VLE Flashcards
1
Q
Describe the Fraser Guidelines (5)
A
Advice and treatment may be given to a child provided:
- She will understand the advice
- She cannot be persuaded to tell her parents
- She is very likely to continue having sexual intercourse regardless
- Without the treatment, her physical or mental health are likely to suffer
- That her best interests require the advice or treatment
2
Q
At what age is a person assumed to possess capacity unless otherwise indicated?
A
16 years + (the MCA 2005 applies from 16)
a child may be found to have Gillick competence <16, but this must be proven rather than assumed
3
Q
Does a child who lacks capacity, have autonomy?
A
No - therefore disregarding their preferences is not overriding their autonomy, as they have none
4
Q
Which factors determine Gillick competence? (3)
A
- The child’s maturity
- The child’s understanding
- The nature of the consent required
5
Q
When can confidentiality be broken (in adults)? (3)
A
If the patient consents
If it is required by Law (notification of infectious diseases, if ordered by a Judge)
If it is justified in the public interest (i.e. public at risk of serious harm; gunshot/knife wound, DVLA)
6
Q
When determining best interests, 3 things should be considered (MCA 2005):
A
- The past and present wishes and feelings of the patient
- The beliefs and values likely to influence their decision if they had capacity
- Any other factors they would likely consider
7
Q
When do professionals have a legal responsibility to refer a child to Children’s Social Services?
A
If it is suspected or believed that the child:
- Has suffered significant harm
- Is likely to suffer significant harm
(Children’s Act 1989)
8
Q
When may health records not be accessed (by those who legally could)?
A
When access is likely to cause serious harm to the physical or mental condition of the data subject or any other person
When the data would reveal the identity of another person
9
Q
Which 2 legal frameworks apply to restraint? (Short/Long term)
A
Short term - Mental Capacity Act
Long term - Deprivation of Liberty Safeguards
10
Q
Which 3 provisions allow an adult to be treated without consent, and in what circumstance?
A
Doctrine of Necessity (allows ‘least restrictive’ treatment for life-threatening conditions when unable to assess capacity and gain valid consent)
Mental Capacity Act 2005 (allows treatment of patient without capacity, provided deemed within best interests)
Mental Health Act (allows treatment given while sectioned/detained within first 3 months, under very specific conditions)
11
Q
Which 4 criteria must be met for implicit consent to be sufficient for the sharing of information?
A
You have no reason to believe they would object
The information is being accessed to support a patient’s direct care
Information is available to patients on how it will be used, and how they may object
You are satisfied that those disclosed to will understand it is in confidence, and treat it accordingly
12
Q
Which 4 principles is the Human Tissue Act founded upon?
A
Consent
Dignity
Quality (of processes involved)
Honesty and Openness
13
Q
Which Act is used to consider best interests of a patient?
A
Mental Capacity Act 2005
14
Q
Which activities are regulated by the Human Tissue Act 2004?
A
Anatomical Examination
Determining cause of death
Public display
Transplantation (living or desceased)
Education/training relating to human health
15
Q
Which legal statute regulates the testing of embryos?
A
Human Fertilisation & Embryology Act 1990
16
Q
Which statute outlines the duty of candour?
A
Health and Social Care Act 2008
17
Q
What are the differing types of consent?
A
Written (Vital for whole body donation - may only be given by patient, not relatives)
Verbal
Implicit
(Broad and Enduring - used for medical research, to prevent further seeking of consent at a later date)
18
Q
What 3 basic elements are required for valid consent?
A
Sufficient Information
Capacity
Freedom from coercion/Voluntariness
19
Q
What 3 things should be included as part of an apology to a patient?
A
What happened
What will be done to mitigate/deal with the harm caused to the patient
What will be done to prevent future harm to others
20
Q
A medical student comes across a man in respiratory distress on his way back from lectures. Is he legally obliged to stop and help?
A
No, but he does have a moral obligation.
BMA advises: “..if no other qualified HCP available, and patient at risk of serious harm, provided they reasonably believe they can improve outcomes”
21
Q
If a patient is found to have HIV, is it legally permissable to break confidentiality if they request it kept strictly between you both?
A
Yes, if they refuse to inform their sexual partners - they are considered at risk of serious harm
However, you may not inform other members of the medical team, as in theory normal handwashing and infection control proceedures should be sufficient to prevent an increased risk of spread.
22
Q
Outline the ethical principles for maintaining confidentiality
A
Consequentialism - impact on patient (upset), impact on other generally (loss of trust), impact on specific others (N.B. possible harm of non-disclosure)
Respect for Autonomy
Virtue Ethics - promise keeping & trustworthiness are virtues!
Deontology - a duty of care; vital some information shared to ensure appropriate treatment
23
Q
Define identifiable information
A
“Any information that could identify a patient, including when combined with other information such as their name, postcode, DOB.”
24
Q
Is sex selection of an embryo permitted?
A
Yes, but only if there is a risk of inheriting sex-related abnormalities
25
Discuss the ethical considerations of in-vitro fertilisation
Maximising Benefit/Minimising Harm - Physical harm (Mother, saviour sibling, embryo), Psychological harm (Saviour sibling, infertile couples), Selective abortion (negative message? E.g. Downs)
Justice/Fair use of resources - Funding issues (postcode lottery) and criteria (BMI, etc)
Autonomy & Rights - Right to procreate? To chose method? Respect for life of embryos?
26
Legally, treatment without consent is..?
Battery
27
In considering whether to restrain a person, what 4 things must be considered?
1. The harm which will occur if they are NOT restrained.
2. The harm OF restraining them.
3. The minimum level of restraint required.
4. The proportionality of restraint required vs. amount of benefit of treatment.
28
What are the ethical arguements for a doctor stopping to assist someone in a "good Samaritan" situation?
Consequentialist - Doctors have a greater ability to help, due to greater knowledge/experience/skill.
Deontological - Professional duty of care (GMC). (N.B. Not established until self-identified to patient as a doctor)
Virtue ethics - Doctors seen as particularly vituous.
29
Is a doctor legally obliged to help a person in distress outside of the work environment?
No, however if self-identifies to patient as a doctor, the normal legal duty of care is established.
(duty of care must be established for legal obligation to occur)
30
What arguements exist against the medical treatment of family or friends? (6)
- Emotional involvement may cause a lack of objectivity
- Poorer standard of care in home setting vs. medical practice
- Interferes with relationship with their own GP
- Harder to maintain confidentiality?
- Doctor may not wish to explore sensitive topics
- Patient may feel unable to refuse advised treatment
31
What do patients need to know, when things go wrong?
What went wrong
Why it went wrong
The possible complications/implications for the patient
Where there are still uncertainties
They should also be apologised to
32
What does the GMC guidance say about the duty of candour when things go wrong?
"Every HCP must be open and honest with patients when something that goes wrong with their treatment or care causes or has the potential to cause, harm or distress."
33
In what circumstances is embryo testing permitted? (3)
To establish if the embryo has an abnormality which will reduce the chance of a live birth
To establish if the embryo has an abnormality which may result in a serious disability or illness
To determine if the embryo is tissue compatible with a sibling who has a serious medical condition which could be treated with umbilical cord blood, bone marrow, or other tissue
34
Mary requires life-sustaining treatment, but refuses it. Can her decision be overriden?
No, provided she has capacity.
| N.B. There is a technical difference between 'doing harm', and 'not doing good' - i.e. by withdrawing treatment
35
What 4 ethical principles underpin confidentiality?
Autonomy
Privacy
Identity
Trust/Promise keeping
36
What are the 4 criteria for an individual to have capacity?
Understand the information given
Retain information long enough to reach a decision
Weigh up the information to make a decision
Communicate that decision
(MCA 2005; Assumed from age 16+ unless demonstrated lack of)
37
Do written consent forms qualify as valid consent?
No - they are evidence of consent, but not that it is necessarily valid...!
38
In regards to disclosing information, list some uses which would not be considered to be directly relevant to a patient's care (i.e. explicit consent required...)
Research
Financial audit
Public Health
Education
Health service planning
39
According to the MCA 2005, who can proxy consent be given by?
Lasting Power of Attorney
Court Appointed deputy
40
Which statute governs the treatment of children?
The Children Act (1989)
41
Until what age may a parent/the court give consent for treatment of a child who has refused treatment, overriding their wishes?
Until the age of 18 (i.e. until an adult)
However, this overriding of refusal must be in circumstances where refusal would "in all probability lead to the death, or serious permanent injury of the child."
N.B. the Dept. of Health advises getting a "court declaration or decision" anyway, to ensure it is lawful...
42
When treating a child or young person, what should the doctor bear in mind?
UN Convention on the rights of a child (Article 3) -
"In all actions concerning children, ...the best interests of the child shall be a primary consideration."
UN Convention on the rights of a child (Article 12) -
"...The views of the child should be given due weight in accordance with the age and maturity of the child."
43
How should a doctor facilitate the involvement of children in discussions regarding their care? (5)
GMC guidance (2007)
- Be honest and open with them (and their parents, while respecting confidentiality)
- Listen to, and respect their views and respond to their concerns
- Communicate in a way they can understand
- Give them the opportunity to ask questions, answering honestly
- Give them the same time and respect that you would adults
44
From what age may a child accept treatment, overriding their parents wishes?
From any age, provided the child is proved to be Gillick competent
45
When making a best interests decision, other than what is clinically indicated, what should be taken into account? (6)
GMC Guidance (2007)
- The views of the child (including previously expressed views)
- The views of parents
- The view of others close to the child
- The views of other healthcare professionals involved
- The cultural, religious, and other belief and values of the child or parents
- Which choice will least restrict the child's future options
46
Who may give consent for treatment on behalf of a child (0-17) who lacks capacity?
- Someone with parental responsibility (provided they have capacity)
- A Court of Law
N.B. A doctor may treat without consent in an emergency
47
How many people die daily, while waiting for an organ transplant?
3
48
Who might be affected by a change in decisions/actions regarding organ donation? (4)
Dying/dead patients (potential organ donors)
Potential organ recipients
Relatives
Medical staff
49
What is the Dead Donor rule? (2)
1) Organ donors must be dead before retrieval of organs
| 2) Organ donation must not cause the death of the patient
50
Define the term Dying
"Irreversible changes to the brain, resulting in irreversible loss of consciousness and irreversible loss of capacity to breathe."
51
What 2 ways exist of confirming death for organ donation?
Brain-stem death
Circulatory death
52
What is Brain-stem death?
"Death following the irreversible cessation of brain-stem function."
53
What is Circulatory death?
"Death following the irreversible cessation of cardiorespiratory function."
54
What implications might the type of diagnosis of death have on the organ donation process? (4)
- Which organs can be donated (DCD heart donation is controversial*)
- The ‘quality’ of the organs when they are retrieved
- Permissible actions to ‘optimise’ organs
- How relevant legislation should be applied
*DCD = Donation after Circulatory Death; if heart 'irreversibly stopped', how can it function for someone else?
55
What is required before a deceased person's organs can be removed/transplanted?
Consent - Joining the Organ Donor Register can count
56
What issues could be debated regarding whether applying to the Organ Donation Register counts as consent? (~3)
Not a fully informed decision (e.g. DBD vs DCD)
Patient may have later changed their mind
Patient's family can successfully oppose the donation
57
Can an organ transplant go ahead legally, if someone in a qualifying relationship objects?
Yes legally, but this does not happen in practice
58
Which 2 ethical principles must be weighed up when considering delaying the withdrawal of life-sustaining interventions so that organ donation can occur?
A Best interests decision must be made, to weight the balance between:
- Respect for the patient's autonomy in choosing to be an organ donor
- Non-maleficence in the avoidance of causing unnecessary harm to the patient
59
According to the Human Tissue Act, who can provide consent on behalf of a patient who has not indicated one way or the other, regarding organ transplantation? (8)
Those in a qualifying relationship to the deceased person are (highest first):
1. Spouse or partner (including civil or same sex partner)
2. Parent or child (in this context a ‘child’ can be any age)
3. Brother or sister
4. Grandparent or grandchild
5. Niece or nephew
6. Stepfather or stepmother
7. Half-brother or half-sister
8. Friend of long standing
60
When a patient is deemed to not have capacity (assessed as per MCA), what steps should be followed in order to ensure the most appropriate treatment is undertaken? (4)
1. Whether an advance refusal of treatment (ART) exists
2. If no ART, is there a Lasting Power of Attorney (healthcare not financial)?
3. If no ART/ LPA, Best Interests criteria (MCA) should be taken in to account
4. Court of Protection is final arbiter of Best Interests
61
What are the 5 key principles of the Mental Capacity Act (2005)?
1. Capacity is presumed until proven otherwise
2. Making an unwise decision is not the same as lacking capacity
3. Any decision made on behalf of a person without capacity, should be in their best interests
4. A person must be given all practicable help to make decisions before a lack of capacity is determined
5. Anything done in a patient's best interests should be the least restrictive of their basic rights and freedoms
62
Which legal document provides for the human right to liberty?
Article 5 of the European Convention of Human Rights
63
What conditions must be met for a patient to be deprived of their liberty under the MCA? (DoLS) (6)
The patient must be >18 years of age
Does not meet requirements for detention under the MHA
Suffering from a mental disorder, e.g. dementia, profound learning disability
Lacks capacity to make decisions about treatment or care
DoL is in person’s best interests and necessary to keep a person safe from harm
No conflict with ART or LPA
64
What extra safeguards must be put in place if a patient is to be deprived of their liberty under the MCA? (4)
A stringent assessment regime
The provision of a representative
A mechanism for review and monitoring
The right of appeal through the Court of Protection
65
How is a deprivation of liberty defined using the 'acid test'? (2)
- A person must be both under continuous supervision and control and not free to leave (the objective element)
- A person must lack capacity to consent to the living and care arrangements (the subjective element)
66
What is the key difference between a restriction and a deprivation of liberty?
Restrictions could deprive someone of their liberty (i.e. if they were continually supervised and unable to leave), but could also act only to limit activities (i.e. they're not allowed in the kitchen, but they can leave whenever they like...)
67
What must be suspected in order to detain someone under the MHA? (Section 5)
How long can they be held for?
It must be suspected that they have a mental disorder that requires psychiatric assessment (a MHA assessment) and possibly the making of any necessary arrangements for his/her treatment or care
Doctor's holding power - <72 hours (no right of appeal)
Nurse's holding power - <6 hours (no right of appeal)
68
What are the criteria for a patient be 'sectioned' for assessment with a view to treatment? For how long can this apply?
Section 2 can be applied on the grounds that the patient:
- Is suffering from a mental disorder of a nature or degree which warrants the detention of the patient in a hospital for assessment (+/- 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
They can be held for <28 days, and do have a right to appeal
69
What are the criteria for a patient be 'sectioned' for treatment? For how long can this apply?
Section 3 can be applied on the grounds that the patient:
- Is suffering from a mental disorder of a nature or degree which makes it appropriate for him to receive medical treatment in a hospital
- Ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons
- Treatment cannot be provided unless the patient is detained; and appropriate medical treatment is available
They can be held for up to 6 months, and do have a right to appeal
70
What is the definition of medical treatment for a mental disorder?
"Medical treatment which is 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 / mental health (re)habilitation and care)
71
What type of treatment can be administered to a patient sectioned under the MHA, without their consent?
Anything given to treat the mental disorder
- Treatment of physical health problems can only be given without consent to the extent that such treatment is part of, or ancillary to treatment of the mental disorder
(i. e. if physical problems arise as a consequence of the mental health disorder, they can be treated, e.g. feeding tube in severe anorexia - HTN meds however, would not count)
72
What are the ethical arguments in favour of screening programmes?
Beneficence:
- Early detection could improve patient outcomes
- Detection of communicable diseases could prevent further spread of infection
Autonomy maintained:
- Invitation to screening sent out, with (in theory) sufficient information to make an informed decision
73
What are the ethical arguments against screening programmes?
Non-maleficence:
- False positives can occur, leading to emotional distress & unnecessary procedures
- Some patients would never have become symptomatic --> stress for no gain?
- Harm from screening?
Autonomy:
- Not necessarily enough information given for informed consent...
74
What are the Wilson & Junger Criteria for a screening programme? (10)
* The condition should be an important health problem.
* There should be a treatment for the condition.
* Facilities for diagnosis and treatment should be available.
* There should be a latent stage of the disease.
* There should be a test or examination for the condition.
* The test should be acceptable to the population
* The natural history of the disease should be adequately understood.
* There should be an agreed policy on whom to treat.
* The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
* Case-finding should be a continuous process, not just a "once and for all" project.
75
What are the underlying principles of the Mental Health Act? (5)
1. Purpose principle (beneficience, non-maleficence)
2. Least restriction principle
3. Respect principle
4. Participation principle (involve patient where possible)
5. Effectiveness, efficiency and equity principle
76
List some arguements in favour of the compulsory vaccination of children against the measles virus, using ethical principles
Nonmaleficence:
- Reactions at the site of infection and transient fever are common but minor
- More serious reactions are rare
- The chances of catching an infection rise as immunisation rates fall
- The symptoms of measles worse are generally worse than the side-effects of vaccination and last for longer
Beneficence:
- Protection from illness at an individual and population level.
Respect for autonomy:
- Respect for autonomy might be satisfied if the public voted for mandatory vaccination
Justice:
- Everyone would be treated equally (as everyone would be required to be vaccinated)
- Everyone would benefit equally from the protection against measles
77
List some arguments against the compulsory vaccination of children against the measles virus, using ethical principles
Nonmaleficence:
- (Parents of) children who do not want to be vaccinated will be forced to comply --> likely to cause distress
Beneficence:
- A programme of public information/incentives re. vaccination might achieve the same results as a compulsory programme without the potential harms
Respect for autonomy:
- Parents are not able to choose for on behalf of their children, undermining their autonomy
- Removing parental decision-making authority leaves them accountable for outcomes for which they are not responsible
Justice:
- Some individuals are more likely to experience adverse reactions to vaccination
- Some individuals are generally less likely to catch measles/experience complications as a result
- If parents are punished/forced to comply, the harms will also be felt by their children, who are not responsible for the decisions their parents make
78
Why might notification of infectious diseases raise ethical issues for doctors?
Sharing personal information is a breach of confidentiality
79
Disregarding the legal obligation to notify PHE with regards to infectious diseases, what ethical arguments exist for disclosure?
Public interest in maintaining confidentiality vs. public interest in disclosure
In favour of disclosure:
- Disclosure enables contact-tracing --> spread of disease can be minimised & timely treatment offered
- Disclosure enables disease surveillance --> wider control measures can be put in place
Public trust can be maintained if this balance is understood and those who are affected are respectfully managed and cared for
80
Disregarding the legal obligation to notify PHE with regards to infectious diseases, what ethical arguments exist against disclosure? (3)
Against disclosure:
- Confidentiality is broken, which could undermine trust in doctors (health implications)
- Patients might not attend if they think their information will be shared – this will have an adverse impact on them and others who may be infected as a result
- Disclose undermines respect for autonomy – choosing how and with whom to share personal information
81
How might the principle of proportionality allow the weighing up of conflicting principles in an ethical conflict?
"The extent and impact of positive benefits must be considered alongside the extent and impact of negative consequences."
- This principle allows us to take into account the aim of the intervention, the number of people who benefit, the severity of consequences of action or inaction, and the cost of interventions
82
What ethical principles might be considered when discussing issues relating to disease control?
```
Respect for Autonomy
Beneficence
Non-maleficence
Justice (equal treatment)
Utilitarianism (right or wrong based on consequences alone)
```
83
What are some ethical arguments for and against breast screening?
For:
Beneficence
- Breast cancer can kill if not treated; early identification can improve individial outcomes
Against:
Non-maleficence
- Mammograms deliver radiation, which could increase the risk of developing cancer
- False positives occur, leading to emotional distress & unnecessary invase procedures
- Some patients with breast cancer would never have been symptomatic in their lifetime
Respect for Autonomy
- The invitation letter (although now better) may not contain enough information for fully informed consent
Utilitarianism
- The number of cases detected which would not otherwise have presented to their GP is small, and the screening programme is very expensive; this money might have achieved a greater amount of good elsewhere
84
What is Advanced Care Planning (ACP)?
"A structured discussion with patients and their families or carers about their wishes and thoughts for the future."
- GMC Guidance
85
What are the Advantages of Advanced Care Planning? (3)
Allows care to be accessed safely, at the right time and with continuity of delivery
Can avoid the conflicts and tensions that arise between doctors, patients and relatives during emotionally fraught times
Can help in determining the right course of action if capacity is lost
86
What should the discussion regarding Advanced Care Planning include? (4)
The patient’s wishes, preferences or fears in relation to future treatment or care
The feelings, beliefs or values influencing the patient’s preferences and decisions
Family members, or others close to the patient or any legal proxies that the patient would like to be involved in decisions about their care
Interventions that may be considered or undertaken in an emergency, such as CPR.
87
Is an ACP legally binding?
No
| But it will be taken into account when deciding what is of overall benefit if patient loses capacity
88
List 3 types of Advance Decision
Advance Requests for Treatment (not technically a ‘decision’)
Advance Refusals of Treatment
Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR)
89
Why might an Advanced Request for Treatment be created?
| Does it have to be followed?
A patient may weigh up risks/benefits differently from doctors, and might worry that if they lose capacity, treatment that they consider to be worthwhile will not be given to them
- Not legally binding but if a doctor does not accede to the request, they must be able to justify why it is not in the patient’s best interests
90
Can an Advanced Refusal of Treatment be legally binding?
Yes, provided:
- It is valid (criteria discussed later)
- It is clearly applicable to the patient’s current circumstances
91
When is an Advanced Refusal of Treatment not valid? (3)
- The person has withdrawn the advance decision since making it
- The patient has subsequently created a Lasting Power of Attorney for health and welfare (someone still available to refuse or consent)
- While capacity was retained, the patient had subsequently done anything that is clearly inconsistent with the advance decision
92
What is required for an Advanced Refusal of Treatment to be valid? (4)
- The patient was an adult when the decision was made (18 years or over)
- The patient had capacity to make the decision at the time it was made
- The patient was not subject to undue influence in making the decision
- The patient made the decision on the basis of adequate information (informed)
93
How must an advance decision have been communicated in order to be valid?
- It must state precisely which treatment is to be refused
- It may set out the circumstances when the refusal should apply
N.B. Advance decisions can be verbal/oral, rather than written
94
In addition to the previous conditions for an advanced decision to be vaild, what conditions must have been met for the refusal of life-sustaining treatment? (4)
- The decision must be written
- The decision must be signed by the person making it
- The decision must be witnessed
- The decision must specify that the treatment is potentially life sustaining, and acknowledge that death could result from the refusal
95
Why might a patient not want CPR? (4)
Low success rate
Invasive
Potential for harmful side-effects
May cause an undignified and traumatic death (if not successful)
96
What types of Lasting Power of Attorney exist?
LPA for financial affairs
LPA for health and welfare decisions
N.B. LPA for financial affairs cannot make health/welfare decisions!
97
What authority does a Lasting Power of Attorney have? What are the conditions for their appointment to be valid? (3)
The LPA has legal authority to make decisions, and must be consulted on behalf of the patient
In order to be valid:
- Must be made when the person has capacity
- Both the patient & LPA must be 18+
- LPA must be registered with the Office of the Public Guardian
98
Who can give consent for a young person under the age of 18? (4)
- The patient (provided 16+, or Gillick competent)
- Someone with Parental responsibility
- A court
- Someone appointed by the court
99
List some examples of when parental choices on behalf of their child may be legal, but raise ethical concerns (4)
- Parental refusal of immunisation
- Parental request for non-theraputic male circumcision
- Parental request for surgical correction of physical characteristics
- Parental refusal of treatment for non life-threatening conditions
(Not sure if this needs to be learnt...)
100
What factors might contribute to best interests, when considering whether to undertake a procedure which does not offer therapeutic benefit? (e.g. circumcision)
- Religious & Cultural beliefs + Values of the child & parents
- Social, Psychological & Emotional benifits
101
What is cost benefit?
Costs & benefits expressed in monetary units
| e.g. £0.04/ibuprofen now, saves having to spend £1.67/sumatriptan later..
102
What is cost minimisation?
Compares cost of alternative treatments of equal effectiveness
(e.g. Sumatriptan £1.67 vs Rizatriptan £1.92)
103
What is cost consequence?
Costs expressed in monetary units, and consequences in natural units (e.g. death/relief of pain)
E.g. Sumatriptan works better at relieving the pain from my headache, but is more expensive
104
What is cost effectiveness?
Ratio of cost in monetary units and consequences in natural units
(e.g. Fast acting Ibuprofen works more quickly than the regular, but is more expensive)
105
What is cost utility?
The ratio of costs in monetary units to overall measure of health status (well being/utility)
E.g. Do I buy ibuprofen for my headache, or E45 for my eczema? (which gives greater QOL per £?)
106
Which of the methods of cost analysis is preferred by NICE?
Cost utility - allows direct comparison between treatments for different disorders
Measured in QALYs (Cost per Quality Adjusted Life Year)
107
What is a QALY?
Cost per Quality Adjusted Life Year
The cost in monetary units of buying one year of life in perfect health
- A year in perfect health is given a score of 1
- A year 'in death' is given a score of 0
108
How is the QOL aspect of QALYs measured?
Various ways - NICE prefers the EuroQol-5D (a self-completed questionnaire)
109
What types of costs are considered when calculating QALYs?
Direct costs:
- The cost of delivering/administering the intervention (NHS perspective)
Indirect costs:
- Patient costs, social care costs (personal social care perspective)
- Lost productivity (societal perspective)
110
What ethical principles/values should be considered in the allocation of resources in healthcare?
How are these reflected in the allocation of resources by the NHS?
- Maximising overal benifit (utilitarianism); i.e. QALY approach
- Responding to need; e.g. "Rule of Rescue" - cap on QALY can be lifted if a life in immediate danger
- Respect for autonomy/respect for persons; facilitating choice within given options, involve the public in the decision making process
111
Define the difference between equity and equality with regards to resource allocation
Equality - everyone has the same access to resources, regardless of need
Equity - resources are allocated according to need (greater need --> greater resources allocated)
112
Define Proportionate universalism
"The resourcing and delivering of universal services at a scale and intensity proportionate to the degree of need."
113
What 4 key principles must apply for fair process in decision making?
- Reasons agreed by all stakeholders as relevant and reasonable
- Consistency of reasoning
- Transparency of decision-making
- Opportunity for appeal/review
114
What are the NHS values and what do they mean?
* Working together for patients - Patients come first in everything we do. We fully involve patients, staff, families, carers, communities, and professionals inside and outside the NHS. We speak up when things go wrong.
* Compassion - We ensure that compassion is central to the care we provide and respond with humanity and kindness to each person’s pain, distress, anxiety or need.
* Commitment to quality of Care - We earn the trust placed in us by insisting on quality and striving to get the basics of quality of care – safety, effectiveness and patient experience – right every time.
* Respect and Dignity - We value every person – whether patient, their families or carers, or staff – as an individual, respect their aspirations and commitments in life, and seek to understand their priorities, needs, abilities and limits
* Improving Lives - We strive to improve health and wellbeing and people’s experiences of the NHS
* Everyone counts - We maximise our resources for the benefit of the whole community, and make sure nobody is excluded, discriminated against or left behind.
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Which bodies can commission health services?
* NHS England
* Clinical Commissioning Groups (CCGs)
* Local Authorities
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Which types of health services are commissioned nationally?
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o Primary Care
o Specialised Services
o Offender healthcare
o Armed Force’s Health Care
o Immunisation, screening, young children
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What types of health services are commissioned locally?
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o Secondary Care
o Community Services
o Mental Health services
o Rehabilitation services
o Local Public Health services
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What is NICE?
The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and advice on promoting high quality health, public health and social care.
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What does NICE do?
Its role is to improve outcomes for people using the NHS and other public health and social care services. They do this by:
• Producing evidence-based guidance and advice for health, public health and social care practitioners.
• Developing quality standards and performance metrics for those providing and commissioning health, public health and social care services;
• Providing a range of information services for commissioners, practitioners and managers across the spectrum of health and social care.
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What types of guidelines are produced by NICE?
o Clinical
systematically-developed recommendations on how healthcare and other professionals should care for people with specific conditions. The recommendations are based on the best available evidence. They can cover any aspect of a condition and may include recommendations about providing information and advice, prevention, diagnosis, treatment and longer-term management. Clinical guidelines are also important for health service managers and those who commission NHS services.
o Public health
Recommendations for populations and individuals on activities, policies and strategies that can help prevent disease or improve health.
o Social Care
Recommendations on "what works" in terms of both the effectiveness and cost-effectiveness of social care interventions and services.
o Medicines Practice
Provide recommendations for good practice for those individuals and organisations involved in governing, commissioning, prescribing and decision-making about medicines
o Cancer services guidelines
Provide recommendations on how healthcare services for people with specific cancers should be organised. They aim to improve care by recommending which health professionals should be involved and the types of hospital or cancer centre best suited to provide care.
o Antimicrobial prescribing
Provide evidence-based antimicrobial prescribing information for all care settings. They focus on bacterial infections and appropriate antibiotic use.
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What additional guidance is provided by NICE?
Technology appraisals guidance:
This guidance assesses the clinical and cost effectiveness of health technologies - such as new pharmaceutical and biopharmaceutical products - but also includes procedures, devices and diagnostic agents. This ensures that all NHS patients have equitable access to the most clinically and cost-effective treatments that are available.
Technologies appraised:
• medicines
• medical devices
• diagnostic techniques
• surgical procedures
• health promotion activities.
Interventional procedures guidance:
This guidance recommends whether interventional procedures - such as laser treatments for eye problems or deep brain stimulation for chronic pain - are effective and safe enough for use in the NHS.
Diagnostics guidance:
This guidance evaluates new, innovative diagnostic technologies. It includes all types of measurements and tests that are used to evaluate a patient's condition.
Highly specialised technologies guidance:
Highly specialised technology (HST) evaluations are recommendations on the use of new and existing highly specialised medicines and treatments within the NHS in England
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To what extent must NICE guidelines be followed by commissioners and service providers?
The NHS is legally obliged to fund and resource medicines and treatments recommended by NICE's technology appraisals. This is reflected in the NHS Constitution, which states that patients have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if their doctor believes they are clinically appropriate. When NICE recommends a treatment 'as an option', the NHS must make sure it is available within 3 months (unless otherwise specified) of its date of publication. This means that, if a patient has a disease or condition and the doctor responsible for their care thinks that the technology is the right treatment, it should be available for use, in line with NICE's recommendations.
Conversely patients should not expect to receive treatments that are not recommended by NICE. In some cases NICE may recommend use of a product for a sub-set of eligible patients or that it should only be used in research.
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What percentage of technologies assessed through NICE technology appraisal system are recommended?
55% recommended in line with their licence
| 22% recommended for a smaller group of patients than license permits (optimised)
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What's NICE's Citizen's Council and what does it do?
The Citizens Council is a panel of thirty members of the public that largely reflect the demographic characteristics of the UK. The Citizens Council provides NICE with a public perspective on overarching moral and ethical issues that NICE and its advisory bodies have to take account of when producing guidance.
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Give four key societal values that the Citizen's council have said should be considered across health care, public health and social care.
Accountability • Collective responsibility • Dignity • Education • Fairness • Honesty • Humanity • Individual rights • Justice • Maximising total benefit/benefit for most/utilitarianism • Quality of life • Respect • Right to health and welfare for all • Safeguarding the vulnerable • Value/quality of service
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List the ethical principles governing research.
Beneficence
Non-maleficence
Autonomy
Justice
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Describe and explain an ethical consideration that might be relevant when considering implementing a screening programme.
a) Ensuring that the overall benefits of the programme outweigh the harms (a consequentialist/utilitarian approach). Benefits could include early diagnosis leading to more effective treatment, and reassurance to the person screened that they do not have or are unlikely to develop the condition. Disadvantages might be harms caused by the carrying out of the test, or psychological harm from getting a diagnosis (e.g. causing worry to the patient or causing them to be stigmatised).
b) Respecting patient autonomy. This may require that patients are given the freedom to decide whether to participate in a screening programme, given enough information to make an informed choice, and in an environment where they are free from coercion (e.g. pressure from the treating clinician).
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State three things you need to do to ensure a patient has sufficient information to consent to being screened.
* Give clear and accurate information about potential benefits and risks;
* Tailor the information to the individual patient, in terms of both their understanding and what they would like to know;
* Take into account the patient’s views, preferences, and concerns about adverse outcomes;
* Provide supplementary material such as information sheets or other aids to facilitate the discussion.
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Provide an argument against a screening programme that although saves many lives, also results in a large degree of over-diagnosis and over-treatment.
The aim of screening programmes should be to reduce harm over a population (premise). Although saving lives reduces harm (premise), over-diagnosis and over-treatment can also be considered harmful. The harm that a screening programme prevents must be considered against the harm that a screening programme saves (premise), and if the programme causes more harm via over-diagnosis than it saves, it should not continue (conclusion).
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Provide an argument in favour of treating a child against their wishes.
It is important that children are treated in a way that brings about the best outcomes for them (premise). Children often lack the understanding required to make a truly informed decision (premise), and are not therefore good judges of what is best for them (premise). In order to bring about the best outcomes, it may therefore be necessary to override the wishes of a child by providing treatment contrary to these (conclusion).
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Describe what must be taken into account when treating a child against his/her wishes.
* Whether the child has capacity
* The views of those with parental responsibility on whether the child should be treated against their wishes
* The harm likely to occur if the child is not treated
* What option will be least restrictive of the child’s future choices
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Describe the ethical conflict facing a doctor who is considering treating a child with capacity against their wishes.
The conflict is a tension between respecting a child’s autonomy and right to make decisions about their own life, and the doctor’s duty to protect the child from harm and act in the child’s best interests. The conflict can also be seen as balancing harms: the harm of not treating the child against the harm of forcing a child to have a treatment that they do not want.
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What is the ‘paramount consideration’ under the Children Act?
The child’s welfare.
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Name three things you should consider when assessing a child’s best interests.
a. the views of the child or young person, so far as they can express them, including any previously expressed preferences
b. the views of parents
c. the views of others close to the child or young person
d. the cultural, religious or other beliefs and values of the child or parents
e. the views of other healthcare professionals involved in providing care to the child or young person, and of any other professionals who have an interest in their welfare
f. which choice, if there is more than one, will least restrict the child or young person’s future options.
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Explain how Gillick competence is determined and what it means for the medical treatment of a child under 16.
A child is Gillick competent if they are deemed to be of ‘sufficient understanding and intelligence’ to understand the treatment that is being proposed. If a child is Gillick competent, this means they can give their consent to receive medical treatment, even if someone with parental responsibility does not want them to receive it.
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Name one party other than the child who can give consent for a Gillick competent child to receive treatment (i.e. “override the child’s refusal”).
A person with parental responsibility, or a court.
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Give one ethical argument for allowing parents to make the final decision about treatment for their child.
We should respect parental autonomy to make decisions for their child (conclusion). They know their child best (premise), and know the family and cultural environment in which the child lives (premise) and are best positioned to consider interests other than purely medical interests (premise). It is important that these interests are weighed into the decision, and parents are best positioned to do this (premise).
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Give one ethical argument for overriding parents' decisions about treatment for their child.
Parents may make decisions that are more about their own interests than that of the child (premise), or due to a lack of medical knowledge may underestimate the level of harm that the child will suffer if medical advice is not followed (premise). The duty to prevent harm to the child is most important in this situation (premise) and places a limit on the extent of parental autonomy (premise). Parental wishes should therefore be overridden (conclusion)
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Explain the ethical principle or value underpinning processes like advance care planning, and advance decisions to refuse treatment.
ACP and ADRTs serve to respect a patient’s autonomy in situations where they do not have capacity, and may therefore be incapable of expressing their autonomous wishes. They help to ensure that a patient’s wishes are respected.
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State who is responsible for making healthcare providers aware of an advance decision. Name two ways that a person might do this.
The person making the advance decision has this responsibility. They can do this by:
• Informing their relatives
• Asking for it to be recorded in their healthcare records
• Carrying a card/wearing a bracelet
• Providing their GP with a copy
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What are the requirements for an ADRT to be legally binding?
It must be:
• Valid
• Clearly applicable to the patient’s current circumstances
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Describe the two different definitions of death that are relevant to organ donation.
* Brain stem death: irreversible cessation of brain stem function
* Circulatory death: irreversible cessation of cardiorespiratory function
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Name the organisation that regulates the use of human tissue and organs (e.g. for transplant) in the UK, and the ‘fundamental principle’ it invokes to determine whether organ donation is permitted.
The Human Tissue Authority; the principle of consent
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Give one ethical argument for moving to an opt-out system for organ donation, with reference to relevant moral theory.
For: An opt-out system would make more organs available for transplant (premise) and would therefore save more lives (premise), which would be a good thing under the principle of beneficence or consequentialist theories (e.g. utilitarianism) (premise). We should have an organ donation that achieves the most good (premise), therefore we should have opt-out (conclusion).
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Give one ethical argument against moving to an opt-out system for organ donation, with reference to relevant moral theory.
Organ donation is an intensely personal choice and we should respect people’s wishes/autonomy (premises). Opt-out might increase the risk of people’s wishes being mistakenly inferred (premise), thereby increasing the chance of people’s organs being donated contrary to their wishes (premise). This violates the autonomy of these people, and we should therefore not have an opt-out system.
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Provide an argument for treatment to facilitate organ donation being in a patient’s best interests
A patient’s best interests include considerations beyond the purely medical (premise). Becoming an organ donor may be in a patient’s best interests if it is in accordance with their autonomous wishes (premise). Treatment to bring about something that accords with their autonomous wishes – in this case organ donation - is also likely to be in their best interests (premise), therefore treatment to facilitate organ donation can be in a patient’s best interests (conclusion).
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Explain the four things a patient must be able to do in order to have capacity under the Mental Capacity Act.
(a) understand the information relevant to the decision,
(b) retain that information,
(c) use or weigh that information as part of the process of making the decision,
(d) communicate his decision (whether by talking, using sign language or any other means).
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Describe the kinds of treatment that can be given without consent under the Mental Health Act.
Only treatments that are part of or ancillary to the mental disorder. This could include symptoms of the mental disorder, such as refusing to eat because of anorexia nervosa.
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Describe two ethical principles/values that are relevant to resource allocation
* Maximising overall benefit (utilitarianism)
* Responding to need
* Rule of rescue (focus on identifiable individuals in immediate danger)
* Respect for autonomy
* Facilitating choice within prescribed options
* Public involvement in decision making processes
* Fairness (equity)
* Allocating resources in proportion to need while acknowledging the differing needs of everyone
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Explain John Rawls’s ‘veil of ignorance’ and how it might be helpful in resource allocation.
The veil of ignorance is a theoretical perspective from which we do not know how well off in society we will be when we are making decisions about what would be a fair society. Rawls suggested that fair allocation of resources will mirror whatever we would choose under the veil of ignorance. That is, if we did not know our position in society we would allocate resources in the fairest possible way.
