of children's coping strategies
Keep pre-illness lifestyle
| Re-designation of illness life as new ‘normal life'
146
What biographical disruption may occur to the mother of a child with a chronic illness?
Redefining of mothers’ self identities
New roles and obligations
Intensification of existing roles and obligations
147
Who can consent for a person under 18?
Someone with parental responsibility
The court
Young person aged 16-18 yrs assumed to have capacity
Young person under 16 years may demonstrate capacity (Gillick)
May treat without consent in an emergency
148
Which Statute governs the treatment of children?
Children act 1989
149
When a court determines any question with respect to the upbringing of a child or the administration of a child’s property or the application of any income arising from it, what is the paramount consideration?
Child’s welfare shall be the court’s paramount consideration
150
In an assessment of a child's best interests, what should be taken into consideration?
Views of the child or young person, so far as they can express them, including any previously expressed preferences
Views of parents
Views of others close to the child or young person
Cultural, religious or other beliefs and values of the child or parents
Views of other healthcare professionals involved in providing care to the child or young person, and other professionals who have an interest in their welfare
Which choice, if there is more than one, will least restrict the child or young person’s future options
151
What ethical principle underlies involving children in discussions and decisions about their care?
Respect for autonomy
152
In order to respect children, what steps should you take when dealing with their care?
Involve children and young people in discussions
Be honest and open with them and parents, respect confidentiality
Listen to and respect views about their health, respond to concerns and preferences
Explain things using language or communication they can understand
Consider non-verbal communication, and surroundings in which you meet them
Give them opportunities to ask questions, answer these honestly and to the best of your ability
Make open and truthful discussion possible, this can be helped or hindered by the involvement of parents or other people
Give them the same time and respect that you would give to adult patients
153
What are ethical challenges in caring for young children?
Both parents and clinicians have a duty of care to the child
Duty is to act in the child’s best interests
Interpretation of this duty in specific contexts may differ between clinicians and parents
Parental autonomy with regard to decisions about their child is not absolute
A child’s autonomy is developing over time
A clinician needs to maintain a therapeutic relationship with both the child and her parents
154
What is the difference between equal and equitable access to health care?
Equal access: everyone the same, regardless of need, widens inequalities
Equitable access: providing services based one someone's needs
155
What is horizontal inequity?
People with same needs don't have access to same resources
| Unequal treatment of equals
156
What is vertical inequity?
People with greater needs are not provided with greater resources to meet those needs
157
What is the inverse care law?
Availability of good medical care tends to vary inversely with need for it in the population served
158
Why should we address inequities in health care?
Justice and fairness
Equitable access to medical and health care can contribute towards reductions in health inequalities
Not addressing inequity in access to health care may widen health inequalities
Duty under Equality Act 2010: public sector duty
159
Will tackling inequities in health care have an impact to reduce health inequalities?
Half of recent fall in CHD mortality attributable to improved treatment uptake across all social groups
Increasing proportion of resources allocated to deprived areas compared with more affluent areas associated with a reduction in absolute health inequalities from causes amenable to healthcare
15-20% of life expectancy gap can be influenced by health care interventions
160
What different inequities exist in the health care system?
Inequities in access to services: Access to facilities, Access to treatment and care
Inequities in utilisation of primary and secondary services
Inequities in availability of responsive services
161
What inequities exist in primary care in the UK?
Those with greatest health needs have greatest access to GP care – pro-poor bias
Higher use of GPs by those on low income, with low educational attainment and minority ethnic groups
Lower use of GPs by older men but not older women
162
Which groups have difficulty in accessing primary care in the UK?
Asylum seekers
Homeless people
Travellers
163
Which groups under utilise preventative services?
Uptake of screening is lower in socially disadvantaged groups for three major cancers (breast, cervix, bowel) and other preventative care
Low income households less likely to take up immunisations, child health screening
164
What inequities exist in secondary care?
Socio-economic inequities in referral from primary to secondary care for hip pain, dyspepsia – less referrals in practices serving more deprived communities
Inequity in access for total hip and knee replacement surgery: people living in most deprived areas less likely to receive hip or knee
replacements
Inequities in cancer care: Lung cancer: most disadvantaged patients less likely to receive active treatment, Breast cancer: more advantaged women more likely to receive breast constructive surgery (when adjusted for stage of disease)
Inequitable access for older people: Greater hip and knee replacement provision for 60-84 year olds than other age groups, regardless of need
Ethnic inequities in patterns of inpatient treatment: South Asian patients less likely to undergo coronary angiographs than White UK
Poorer access for disabled people: People with learning disabilities and mental health poorer access to some aspects of primary and secondary care. Significant levels of untreated ill-health and high number of avoidable deaths
165
What are reasons for inequitable access to health care?
Physical access (availability): Difficult to register with GP, migrants, refugees and asylum seekers, homeless people. Difficult to get appointments/appointment times not convenient
Geographical access: distance to services and time to travel
Financial costs: prescription and dental charges
Cultural access: lack of interpreters, culturally appropriate services
e.g. female-led family planning services; LGBT responsive services
166
How can clinicians beliefs and attitudes cause inequities in access to health care?
In consultation: some groups given less time and opportunities to participate
Differential referral rates
Different treatment options offered
167
What barriers exist to equity in access to health care?
```
Supply side (provider) barriers
Demand side (users) barriers
```
168
What is required to address barriers in access to health care?
Reduce physical and geographical barriers
Address attitudinal or knowledge biases of clinicians
Reduce variations in quality of services offered to patients with identical needs: eg between areas, age groups, genders
Reduce costs (financial or other) to individuals: these may vary between populations or people with identical needs
Take account of affordability and indirect costs: taking day off
work, childcare, prescription and dental costs
Ensure health service information on availability and type of service is known with equal clarity
Take account of preferences for services, in particular locations/times, services delivered in particular ways
Take account of community and cultural attitudes and norms: eg. some groups of women may prefer women clinicians
169
What is required to reduce inequities in access to health care?
Multidisciplinary approach
Driven by information from health needs assessments
Action at organisational level
170
What are core competencies and characteristics required for primary care?
```
Primary care management
Community orientation
Specific problem solving skills
Comprehensive approach
Person centred care
Holistic approach
```
171
What percent of NHS interactions are in GP?
90%
172
Increasing the supply of primary care physicians, even after correction for socioeconomic factors, results in what changes?
Lower all cause mortality
Lower mortality from cancer, heart disease and stroke
Increased life expectancy and better self reported health
Lower rates of admission to hospital
Lower infant mortality
Reduced health inequalities
Reduced costs
173
Why does primary care work?
Greater access to needed services
Better quality of care
Greater focus on prevention
Early management of health problems
Cumulative effect of main primary care delivery characteristics
Role of primary care in reducing unnecessary and potentially harmful specialist care
174
What are the 5 domains of the quality outcomes framework?
```
Clinical
Public Health
Public Health - Additional Services
Patient Experience
Quality and Productivity
```
175
What are local and directed enhanced services?
Local enhanced services: schemes agreed by PCTs in response to local needs and priorities, sometimes adopting national service specifications. Childhood immunisation, learning disability health checks
Directed enhanced services: schemes that PCTs are required to
establish or to offer contractors the opportunity to provide, linked to national priorities and agreements. Extended opening hours
176
What did the 2012 health and social care act do for the provision of primary care?
Abolished strategic health authorities and Primary Care Trusts
211 Clinical Commissioning Groups formed in England
Responsible for £65 billion of NHS £95 billion commissioning budget
Commissioning for hospital care, community care and mental health services
All GP practices have to be members of a CCG
177
What are clinical commissioning groups?
Planning services based on the needs of local population
Securing services that meet the needs of local population
Monitoring the quality of care provided
178
What is a federation in primary care?
Group of practices and primary care teams working together, sharing responsibility for developing and delivering high quality, patient focussed services for their local communities
179
What are current challenges being faced in primary care?
Ageing population
Case management
Unplanned admissions
More services in primary care
180
What is family medicine?
Lasting, caring relationships with patients and their families
Integrate biological, clinical and behavioral sciences to provide continuing and comprehensive health care
Encompasses all ages, sexes, organ systems and every disease entity
181
What is hypertension?
Blood pressure level above which investigation and treatment do more good than harm
Usually over 140/90
182
What is essential or primary hypertension?
Unknown cause
183
What is secondary hypertension?
Has a known diagnosable cause
184
What is the definition of severe hypertension?
Over 180/110
185
In a 24 or 48 hour blood pressure recording, what features would you expect to see in a person with labile hypertension?
Nocturnal dip - decrease in BP at night time
| Morning rise back to hypertension
186
If a long term BP monitor shows hypertension that is non dipping, what is the risk?
Higher risk of cardiovascular mortality
187
List some causes of secondary hypertension
```
Primary hyperaldosteronism (Conn’s syndrome): Adrenal adenoma, Adrenal bilateral hyperplasia
Renovascular disease: fibromuscular dysplasia, atherosclerotic
Obstructive Sleep Apnoea
Chronic Kidney Disease
Phaeochromocytoma
Aortic coarctation
Cushing’s disease
Hyperparathyroidism
```
188
What is fibromuscular dysplasia?
Non-atherosclerotic, non-inflammatory disease of blood vessels that causes abnormal growth within wall of an artery
Most common arteries affected are renal and carotid arteries
Causes renal artery stenosis
189
What is treatment for Conns syndrome?
Spironolactone ± surgery
190
What are key investigations for Conns syndrome?
Plasma Aldosterone: Supine and Standing
Plasma Renin Activity: Supine and Standing
24h Urinary excretions: K, Cr, Vol
191
What are the symptoms of phaeochromocytoma?
```
Severe hypertension (intermittently)
Hot flushes
Palpitations
Sweating attacks
Chest pain
Headache
Blurred vision
```
192
What is Phenoxybenzamine?
Alpha blocker
| Used in treatment of hypertension, particularly when caused by phaeochromocytoma
193
What histopathological findings would you expect to find in a patient with phaeochromocytoma?
Spindle-shaped chromaffin cells and their supporting cells (sustentacular cells) aggregated into small nest known as Zellballen with a rich vascular network
194
What can be causes of pseudo resistant hypertension?
White-coat hypertension
Inaccurate measurement: e.g. cuff-size
Poor adherence to treatment
195
What is resistant hypertension?
Patient’s BP not controlled to recommended BP goals
196
What are the general characteristics of resistant hypertension?
```
Older age (especially >75 years)
High baseline BP
Chronicity of uncontrolled hypertension
Target organ damage (LVH and/or CKD)
Diabetes
Obesity
Atherosclerotic vascular disease
Aortic stiffening
Women
Black African origin
Excessive dietary sodium
Drugs
```
197
Give some examples of drugs which raise blood pressure
```
NSAIDs
Oral contraceptive pills
Theophylline
Cyclosporine
Erythropoietin
Cocaine
Nicotine
```
198
What non pharmacological treatment options are there for blood pressure lowering?
```
Reduction in sodium (salt) intake
High potassium diet
Weight reduction
Regular dynamic exercise
Moderate alcohol consumption
```
199
What classes of drugs can be used to treat hypertension?
```
Diuretics
Beta-adrenoceptor blockers
Calcium channel blockers
ACE inhibitors (ACE-i)
Angiotensin II receptor blockers (ARB)
Direct renin inhibitors (DRI)
Alpha-adrenoceptor blockers
```
200
Define risk
Probability that a hazard will give rise to harm
201
What is a benefit of risk communication with patients?
Patients can be more involved about making decisions about their healthcare
202
What are potential challenges of risk communication with patients?
Collective statistical illiteracy
| Patients’ may lack numeracy skills
203
What are different methods for presenting risk reduction?
Relative risk reduction
Absolute risk reduction
Number needed to treat
204
What is relative risk reduction?
Absolute risk reduction / event rate in control group
205
What is absolute risk reduction?
Event rate in control group - event rate in intervention group
206
What is number needed to treat?
100 / absolute risk reduction
207
Which of absolute risk reduction and relative risk reduction is more likely to suggest that the benefits of treatment are greater than they are?
Relative risk reduction
208
Risk of disease in control group is 20% compared with risk of 10% in the intervention group. What is the Relative Risk Reduction (RRR)?
20 - 10 / 20 = 50%
209
Risk of disease in control group is 20% compared with risk of 10% in the intervention group. What is the Absolute Risk Reduction (ARR)?
20 - 10 = 10%
210
Risk of disease in control group is 20% compared with risk of 10% in the intervention group. What is the Number Needed to Treat (NNT)?
100 / (20-10) = 10
211
What is mismatched framing?
Use relative risk to point out the benefits but absolute risk for the harms
212
What is ratio bias?
Use bigger denominators to make it look impressive (5/10 v 500/1000)
213
What is framing when explaining risk?
Use the bigger percentage to make your point (chance of winning is 10%;chance of losing is 90%)
214
What emotional tactics can be used when explaining risk?
Smiley faces on patient decision aids
Groups of faces, red for negatives
DNR v allow natural death
215
What is a patient decision aid and what are benefits of using them?
Aim to clearly present evidence based information about risks and benefits of treatments in a format that patients understand
Improves patients’ knowledge
Promotes effective shared decision making
216
What is a QRISK2 calculator?
Calculates risk of a patient having a heart attack or a stroke over next 10 years
Aids decisions about starting medications e.g. statins
217
What are limitations of patient decision aids?
Patient factors: do patients understand
Doctor factors: how we use them
Recent BMJ study found no improvement in patient empowerment
218
What is it called if doctor control is high and patient control is low?
Paternalism
219
What is it called if patient control is high and doctor control is low?
Consumerism
220
What is it called if both doctor and patient control is high?
Mutuality
221
What are steps to a patient centred clinical method?
Explore both disease and illness experience
Understand whole person
Finding common ground
Incorporate prevention and health promotion
Enhance patient doctor relationship
Be realistic
222
What factors may affect the level of control a patient feels that they have?
```
Social factors
Education
Sex
Age
Minority group
Personality
Experiences
Time pressure
Perceived attitudes of doctors
```
223
Describe the process of shared decision making
Both doctor and patient involved
Sharing of information and expertise
Steps taken to build consensus
Agreement on course of action
224
What doctor communication skills facilitate shared decision making?
```
Attentive listening
Provision of explanation
Acknowledging patient as equal
Provision of choice
Willing to discuss expertise
Offer expert opinion
```
225
What doctor characteristics facilitate shared decision making?
Patient centred
Caring
Holistic
Open and honest
226
What makes a successful consultation from doctor and patient perspectives?
Doctor: Exploring symptoms and signs, Investigations, Consideration of the underlying pathology, Differential diagnosis
Patient: Exploring ideas, concerns, expectations, Feelings, thoughts and effects, Understanding of patient's unique experience of illness
227
What are patient views on what makes a successful consultation?
Having a friendly and caring attitude
Understanding of how life is affected
Seeing same health professional
Guiding through difficult consultations
Taking time to answer questions and explain things well
Pointing towards further support
Efficient sharing of health information across services
Involving patient in decisions about their care
228
What is the Stott and Davies model of a consultation?
Management of presenting problems
Management of continuing problems
Modification of health seeking behaviour
Opportunistic health promotion
229
What is the medical model of a consultation?
```
Patient comes with symptoms
Doctor gathers more information by history taking and examination
Doctor forms a diagnosis
Doctor tells patient diagnosis
Doctor informs patient about treatment
```
230
What are Balints key ideas?
```
Ticket of entry and hidden agenda
Active listening
Doctor as a drug
Apostolic function
Mutual investment fund
The “Flash”
```
231
What ego states may be adopted by a patient in a consultation? And what are some advantages and disadvantages of these?
Parent: + Keep safe, calming, nurturing, supportive
- Controlling, patronising, critical, finger-pointing
Adult: ideal state
Child: + Curious, playful, creative, spontaneous
- Rebellious, tantrums, difficult, insecure
232
What is concordance?
Negotiated, shared agreement between clinician and patient concerning treatment regime, outcomes and behaviours
More co-operative relationship than those based on issues of
compliance and non-compliance
233
What is compliance?
Fulfilment by patient of the healthcare professional’s recommended course of treatment
234
What is adherence?
Extent to which a person's behaviour - taking medication,
following a diet, and/or executing lifestyle changes,
corresponds with agreed recommendations from a health care provider
235
How can concordance be reached?
Therapeutic alliance and negotiation between prescriber and patient
Patient encouraged to discuss concerns about medications that have been prescribed, preferences for treatments and participation in decision making
Health professional gives evidence based information to patient and shares his or her clinical experience
236
What types of therapeutic behaviours may need to be negotiated with a patient?
```
Seeking medical attention
Filling prescriptions
Taking medication appropriately
Obtaining immunisations
Attending follow-up appointments
Behavioural modifications that address personal hygiene
Self-management of asthma or diabetes
Smoking
Contraception
Risky sexual behaviours
Unhealthy diet
Insufficient levels of physical activity
```
237
What are the problems caused by poor concordance?
Poor treatment outcomes and direct clinical consequences
| Increases financial burden on society: excess urgent care visits, hospitalisations and higher treatment costs
238
What are patient centred factors which affect concordance?
```
Demographic
Psychological
Patient Prescriber Relationship
Health Literacy
Patient Knowledge
```
239
What demographic factors may affect concordance?
Age: better concordance as get older until disabilities occur, younger patients’ work commitments hamper concordance, adolescents have poor concordance - rebellious behaviour and disagreement with parents and authorities, want to live a normal life like their friends
Ethnicity, Gender & Education: equivocal results, except in adolescents with diabetes
Marriage: increases concordance, due to support from spouse
240
What psychological factors may affect concordance?
Beliefs and Motivations: positive - Patient believes illness poses threat, Motivated to take treatment if believe it is effective. Negative - Patient believes disease uncontrollable, Fear dependence on treatment, Fear treatment will become ineffective, Religious Beliefs, Cultural
Attitude towards therapy: Depression, anxiety, anger towards illness, Adolescents feel stigmatised and different to their peers
241
How can the patient- prescriber relationship affect concordance?
Communication
Patient’s trust in prescriber
Empathy of prescriber towards patient
Negative - Patients feel that Doctors lack compassion for their problems, Multiple physicians involved in care
Positive - Patients help design treatment plan, Detailed explanation re disease and treatment, Patients need to understand illness and therapy
242
What factors of health literacy can affect concordance?
Being able to read
Understanding what is read
Remembering what is read
Acting on information
243
What factors of knowledge can affect concordance?
Therapy and its role
Lifestyle changes
Clinics and their role
Long term complications
244
What are some lifestyle factors which are patient centred and may affect concordance?
Smoking and alcohol: asthma, HT, renal transplant
| Forgetfulness: related to meal frequency
245
What therapy related factors may affect concordance?
Route of Administration: oral best
Treatment complexity: dosing frequency not quantity
Side effects
Degree of behavioural change needed: Type II diabetes
Duration of treatment
246
What social and economic factors may affect concordance?
Time commitment for appointments
Affording prescriptions
Social Support: family and friends
247
What factors of the healthcare system may affect patient concordance?
Availability & Accessibility of services
Waiting times Problems getting prescription
Quality of Consultation
248
What factors of the disease may influence a patients concordance?
Concordance reduces with: Fluctuating/ absent symptoms eg hypertension, Severity eg adolescents better with mild asthma
Concordance improves with: Marked improvement of symptoms, Perceived poor health status
249
What are the doctors and patients roles in a concordant relationship?
Doctor and patient are equals and in partnership
Doctor explains illness and explores patient beliefs
Doctor describes treatment options so understandable
Patient and doctor discuss beliefs about treatment
Patient makes informed decisions
Patient controls choice and takes responsibility
250
What are the challenges to the health service with concordance of long term condition treatment?
Multiple treatments required
Depression is prevalent
Promote self management
251
What health problems do adolescents face which require a change of attitude?
Learning to manage onset of new conditions: Type 1 diabetes, mental health conditions and cancer
Long-term self-management of chronic conditions largely initiated in
adolescence
252
What are risk behaviours?
Those that potentially expose people to harm, or significant risk of harm which are associated with poor health or psychosocial outcomes
253
Why are risky behaviours prevalent in adolescents?
Disparity in maturation between limbic system and prefrontal cortex during early to mid-adolescence
Early development in limbic system: pleasure seeking, reward processing, emotional responses, sleep regulation
Protracted development in the pre-frontal cortex: decision-making/reasoning, organization, impulse control/behavioural inhibition, planning for future
254
In which age group are control of and outcomes for long-term conditions the poorest?
Adolescence
255
Why are young people with chronic conditions doubly disadvantaged by risk taking behaviour?
Engage in risky behaviours at similar rates as healthy peers
Potentially have greater risk of adverse health outcomes for these behaviours
256
When is self management laid down?
Strong evidence that self-management is partially laid down in adolescence
Adolescence is a period of transition to self-management with ups and downs along the way
257
Why do young people find self management and adherence challenging?
Working towards independence and autonomy
New environments and activities
New relationships with peers, family and clinicians
258
What factors may influence concordance in adolescents?
Developmental age
Gender issues
Family relationships
259
What proportion of young people with diabetes achieve recommended HbA1c levels?
18%
260
What are young people’s views about why self-management can be difficult?
Management regimes perceived as difficult and demanding
Self monitoring perceived as inconvenient and disruptive – social activities take priority
Feeling of being controlled by parents, school staff,c linicians
Management regimens can make it difficult to ‘fit in’ – Wanting to ‘pass’ as normal
261
What is gender?
Social and cultural meanings assigned to being male or female
262
What are differences between how girls and boys deal with their diabetes management?
Girls more likely to incorporate diabetes into their identify, More open about their condition with friends, able to self-care, associated with less parental monitoring, Secret non-adherence: associated with less monitoring, Consequential feelings of guilt and self-blame, Can feel pressures of taking over self-care
Boys: perceive diabetes to be more of a threat to their gender
identify (masculine status) than girls, Less open about condition or
managed condition in public – 'passing’ strategy, Less independent in management - mothers more likely to be involved in management of diabetes
263
What do young people with chronic conditions want?
```
Treat them like a person
Under-standing
Don’t treat them differently
Encouragement and support
Don’t force them
Know what you are doing
Give them options
```
264
What is Gillick competence?
Applies to young people under age of 16 years
If assessed as competent to make decision in question
then can consent to treatment
Competence test: depends on child’s maturity and understanding and nature of consent required
Child must be capable of making a reasonable assessment of the advantages and disadvantages of treatment proposed
265
What are the Fraser guidelines?
Specific to contraception, abortion and STIs
Doctor can give advice and treatment if satisfied with following:
The girl (although under 16 years of age) will understand advice
He cannot persuade her to inform her parents or to allow him to
inform the parents that she is seeking contraceptive advice
She is very likely to continue having sexual intercourse with or
without contraceptive treatment
Unless she receives contraceptive advice or treatment her physical
or mental health or both are likely to suffer
Her best interests require him to give her contraceptive advice,
treatment or both without the parental consent
266
Who can consent for a young person under 18 years old?
Competent child (over 16yrs assumed competent)
Someone with parental authority
The court
Someone appointed by the Court
267
When can a doctor override an adolescents refusal of treatment?
Circumstances which will in all probability lead to the death of the child or to severe permanent injury
268
Which acts cover the refusal of medical treatment in adolescents?
Children Act 1989
United Nation Convention on the Rights of the Child 1989
Reflect the tension between wishing to respect a child’s autonomy and to protect them from harm
269
What does the UN convention on rights of a child say about refusal of medical treatment by an adolescent?
In all actions concerning children, best interests of the child shall be a primary consideration
Child who is capable of forming his or her own views has right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child
270
What does the children act say on child’s welfare and views?
When court determines any question with respect to: upbringing of a child or administration of a child’s property or application of any income arising from it, child’s welfare shall be the court’s paramount consideration
Court shall have regard in particular to ascertainable wishes and feelings of the child concerned (considered in the light of his age and understanding)
271
What progressional guidance is there for cases of refusal of treatment by adolescents?
Carefully weigh up the harm to rights of children and young people of overriding their refusal against benefits of treatment, so that decisions can be taken in their best interests
Consider involving other members of the multi-disciplinary team, an independent advocate, or a named or designated doctor for child protection
Legal advice may be helpful in deciding whether you should apply to the court to resolve disputes about best interests that cannot be resolved informally
272
When an adult lacks capacity, what do you need to check?
Whether an advanced directive exists
If no ART, is there a Lasting Power of Attorney?
If no ART/ LPA, Best Interests criteria
273
What philosophy underlies the mental health act?
Limiting autonomy in order to assess and treat vulnerable patients with a mental disorder
274
What are the 5 key principles of the mental capacity act?
Every adult has right to make his/her own decisions and is assumed to have capacity unless it is proved other wise
Just because an individual makes what is seen as an unwise decision, they should not be treated as lacking capacity to make that decision
Anything done or any decision made on behalf of a
person who lacks capacity must be done in their best interests
Person must be given all practicable help before anyone treats them as not being able to make their own decisions
Anything done for or on behalf of a person who lacks capacity should be least restrictive of their basic rights and freedoms
275
What is the purpose principle of the mental health act?
Decisions under MHA must be taken with a view to minimising undesirable effects of mental disorder, by maximising safety and wellbeing (mental and physical) of patients, promoting their recovery and protecting other people from harm
276
What are the underlying principles of the mental health act?
```
Purpose principle
Least restriction principle
Respect principle
Participation principle
Effectiveness, efficiency and equity principle
```
277
What is the legal definition of a mental disorder?
Any disorder or disability of the mind including:
Mental health problem normally diagnosed in psychiatry
Learning disability, only when associated with abnormally aggressive or seriously irresponsible conduct
Substance misuse, only when it exists in association with another psychiatric diagnosis
278
Who is sectionable?
Holding powers: For assessment, For treatment
| Even if the patient has capacity to consent
279
What is the mental health act holding power?
Power to detain a person or take them to a place of safety, if it is suspected they might have a mental disorder that requires psychiatric assessment and possibly the making of any necessary arrangements for his/her treatment or care
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Who carries out a mental health act psychiatric assessment?
Two doctors (at least one trained and registered under section 12(2) of the MHA1983) and a non-medical Approved Mental Health Professional (AMHP)
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What is the process for Application at a hospital registered with the Care Quality Commission for use of the MHA holding power?
Application by the Registered Medical Practitioner or nominated deputy/Approved Clinician
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What is the process of Application by the Police for a mental health act holding power?
Section 136 empowers a police constable to remove anyone in a public place who appears to be mentally disordered to a place of safety for psychiatric assessment and the making of any
necessary arrangements for his/her treatment or care
no right of appeal
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Who would fulfil the criteria for an admission for assessment under the mental health act holding powers?
Person suffering from mental disorder of a nature or degree
which warrants detention of the patient in a hospital for assessment (or for assessment followed by medical
treatment)
Ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons
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What does detention for treatment under the mental health act require?
Mental health act psychiatric assessment
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Who fulfils the criteria for detention for treatment under the mental health act?
Patient suffering from mental disorder of a nature or degree which makes it appropriate for him to receive medical treatment in a hospital
Treatment is necessary for the health or safety of patient or for the protection of other persons
Treatment cannot be provided unless the patient is detained
Appropriate medical treatment is available
Up to 6 months; rights of appeal
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What kind of treatment can a patient under detention by the mental health act receive?
Medical treatment for the purpose of alleviating or preventing a worsening of a mental disorder or one or more of its symptoms or manifestations
Includes nursing, psychological intervention and specialist mental health habilitation, rehabilitation and care
Treatment of physical health problems only to the extent that such treatment is part of, or ancillary to treatment for mental disorder
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Some treatments for mental health problems have special rules and procedures with regards to treatment under detention of the mental health act, which are these?
Neurosurgery for mental disorder
Surgical implantation of hormones to reduce male sex drive
Electroconvulsive therapy (ECT)
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What does the European Convention of Human Rights say on deprivation of liberty?
Everyone has right to liberty and security of person. No one shall be deprived of his or her liberty unless in accordance with a procedure prescribed in law
No one can therefore be deprived of their liberty without lawful authorisation
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What are Deprivation of Liberty Safeguards (DOLS)?
Mental Capacity Act allows restraint and restrictions to be used but only if they are in a person's best interests
Extra safeguards are needed if the restrictions and restraint used will deprive a person of their liberty
Can only be used if person will be deprived of their liberty in a care home or hospital. In other settings the Court of Protection can authorise a deprivation of liberty
Care homes or hospitals ask local authority if they can deprive a person of their liberty - requesting a standard authorisation
Six assessments which have to take place before a standard authorisation can be given
One key safeguard is that person has someone appointed with legal powers to represent them - representative - and will usually be a family member or friend
Other safeguards include rights to challenge authorisations in the Court of Protection, and access to Independent Mental Capacity Advocates (IMCAs)
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How can you tell if something is a deprivation of liberty?
Is the person subject to continuous supervision and control?
Is the person free to leave? – with the focus being not on whether a person seems to be wanting to leave, but on how those who support them would react if they did want to leave
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Give some examples of deprivation of liberty which may occur in care homes or hospitals
Frequent use of sedation/medication to control behaviour
Regular use of physical restraint to control behaviour
Person concerned objects verbally or physically to restriction and/or restraint
Objections from family and/or friends to restriction or restraint
Person is confined to a particular part of the establishment in which they are being cared for
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What is a social stigma?
Attributes, behaviours or pathological states that set people apart from others, mark them as less acceptable or inferior beings in some way
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List some conditions which are associated with particular social stigma
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Epilepsy
Hearing and visual impairments
HIV and AIDs
Mental Illness
Psoriasis
Physical impairments
Some cancers e.g. lung cancer
Alcohol dependency
Obesity
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What are the different types of social stigma?
Enacted stigma: Real experience of negative attitudes and discrimination
Felt stigma: Fear that prejudice or discrimination may occur
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What is the difference between discreditable stigma and discrediting stigma?
Discreditable stigma: attribute, condition or impairment not immediate obvious or known by many e.g. mastectomy
Discrediting stigma: obvious and visible attribute, condition or impairment
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What type of stigma may someone with mental illness experience?
In times of wellness: felt and discreditable stigma
| During periods of illness: enacted and discrediting stigma
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What are the principles of the mental health act?
Purpose principle: minimise undesirable effects of mental disorder
Least restriction principle
Respect principle
Participation principle
Effectiveness, efficiency and equity principle
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What services are offered by mind?
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Journey bus
Anxiety management courses
Reach - service for children
School support group and teacher training
Befriending service
Gardening group projects
Pathfinder counselling services
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