Changing the way you learn

Question	Answer
Four principles of medical ethics	o Autonomy • Allow patients to come to their own decisions, freely and independently Sometimes known as self determination only exception is compulsory treatment under mental health legislation o Beneficence • Doing what is best for the patient o Non-maleficence • Avoid and do not harm patients o Justice • Distribute our resources and services fairly
Ethical theories	o Consequentialism • The morally right action is the one that has the best foreseeable consequences • Utilitarianism – action that maximizes utiliy o Duty-based (deontological) • An action is right if it is in accord with moral rule or principle • A moral rule is one that is • Laid on us by God • Laid on us by reas • Would be chosen by rational beings o Virtue ethics • The focus is the character of the person • The right act is the act that a virtuous person would do in the circumstances • A virtuous person is someone who, with the virtues they have, will allow them to live the best life • Actions that maximize happiness for the person
Definitions of the following: o Euthanasia o Active euthanasia o Passive euthanasia o Voluntary euthanasia o Non-voluntary euthanasia o Involuntary euthanasia o Suicide • No longer illegal o Assisted suicide o Murder	o Euthanasia – X intentionally kills Y, or permits Y’s death. For Y’s benefit o Active euthanasia – X performs an action that kills Y o Passive euthanasia – X allows Y to die. X withholds life-prolonging treatment o Voluntary euthanasia – Y competently requests death o Non-voluntary euthanasia – Y is not competent to express a preference (ie. a baby) o Involuntary euthanasia – Y does not want to die, but X permits or imposes Y’s death o Suicide – Y intentionally kills himself • No longer illegal o Assisted suicide: X intentionally helps Y to kill himself o Murder – X intentionally kills Y
The legal euthanasia	Passive euthanasia - withholding/withdrawing treatment
Arguments for euthanasia	Suicide is accepted and legal Passive euthanasia is already accepted Painkillers and sedatives are already given to terminally ill patients benificence/mercy autonomy
Arguments against euthanasia	Palliative care removes need for euthanasia Manipulation or exploitation by others Slippery slope objections Contrary to aims of medicine
Helsinki declaration ethics principles	scientific validity Risk of harm Consent, information and competent adults incompetent adults Mental capacity act
When does a person lack capacity	When they cannot: • Understand the information • Retain the information • Weigh that information as a part of decision making • Communicate his decision
5 principles of the mental capacity act	• Presumption of capacity • Right for individuals to be supported to make their own decisions • The right to make bad decisions • Anything done on behalf of patients is down in their best interests • Anything done on behalf of the patient should be the least restrictive intervention
Order of consent in someone who lacks consent	• Advanced directive • Lasting Power of Attorney • Patients best interests as decided by the doctor
Confidentiality in those that cannot consent	Same rights • The doctor has to act in the patients best interest • Passing information to close relatives and carers is considering ‘in the patients best interest’
Mental health and overriding capacity	• This patient lacks capacity because the illness interferes with her normal values o This is more similar to common law as it means that we can only override refusal if they lack capacity • It is right to override the patients refusal on the grounds that it is her best interest and that she is suffering from a mental illness - e.g. force feed anorexia o This is the English Law stance o This allows for the assumption that mental illness = no capacity o This is a slippery slope
Section 2 - admission for assessment	o Suffer from a mental disorder o Nature and degree of disorder make it appropriate for the treatment in hospital o Necessary for safety of patient, or others • 28 days • Authorized by relative/social worker and 2 doctors • Can be appealed in the first 14 days by, or on behalf of the patient • Reviewed by the Mental Health Review Tribunal • Can be treated after assessment, or can be a assessment of response to treatment
Section 3 - admission for treatment	o Suffer from a mental disorder o Nature and degree of disorder make it appropriate for the treatment in hospital o Necessary for safety of patient, or others • 6 months, can be renewed for another 6 months, then yearly after that • Authorized as section 2 is • Appeal can be in the first 6 months, then the next 6 months, and then annually after that • Review by the tribunal is done automatically if there has been no appeal in the first 6 months or in any 3 year period
Section 4 - emergency admission	• When there is no senior psychiatrist available within the time needed • Need a social worker and a GP • 72 hours
Section 5 - detention of a patient already in hospital	• Section 5.2 • Can be done quickly without 2nd opinion • 72 hours • Section 5.4 • Nurse can do this • 6 hours
Confidentiality - when should you not breach	• To prevent minor crime • To prevent minor harm • In GUM clinic, no information identifying a patient should be given • Should not breach to insurance company
Confidentiality - when to breach	• Notifiable disease • Termination of pregnancy • Birth/death • To police on request under the Road Traffic Act • Search warrant • Court orders
Confidentiality, when to have discretion	• Other members of the healthcare team • Patient continuing to drive who is not fit to do so (contact DVLA) • Third party is at significant harm • Prevention of serious crime
HIV and AIDS - confidentiality	• Breach confidentiality if this patient could put healthcare team at harm • However if you discuss the issue with patient, normally the patient will disclose information • If a patient refuses to tell their partner they have HIV, you can breach confidentiality and warn person in order to safeguard
NHS venereal disease regulation	• Patient information should not be disclosed except for the treatment and prevention of spread (contact tracing) • Disclosure can only be made to doctor, or healthcare staff • HUM clinic is not allowed to inform insurance company, even with the patients consent • GUM clinic notes are separate from general hospital notes
four conditions of abortion	• Not >24 weeks, and continuing would risk injury to the patients physical or mental health of the woman or family • Termination is necessary to prevent grave permanent injury to physical or mental health of patient • Continuance of pregnancy would involve risk to the patients life • IF the child were born it would have severe physical or mental abnormalities Opinion of 2 doctors is needed
Pro-life stance abortion	o All human life is sacred and an embryo counts as life o See The embryo is morally valuable because it is a potential human being o Abortion = murder o Since it is a potential human it should have rights
Pro-choice stance	o Ending pregnancy is a choice made y the woman involved o Value of the embryo is not necessarily zero, it is just subordinate to the rights of the mother o Consequentialist • Harm may occur if there was no legal/safe option of abortion • Increasing poverty of women and their existing children • Pregnancy may be at risk to the health • Women may seek unsafe termination
Rights based arguments and abortion	• Restricting abortion is a breach of autonomy • Infringes on the women’s right to health and satisfactory life
What to do if suspect child abuse	• Contact senior • Call child protection worker • Possible admit to hospital • If parents refuse, emergency protection order or police protection
Specific orders in child protection	o Child protection orders – Children Act 2004 • Children at risk of significant harm • Allows parents to be overruled • Child in need of assistance to flourish • Consent is required for social services to be involved o Specific issue orders • Courts decide a decision when there is a dispute between parents and doctors o Care and supervision order • Give parental authority to the local authority when there is a child at risk o Emergency protection order • Urgent need to move and child at risk to a safe place o Child assessment order • Allows a court to have a child assessed by doctor for evidence of abuse
The two stage test for mental capacity	1. is there an impairment of, or disturbance in the functioning of, the mind or brain 2. can the person make a specific decision at a specific time (consider ability to understand relevant information, retain that information, use and weigh that information and communicate their decision)
MCA vs MHA	mental capacity act - ability to make a decision Mental health act - assessment and treatment of mental health problems
The two types of lasting power of attorney	Property and affairs - can make decisions even when person has capacity personal welfare - cannot make decisions when person has capacity
Two key questions to ask in deprivation of liberties	Is person subject to continuous supervision and control Is the person free to leave? think how staff would react if they tried to leave?
Define: Primary prevention: Secondary prevention: Tertiary prevention	Primary prevention: activities aimed at stopping a disease developing in the first place. Secondary prevention: activities aimed at stopping adverse events happening once a disease has developed. Tertiary prevention: limiting the impact that adverse events have on health.
4 questions in establishing a successful strategy	Where are we now? Where do we want to go? How can we get there? How will we know if we're there?
5 stages in the audit cycle	preparing for audit, selecting criteria, measuring levels of performance, making improvements (implement a change), sustaining improvements (repeat audit)
who to notify in suspected food poisoning	Consultant for communicable disease control
Identifying and preventing type 2 diabetes	NHS health check Change4life
the 9 recommended health tests and screening to reduce stroke, heart disease and amputations	o Weight and BMI measurements o Blood pressure o Smoking status o Blood test (hba1c – blood glucose levels) o Urinary albumin test (or protein test to measure the kidney function) o Serum creatinine test (creatinine is an indicator for renal function) o Cholesterol levels o Eye check (retinopathy screening) o Feet check
Calman hine 3 levels of cancer care	o Primary care o Cancer Units – serving DGHs populations of 250,000 • Treating Common Cancers • Diagnostic procedures • Common Surgery • Non Complex chemotherapy o Cancer Centres – serving populations in excess of 1 million • Treating Rare cancers • Radiotherapy • Complex chemotherapy o Key to managing patients would the multidisciplinary team
criteria for cancer screening	• Common cancer • Natural history understood • Effective test • Acceptable test • Effective intervention • Health system can cope • Demonstrable change in survival rate • Favourable cost benefit ratio
What can you prescribe smokers	NRT, varenicline or bupropion
2 main reasons for post mortem	o At the request of a Coroner, because the cause of a death is unknown, or when a death happens unexpectedly or suddenly. No consent given as - o The Coroner is required by law to investigate deaths which are violent, unnatural or sudden with unknown cause, or those which occurred in prison. o At the request of a hospital, to provide information about an illness or cause of death, or to advance medical research.
4 domains of cancer pain	physical, social, psychological and spiritual
What is palliative care according to WHO	Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
Organisation of mental health services	Mental health trusts Community mental health teams Crisis resolution teams Assertive outreach teams early intervention in psychosis team Forensic mental health services Hospital or day hospital Rehabilitation
Mental health act 1983. what is a mental disorder	• Mental disorder defined as: o Mental illness o Arrested or incomplete development of mind o Psychopathic disorder o Any other disorder or disability of mind • Excludes, and not grounds for detention in hospital under act, if only: o Promiscuity/immoral conduct o Sexual deviancy o Dependence on alcohol or drugs
How to section people quickly	o Section 4 and Section 136 can be used to admit people from the community and Sec- tions 5(2) and 5(4) to detain informal inpatients who want to leave the ward
3 stages of assessing capacity	• Three stages of assessing capacity o Comprehension and retention of relevant information o Ability to believe information (e.g. no delusion interfering) o Weigh information and make decision
What is required for consent to be valid	o Have mental capacity o Act under free will (not pressurised) o Provided with enough information to understand decision and likely consequences
Cervical screening ages and frequency	o Women between 25 and 64 are eligible • 25-49 every 3 years • 50-64 years every 5 years
o Women 65 and older should be screened if	o Women 65 and olfer should be screened if • They have not had a cervical screening test since 50 • A recent cervical cytology sample is abnormal
Cervical screening in immunosuppressed	• Offer screening at the time they are put on the transplant list if they have not been screened as required • Offer screen 1 year after renal transplant • Treat any abnormality as high grade • Same for those starting cytotoxic drugs • HIV – annual screening
Follow up of cervical cancer	o CIN1 should be offered cervical screening at 6, 12, and 24 months after treatment. If the cervical cytology results are negative, they then return to the normal recall system. o CIN 2, CIN 3 or cervical glandular intraepithelial neoplasia should be offered cervical screening at 6 and 12 months after treatment and then annually for 9 years (that is, 10-year follow up). o If women do not have a negative test following treatment, they should be offered repeat colposcopy at least once during the following 12 months.
What is screened for in the newborn blood spot screening	(Previously known as blood spot and Guthrie test. Ideally at day 5 (5-8) • Phenylketonuria (PKU) • Congenital hypothyroidism • Sickle cell disease • Cystic fibrosis • Medium-chain acyl CoAdehydrogenase (MCAD) deficiency • Homocystinuria • Maple syrup urinary disease • Glutaric aciduria type 1 • Isovaleric acidaemia • UK variation in the blood spot test
Approximate outline of child protection	assess Does child need immediate protection strategy meeting usually in 24 hours, no parents Then child protection conference
When does an adult lack capacity	First it has to be shown that the adult is suffering from some sort of impairment or disturbance of the mind or brain. This is known as the ‘diagnostic’ criterion. Having identified the impairment it then has to be established that it prevents the individual from making the relevant decision.
what is a best interests test	an objective test of what would be in the person’s actual best interests, taking into consideration all relevant factors. A best interests test is not a ‘substituted judgment’ test. A substituted judgment test seeks to identify what the patient would have wanted and to decide accordingly. A best interest test takes the patients wishes into account where they are known, but they may not be determinative.
When is an advanced decision (or directive) binding?	the person had capacity and was aged 18 or over when he or she made it it specifies, in lay terms if necessary, the specific treatment to be refused and the particular circumstances in which the refusal is to apply the person making the decision has not subsequently withdrawn the decision or appointed a proxy to make it the person has not subsequently done anything clearly inconsistent with the decision if the decision relates to life-prolonging treatment it must be in writing, signed and witnessed and contain the statement that the decision is to apply even if life is at stake
At what age is presumed capacity	16 years
Who has parental responsibility	In relation to children born after 1 December 2003, both of a child’s biological parents have parental responsibility if they are registered on a child’s birth certificate. In relation to children born before this date, both of a child’s parents only acquire parental responsibility if they were married at the time of the child’s conception. If the parents were not married, only the mother automatically has parental responsibility, but the father may acquire it by order or agreement. This is a legal agreement
Emergency situation for treating children	‘Emergency, parental neglect, abandonment of the child, or inability to find the parent are examples of exceptional situations justifying the doctor proceeding to treat the child without parental knowledge and consent.’
Can a competent young child refuse treatment	Although capacity to consent and to refuse treatment would appear two sides of the same coin, the courts have ruled that a refusal of treatment by a competent person under the age of 18 is not necessarily binding. In some circumstances, particularly if the young person’s life is at stake, doctors may still be able to provide treatment that is in his or her best interests but legal advice should be sought. Where a competent young person refuses treatment, the harm caused by overriding his or her choice and possibly using restraint will need to be balanced against the harm caused by failing to treat.
what information is confidential	All identifiable patient information, whether written, computerised, visually or audio recorded or simply held in the memory of health professionals is subject to the duty of confidentiality
When can confidential information be disclosed in the public interest	Confidential information can be disclosed without consent where the public interest in the disclosure is sufficiently strong. These can include disclosures that are essential to prevent a serious and imminent threat to public health, national security, the life of the individual or a third party or to prevent or detect a serious crime. Any disclosure must be both necessary: the goal cannot be achieved without it; and proportional: only as much information as is necessary to achieve the goal should be disclosed.
Confidentiality and police	As with all other requests for information, the presumption would be that confidential information should only be disclosed to the police where the patient has given explicit consent. Exceptions to this would be where there is a court order requiring disclosure, where the public interest in preventing or prosecuting a serious crime outweighs the individual’s right to confidentiality or where someone is at risk of death or serious harm.
Child protection procedure	1) Junior has concern 2) Discuss with senior 3) Pediatric assessment 4) Refer to social services +/- Child Abuse Investigation Team (CAIT) 5) Strategy meeting 6) Case Conference a) Child in need b) Child at risk 7) Child Protection Plan

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	Created by Sameet Govan almost 9 years ago