Station 4 Flashcards
What are the ethical principles of good medical practice?
Autonomy: respect for individual and their ability to make decisions regarding their own health
Beneficence: Acting in best interest of the patient
Non-maleficence: Do no harm
Justice: fairness and equality for the wider community
Tell me about confidentiality?
Confidentiality is a patient’s right and must be respected by entire healthcare team (Human Rights Act 1998)
The Data Protection Act 1998 regulates processing of information about individuals which includes paper and computer records.
The duty of confidentiality continues after a patient has died (Access to Health records Act 1990)
When might you have to disclose confidential information without consent?
Disclosed in public interest where the benefits to an individual or to society of the disclosure outweight the public and patients interest in keeping the information confidential
May be justified to protect patients or others where failure to disclose may expose the patient or others to risk of death or serious harm
The information disclosed must always be proportionate and limited to relevant details only.
Seek consent where able.
Informa patient in writing as soon as a disclosure has been made.
When is implied, express and no consent required?
Implied consent:
- Sharing information within the healthcare team
- CLinical audit
Express consent required:
- Disclosure of identifiable information to 3rd parties eg insurance companies
- medical research
No consent is required:
- Reporting terrorist activity under Terrorism Act 2000
- Notification of communicable diseases
- Reporting serious crime eg murder
- if ordered by judge
What are the stages of grief according to the Kubler-Ross model?
- Shock
- Denial
- Bargaining
- Depression
- Acceptance
Who can be assessed and/or treated under the mental health act 2007?
Excludes- alcohol and drug dependance and learning disability
The patient must be:
- suffering from a mental disorder of a degree that warrants the detention of the patient in hospital for assessment
- ought to be detained under interests of their own health and safety or for protection of others
For treatment:
- purpose is to alleviate or prevent deterioration
- can be treated under section 2 and section 3 (for 3 months)
What adverse outcomes must you consent for?
Side effects, complications or failure to reach desired outcome
- any serious adverse outcome resulting in disability or death however small the risk
- less serious side effects or complications if they occur frequently, and explain what the patient should do if they experience any of them
Explain the difference between a section 2, 3, 4 and 5?
Section 2: admission for assessment
- required application by a AMHP or relative and assessment by 2 doctors (normally pscyhiatrist and GP)
- lasts 28 days
- can’t refuse treatment
Section 3: admission for treatment
- requires application and approval same as section 2
- valid for 6months
- can’t refuse treatment for 3 months then need a second opinion appointed doctor if continuing to treat against will.
(get free after care under section 117)
Section 4: admission for assessment in cases of emergency
- Requires application by relative or AMHP and one clinician to assess
- Valid for 72hrs
- cannot be treated
Section 5: application in respect of a patient already in hospital
- used when difficulty finding an approved clinician
- Section 5(2): allows a doctor to detain a patient for 72hrs
- Section 5(4): allows a nurse to detain a patient for 6hrs
- cannot be treated
Section 137: public place by police- taken to place of safety
What is the disability discrimination act 2005 and who does it apply to?
Defines a diasabled person as someone who has a physical or mental impairment that has a substantial long term adverse effect on their ability to carry out normal day to day activities
Gives disabled people rights in the areas of:
- Employment (entitlement to work place adjustments)
- Access to goods, facilities and services
- Buying or renting land or property
Applies to all employers and everyone who provides a public service except armed forces
Patients with HIV, cancer and MS are covered by act effectively from point of diagnosis rather than disability
What is the DVLA guidance for diabetes in group 1 and group 2 drivers?
Group 1: Not on insulin - only need to notify if >1 episode of hypoglycamia or loss of hypoglycaemia awareness
Group 2: not on insulin- must notify DVLA. Licence renewed if no episodes of hypoglycaemia in last 12m and keeps BD sugar monitoring near times of driving and no loss of hypoglycaemia awareness, no visual issues
Group 1 on insulin: notify the DVLA and must have no more than 1 episode of hypoglycamia, retain awareness of hypoglycamia, measure sugars at start of journey and every 2hrs
Group 2 on insulin: notify DVLA and must have full awareness of hypos, no episodes of hypoglycaemia, measure glucose every 2hrs while driving and have a glucometer with >3months of memory for review
What is DVLA guidance for first fit and epilepsy?
1st unprovoked seizure:
Group 1: notify DVLA and 6months off driving
Group 2: notify DVLA and 5yrs off driving
Epilepsy or mutiple seizures:
Group 1: Notify DVLA, seizure free for 5yrs
Group 2: Notify DVLA, seizure free for 10yrs
When should the DVLA be informed about a transient loss of conciousness
When patient is sitting
Must not drive if occurs while sitting or cardiovascular cause
What are the rules for driving after stroke?
Group 1: must not drive for 1 month, inform DVLA if residual defect at 1month
Group 2: Inform DVLA and must not drive for 1yr
What are the rules for driving after ACS?
Group 1: may resume driving after 1 week if successful coronary angioplasty with LVEF >40% and after 4 weeks if not treated with angioplasty
Group 2: notify DVLA and reviewed at 6weeks
What are the rules for driving after insertion of an ICD?
Group 1: if inserted due to sustained ventricular arrythmia must stop for 6m from date of ICD insertion
Group 2: permanent ban
What are the rules for driving after pacemaker implant or box change?
Group 1: not drive for a week
Group 2: notify DVLA and not drive for 6 weeks
What are the rules for driving if you have Hypertrophic obstructive cardiomyopathy?
Group 1: continue
Group 2: must not drive and must notify DVLA.
If asymptomatic may be able to if at least 25mmHg increase in BP during exercise testing and at least 2 of following criteria:
1. No 1st degree FH of premature death
2. HCM not anatomically severe
3. No serious abnormalitiy of heart rhythm eg non susatined VT
If symptomatic then banned
How might genetic testing for Huntingdons affect somebody?
Financial- career, life insurance
Psychological: anxiety, no cure
Social: family and friends, potential children
Test wont find out what age and how you will be affected
False positive/negative- give false hope
What is the association for British Insurers genetic testing code of conduct?
No insurer can request an applicant to undertake a genetic test in order to obtain insurance
Individuals can apply for 500,000 pounds of life insurance & 300,000 pounds of critical illness insurance without having to tell insurer results of genetic tests
For life insurance >500,000 pounds then results of genetic tests will not be used in assessment unless results in favour or test approved by Genetics and Insurance commitee (currently HD is approved)
What is required for valid consent?
Given voluntarily
Patient appropriately informed
Capacity to make decision
( also must give reasonable alternatives)
Explain the key principles of the mental capacity act?
Every adult has the right to make his or her own decision and must be assumed to have capacity.
Individuals have right ot be supported in thier own decisions
Individuals have the right to make unwise decisions
Anything done for or on behalf of a person without capacity must be in their best interests and must be the least restrictive option.
Applies people aged 16yrs +
What do you do in cases of self harm and consent to treatment?
Assess mental capacity- if incompetent can be treated on basis of temporary incapacity
If competent and refusing treatment then they need a psychiatric assessment to decide whether MCA can be used.
If use of MCA not appropriate then refusal must be respected
What is the NHS and social care complaints procedure?
Complaint must be made within 12months of date the matter occured
Patients can seek advice from PALS (patient advice liaison service) or Independent Complaints Advocacy Service (ICAS)
Local resolution
- aim to resolve verbally with consultant or ward manager
- if unresolved, complaint should be made in writing to consultant, practice manager
- if still unresolved it should be sent to complaints manager
Parlimentary and Health service ombudsman
- If remains unsettled then can complain to health service ombudsman
What does a patient need to prove to bring a claim of medical negligence?
- the treatment fell below a minimunn standard of competence and
- that he or she has suffered injury and
- that it is more likely than not that the injury would have been avoided or less severe with proper treatment
The claim must be made within 3yrs of date of injury
What is the Bolam and Bolitho test?
Bolam test:
In law a practitioner does not breach standards if a responsible body of similar medical peers supports the practice in question.
The montgomery case has changed this and says patients need to be told what a reasonable patient would like to know to make an informed decision.
Bolitho test: (1) “The court should not accept a defence argument as being ‘reasonable’, ‘respectable’ or ‘responsible’ without first assessing whether such opinion is susceptible to logical analysis”, and
(2) “However, where there is a body of medical opinion which represents itself as ‘reasonable’, ‘respectable’ or ‘responsible’ it will be rare for the court to be able to hold such opinion to be other than represented”.
Describe the cycle of change model (Prochaska and DiClemente)
- Pre-contemplation- pt sees no problem with behaviour
- Contemplation- weighing up pros and cons
- Determenation- to carry on as before or to change
- Active change
- Maintenence
- Lapse/replapse
What are the ethical issues surrounding renal transplantation?
Living donor organ donation is always non-conditional (can’t pay somebody)
Careful screening to ensure no harm comes to donor post donation. Work up for donor can potentially reveal new health problems eg HIV
Post transplant- need long term care and compliance with meds and appts.
Living donors must be at least 18yrs
What is the human tissue act 2004?
Regulates removal, storage and use of human tissue
Consent is nearly always required to store human tissue
Before organ donation the donor must be interviewed by an independent assessor fully familiar with Human Tissue Act and not a member of transplant team.
When can life prolonging treatment be withdrawn?
If a patient with capacity has requested or made an advance directive
In best interests of an incompetent patient
The right to life and the prohibition of inhuman or degrading treatment as outlined in The Human Rights Act 1998
What is the doctrine of double effect?
Administration of large doses of medications to reduce pain and suffering may consequently hasten a patients death. Legal providing your intention was to relieve pain and suffering,
Describe the incident reporting system and when incidents need to be reported?
- Local incident reporting systems in each trust- IR1 (incident record 1) form or datix.
- Incidents that have occured, near misses and incidents that might happen (eg due to faulty equipment) should be reported.
What is a significant event?
Any event (positive or negative) which is important or unusual and provides an opportunity to identify an area for learning, improvement or the dissemination of good practice eg unexpected deaths delayed or missed diagnoses medication errors communication failures.
What are the 7 stages of analysis of a significant event?
- Identify significant event
- Collate information
- Facilitated team-based meeting
- Analysis of significant event
- Agree, implement and monitor change
- Write it up
- Report, share and review findings
What is duty of candour?
Being open and honest when things go wrong.
Name some notifiable communicable diseases?
- Acute encephalitis
- Acute infectious hepatitis
- Acute meningitis
- Acute poliomyelitis
- Anthrax
- Botulism
- Brucellosis
- Cholera
- Diphtheria
- Enteric fever (typhoid or paratyphoid fever)
- Food poisoning
- Haemolytic uraemic syndrome (HUS)
- Infectious bloody diarrhoea
- Invasive group A streptococcal disease
- Legionnaires’ disease
- Leprosy
- Malaria
- Measles
- Meningococcal septicaemia
- Mumps
- Plague
- Rabies
- Rubella
- Severe Acute Respiratory Syndrome (SARS)
- Scarlet fever
- Smallpox
- Tetanus
- Tuberculosis
- Typhus
- Viral haemorrhagic fever (VHF)
- Whooping cough
- Yellow fever
What is brainstem death?
When a patient is never going to regain conciousness and never going to breath on their own again
To diagnose it their must be a irreversible pathology causing brain damage
- must be deeply unconscious and must have excluded hypothermia, drugs and metabolic disturbance as causes
- must be apnoeic and requiring mechanical ventilation (this must not be due neuromuscular blockade)
How do you confirm brainstem death and who can do the tests?
Must be carried out by 2 different doctors with at least 5 years registered with GMC
- Pupils must be fixed in diameter and not responsive to incident light. (Cranial nerves II, III).
- There must be no corneal reflex (avoid damaging the cornea). (Cranial nerves V, VII).
- Vestibulo-ocular reflexes are absent. No eye movements occur following the slow injection of at
least 50mls of ice cold water over one minute into each external auditory meatus. Note that the
normal reflex is devation of the eyes away from the side of the stimulus. Access to the tympanic
membrane should be confirmed by otoscopy. Injury or pathology may prevent this test being
performed on both sides – this does not invalidate the test. (Cranial nerves VIII, III). - No motor responses in the cranial nerve distribution should occur as a result of stimulation of any
somatic area. No limb movement should occur in response to supra-orbital pressure. (Cranial
nerves V, VII). - No gag reflex should occur in response to posterior pharyngeal wall stimulation with a spatula.
(Cranial nerve IX). - No cough or other reflex should occur in response to bronchial stimulation by a suction catheter
being passed down the endotracheal tube. (Cranial nerve X). - No respiratory movements should occur in response to disconnection from the ventilator. Hypoxia
should be prevented by pre-oxygenation and insufflation of oxygen through a tracheal catheter.
This tests the stimulation of respiration by arterial carbon dioxide tension which should be allowed
to rise to 6.65 kPa – confirmed by arterial blood gases.
Describe the issues around end of life decisions?
Sanctity of life- view that whenever possible human life should be maintained, could be argued as ethically unjustified if that results in suffering.
Killing vs letting die
Withholding vs withdrawing treatment: withdrawing treatment is a passive act and not killing
In terms of overdose what do you have to consider?
Competency- is psychiatric illness affecting her judgement or is overdose affecting judgement
If lacks capacity then can treat by common law
If has capacity can refuse treatment
Mental Health act cannot be invoked to treat overdose patients.
