Week 10 Flashcards
Professional identity
Values and beliefs you hold as doctor and the values and beliefs the governing body holds
Reflections
Enacting roles
Thinking to some purpose
Speaking to some purpose
Inclusivity
Respect
Assertiveness
Governance
Care ethics
The ethics of care are a fundamental moral prerogative to treat ourselves and others well
It involves promoting wellbeing for those giving care and those receiving care
There should be a care driver behind everything you do
Humanism
“The universe is a natural phenomenon with no supernatural side we can live ethical and fulfilling lives on the basis of reason and humanity. Places human welfare and happiness at the centre of ethical decision- making”
While humanists do not believe in afterlife the principles at stake can arguably be helpful in med(irrespective of personal faith)
The principles of humanism are:
-trust in scientific method
-basing ethical decisions on reason, empathy and a concern for humans and other sentient creatures
-giving life meaning by seeking happiness and helping others achieve the same
Person centred care
Focusing on elements of care, support and treatment that matter most to the patient , their family and careers
It links to humanism:
-concept of personhood
-belief in autonomy
-moral equality
-showing repeat irrespective of another’s individual characteristics
-values based consulting (enacting values)
Shared decision making
Key principles of mecial ethics
Autonomy
Beneficence
Non-maleficence
Justice
You can’t enact these effectively without good communication
Barriers to integrating ethics successfully
Time management
Training needs
Making assumptions which may turn out to be incorrect
Legal ethical conflict: adhering to patient confidentiality vs needing to report things that are required by law
Personal/emotional challenge
Paperwork
Patient perceptions of jobs worthiness
Frustrations with rejection of consent
Managing an ethical interaction
Self suppression
Self reflection very important
Offer good explanations to why you’re doing certain things
Know limitations in complex ethical situations
Be resilient
Relationship between communication and complaints
Strongly linked
A US study found that “an analysis of patient complaints showed that communication and relationships are more valuable for the patient experience than care quality and patient safety”
UK quality care commission analysed 30000 complaints over 6 years found they’re most related to:
-effective communication with patients
-staff attitudes
-record keeping
-privacy and dignity
Concern or complaints
Raising concerns as part of feedback process is a healthy and positive thing its not the same as making a formal complaint
A patient expressing concern is not same as making complaint
Evaluating the seriousness of the reported info is an important communication task
Patient/relative/carer/advocate defines the problem and that is what the HP should work with
How a patient initially defines the problems may change during handling
Whether informal or formal the complaint must be acknowledged and answered
Understanding equality and diversity in practice relates to person centred care
Equality is about equality of opportunity access and care
Diversity is about acknowledging people have different needs
Whilst you give people equality of access to a particular conversation the way it pans out is influences by their individuals beliefs, needs, backgrounds, abilities and other things
Net survival (sometimes called relative survival)
Survival removing other causes of death, thus theoretical scenario where the only cause of death can be the cancer, thereby isolating cancer as the sole cause of mortality
Total number survivors of malignant neoplasms
Today around 3 million people in UK which have been previously diagnosed with cancer and are alive today
These numbers will increase over time
Latest survival info relating to survivors of childhood cancer in Britain and its implications
Latest survival date relating to individuals diagnosed with childhood cancer in Britain indicates that 82% survived at least 5 years
With such impressive figures questions relating to the quality of survival become increasingly important particularly for survivors of childhood cancer who still have many decades to live
Clinical trials to investigate the impact of therapeutic interventions on survival rarely follow up survivors beyond 5-10 years from diagnosis
20 years ago it became apparent that what was needed was large scale studies (ideally population based) involving direct contact with survivors and addressing a wide spectrum of outcomes (including health and social outcomes) which might be adversely affected by childhood cancer or its treatment
British childhood cancer survivor study BCCSS original cohort
The original BCCSS comprised the population based cohort of 17981 individuals diagnosed with cancer before aged 15 years, between 1940 and 1991 inclusive in Britain who’ survived at least 5 years from diagnosis
An on going programme of population based studies of:
-risks of specific underlying causes of deaths occurring beyond 5 year survival 3049 observed so far
-risks and aetiology of subsequent primary neoplasms developing beyond 5 year survival 1354 observed so far
Whenever possible a postal questionnaire was sent to each of the 15000 survivors aged at least 16 years,. The questionnaire was concerned with a wide spectrum of health and social outcomes and 10500 survivors returned a completed questionnaire 70% of those eligible
British childhood cancer survivor study specific objectives
To obtain estimates of the risk of particular adverse health and social outcomes occurring among survivors and to investigate variation of such risks in relation to several factors including type of childhood cancer and its treatment.
1) To investigate long-term survival and the risk of death subsequent to 5-year survival from specific causes in relation to type of childhood cancer and its treatment. In particular, to compare observed mortality from specific causes of deaths with that expected from the general population.
2) To determine the risks and causes of second primary neoplasms. Cohort studies will address absolute risks and nested case-control studies will address aetiological questions.
3) To investigate the risk of cardiac, pulmonary, renal, hepatic,intestinal and other major organ toxicity in relation to types of childhood cancer and its treatment.
4) To explore the fertility of survivors in relation to types of childhood cancer and its treatment. In particular, to evaluate the risk of premature menopause in specific subgroups of female survivors.
5) To assess the risk of adverse outcomes of pregnancy, among female survivors and wives/partners of male survivors, in relation to type of childhood cancer and its treatment. Including recognised miscarriages, induced abortion, stillbirth, low birth weight and congenital anomaly.
6) To determine the extent of use of health services by
survivors and compare it with that expected from the general population.
7) Compare the extent and quantity of smoking and drinking among survivors with that expected from the general population.
8) Compare the educational attainment and occupational status of survivors with those expected from the general population.
9) Compare the self-evaluated health status (SF-36) of survivors with that expected from the general
population.
10) Compare the observed patterns of marriage among survivors with that expected from the general
population.
Absolute excess risk of death
Absolute Excess risk: ([O-E]/person years at risk) x10000
Odds ratio (99%CI) for likelihood of being current regular smoker in BCCSS compared with general population in Britain
Overall for the survivors of childhood cancer the likelihood of them being a current regular smoker is half of what you would expect for general population
British childhood cancer survivor study educational attainment
At all stages of educational attainment that were considered survivors of childhood cancer were found to perform worse than the general population
Deficits are observed in survivors of CNS neoplasma and leukaemia
Those with CNS neoplasm who had radiotherapy performed worse than those with surgery so clear radiation has impact
Excesses are observed for survivors of bone sarcoma and retinoblastoma
Comparison of percentage ever married in the BCCSS and the general population of England and wales in specified age and sex strata
Among males survivors 10% less
Under marrying is less in females
Health status of adult survivors of childhood cancer SF-36
Directly (age and sex) standardised prevalence or reporting being limited in specific activities
All survivors 12% limited in bathing and dressing
Bone tumours and brain tumours substantial
Survivors 18% limited in climbing stairs
Bone tumours 37% limited in climbing stairs
All survivors 14% limited in walking 100 yards
Extended BCCSS cohort
The BCCSS cohort has recently been extended using the NRCT to include records relating to an additional 16588 individuals who were diagnosed with cancer when aged under 15 between 1992 and 2006 inclusive inebriating and who survived at least 5 years from diagnosis
The extended cohort therefore comprises 34569 5 year survivors of childhood cancer
There will be a continuation of the programme of population based investigations of:
-risks of specific causes of death
-risks and aetiology of subsequent primary neoplasms
In addition data will be linked to hospital episode stats HES database for England , the patient episode database wales PEDW, info services division ISD linked database for Scotland and myocardial ischaemia national audit project MINAP database England and wales
Clinical and policy implications
Such large population based investigations of risks of a wide spectrum of fatal and non fatal adverse health outcomes provide the most reliable, unbiased and comprehensive evidence base available for:
-counselling, educating and empowering survivors
-providing clinical follow up guidelines
-preparing “survivorship care plans”
-providing educational material for healthcare professionals
-evaluating risks and benefits of proposals for future treatment protocols
-advising the DH in relation to groups at sufficiently elevated risk to consider recall for counselling, screening or other interventions
-identify low risk groups for discharge from hospital follow up
-providing risk stratification evidence to inform decisions by those commissioning clinical follow up in the NHS
-provide health economic evaluations
Cancer and age
More than 70% cancers occur in over 65s
Increase as people get older, longer life expectancy more cancer
Other factors driving up demand for more diagnostic tests and treatment cancer
Diet
Lack of exercise
Different risk factors, lifestyle behaviours,
Increasing expectations
More technology
For many cancer survival is poorer for men than women
Higher incidence in men
Less likely to get checked or screened
More lifestyle risks, alcohol, smoking
More occupational exposure
Present later
Mortality is associated with socio-economic deprivation for most cancer types
Majority higher in more deprived groups
Gap is greatest for smoking related cancer such as lung, laryngeal, oral cavity reflect high prevalence of smoking
More deprived tend to have higher risk lifestyle factors
What cancers do we have national screening programmes for
Breast cancer 50-70 every 3 years, mammogram
Bowel cancer 60-74 every 2 years faecal test, males and females
Cervical cancer 25-64 HPV smear tests 3-5 years
Why are uptake of screening rates less than 100%
Awareness and education
Perceived risk and fear
Access and convenience
Stigma and cultural beliefs
Personal circumstances
Ineffective communication and outreach
How can screening uptake rates be increased
Improve awareness and atttidues and educate
Text reminders
Train HCP empower patients
Work more out of hours, incentives for workers
Work with faith and community leaders
Good practice on physical and learning disabilities
Social media campaigns
