Station 4: Ethics Flashcards
Approach to this station:
- Introduction + open questions about understanding
- ICE: respond to cue
SPIKES: delivering bad news
Setting up: privacy, involve other family members
Perception: explore understanding
“what have you been told so far?”
“what is your understanding of the reason we did the test?”
Invitation: how much patient wants to know
“how would you like me to give the information about the test results?”
“would you like me to give all the information, or sketch out the results and spend more time discussing the treatment plan?”
Knowledge: explain at patient’s level of comprehension, and give warning
“I’m sorry to tell you…”
“I’m afraid I have bad news about…”
Emotions: make connecting statement that connects patient’s emotions and its reasons
“I know that this isn’t what you want to hear”
“I can see that this is upsetting news for you”
“I wish the news were better”
Strategy and summary: clear action plan
Emphatic responses
“Yes your understanding of the reason for the tests is very good”
“I can understand how you felt that way”
“You were perfectly correct to think that way”
“It appears that you’ve thought things through very well”
4 ethical principles?
- Automony: right to self-determination
- Beneficence: promoting of well-being to others
- Non-maleficence: do no harm
- Justice: fair distribution of resources
Informing DVLA - example sentences:
- The risk of you having this disease and driving can be quite serious, we wouldn’t want this to happen when you’re behind the wheel, both for your safety and the safety of others
- The DVLA has guidelines regarding driving with (disease), and I am afraid to say that legally you are not allowed to drive, probably for (duration)
- There is a legal requirement for you as a driver to inform the DVLA that this has happened
- I can see that this news has come as a big shock for you today and that this isn’t what you want to hear
- We have to safe, both for you and other road users, and you’ve got to think about your family if you were in this position
- Let me put it this way: if you knew that you were driving on the road, and there was another driver who at any moment could blackout; or you knew your kids were playing in the street and there was a driver who were going down the road who could blackout, how would that make you feel?
- What do you think your family would say?
- I can appreciate that you are worried about the impact of this on your income - is there for instance any role that you can take with your employer that does not involve driving?
- Would it be useful/helpful to talk to your occupational health department at work, to discuss about specific employment advice?
- Would it be useful/helpful to take a letter from me explaining what has been said today, that you are legally not allowed to drive, which you can show your employer and the occupational health department if you’d like?
- If you can’t work, because of this diagnosis, and it sounds like you can’t, I can provide you with a short-term fitness to work certificate that would allow you some time off work whilst we get everything sorted
- I don’t need to get in contact with your employer or DVLA - however you do have a legal responsibility to inform your employer, your insurance company and DVLA about this diagnosis
- The law states that you’re not allowed to drive for (duration)
- It’s important for me to tell you this - this is your responsibility
- However, if you didn’t inform the DVLA or your insurance company, and then you had an accident - your insurance would be invalid and you’d most likely be culpable for the accident, given that you’ve now got this diagnosis
- Equally if myself or your GP knew you were driving despite having that diagnosis, legally we then become responsible for telling the DVLA
- I don’t want to inform the DVLA, and I think it’s important that you do
Informing DVLA - duration of driving ban based on licence group?
Group 1 licence: motor cars, motor cycles
Group 2 licence: large lorries, buses, taxis
Epilepsy:
G1: normal EEG 6 months, abnormal EEG 1 year
G2: 5-10 years, depending on neurologist assessment
TIA/CVA
G1: 1 month
G2: 1 year
MI
G1: 1 week if successful PCI, 4 weeks if unsuccessful PCI
G2: 6 weeks
DM
G1: 1,2,3 years licence depending on awareness of hypoglycaemia and visual standards are met
G2: annual renewal provided awareness of hypoglycaemia, no hypoglycaemic episodes in the last 12 months, 3 months record of glucose monitoring 2x daily
OSA with excessive sleepiness
G1: must not drive until symptoms are under controlled, and compliant to CPAP
G2: must not drive until symptoms are under controlled, and compliant to CPAP
HOCM
G1: can continue driving
G2: permanently banned
ICD
G1: various lengths of ban depending on exact circumstances for ICD
G2: permanently banned
Confidentiality - why is it important?
- Protect patient: could be at risk of exploitation if information was shared without approval
- Maintain patient-doctor relationship: both in specific consultation and wider context
Confidentiality - under what circumstances is it allowed to break confidentiality?
Patient confidentiality should always be maintained, except:
- Court order requesting information
- Statutory orders that dictate requirement e.g. notifiable diseases
- Risk to national security e.g. terrorism
- Serious threat to a 3rd party e.g. serious infection and likely to pass to someone else
- Public interest e.g. driving and epilepsy
Confidentiality - what are the consequences of breaking confidentiality?
- Breakdown in patient-doctor relationship which could affect patient’s care in the future
- If broken appropriately, doctors can face action from GMC
Medical error - example sentences:
Duty of candour
- Need to be open and honest
- Someone from healthcare team should speak to patient as soon as mistake has been identified
- Applies even when patient has not come to apparent harm
Examples:
- I actually came to share some bad news with you, and offer an apology, the reason being…
- I think this is early days, we’ve just learnt about this error and the symptoms that you’re having - what is important at this moment is to get more information regarding…
Why has it happened?
- I am sorry, it was an error, and it should not have happened, and I do apologise for that
- That shouldn’t be the case, I think there can never be guarantees in medicine, but I think that it shouldn’t be the case that it is affected for a long time, and with the right management we should see a full recovery in the next few days
- Unfortunately even though we try our very best to have good systems in place in the hospital, with team structures, safety netting and good documentation, occasionally there can be errors and I’m just so sorry that you were involved with one of these errors
- Even working to the best of our abilities, sometimes these things can still happen and I’m really sorry that you were involved with this
Discuss next steps:
- Talk to experts about what the next steps are and how we might manage this
- Referral to experts so we’re getting expert guidance regarding your management
- Report this incidence so that it can be looked into, investigated so that changes to practice can be made so we can prevent this happening again
- Learning process for clinicians involved, and also as a team and organisation to learn from this and change systems in place to errors such as these do not happen again
Formal complaints:
- Write formal letter to complaints manager
- Put you into contact with the Patient Advisory Liaison Service, to help navigate through the process
Delayed diagnosis - example sentences:
- I can appreciate that you’re feeling angry with the situation
- The issues that you’ve raised today are absolutely valid and completely important
- However I’m afraid I’m not in the position to comment on what had happened with your previous visits to your family doctor, which is why it is important for us to get in contact with them to get their thoughts regarding this
- Mainly because I do not have all the facts regarding the situation
- Additionally, many medical conditions present in vague, non-specific or unusual manners and although it was apparent when you came to us that you had (diagnosis), that might not have been the case when you visited your GP
- Apart from that, examination findings and even investigations may change over time
- I’m sure your GP would be upset to know that you have been diagnosed with this, and I’d encourage you to talk to your GP after you’ve been discharged
Discuss next steps:
- Starting treatment as soon as possible
- Provide support in terms of care at home
- In terms of making complaints, I think it would be helpful to talk to your GP first, and if after having spoken to him, your concerns or frustrations have not been alleviated, then I would suggest you contact the practice manager in the first instance
- I would put you in contact with the Patient Advisory Liaison Service to help you navigate through this
Medical negligence - how to claim and prove negligence?
Claiming negligence:
- A duty of care between doctor-patient must be established
- Breach in duty of care: treatment fell below the minimum standard of competence
- And patient has suffered an injury
- And it is more likely than not that the injury would have been avoided or have been less severe with proper treatment
- Claim must be made within 3 years of date of injury
Bolam test:
- If an expert opinion considers the doctor’s actions as those of responsible practitioners, then the doctor is not liable for negligence
- Criticised as this test allows the standard in law to be set subjectively by doctors
Bolitho test:
- If an expert opinion regarding the doctor’s actions can withstand logical analysis, then the doctor is not liable for negligence
