Transcript Ethics-and-communcation-notesm

FFICM teaching notes
25/6/15
Justin Mandeville
FFICM - SOE
• SOE section is to test knowledge in clinical science as applied to the
practice of Intensive Care Medicine.
• 4 x 14 minute stations with two questions in each.
• 2 minutes to read the information outside each station
• 2 x 7 minute questions
• Focus usually on clinical problems (may be given a brief clinical
scenario)
• Then structured questions.
• Marks are: Pass=2, borderline pass=1 and fail = 0
FFICM – OSCE
Test knowledge and skills essential to the safe practice of intensive care.
• 7 x 13 min stations
• 12 live and 1 test
• 1 minute for reading
• No 'killer stations' and negative marking is not used.
• Selected to ensure coverage of a wide area of the curriculum, grouped:
• Professionalism - communicate with relatives and staff and handle ethical and
administrative problems
• Resuscitation and Equipment - ability to demonstrate protocols/use
• Data stations test radiological interpretation of X-Rays, CT scans and MRI scans.
• Marking
• Each station is marked out of 20 with the pass mark for each station being determined by the
Examiners
• Summed to obtain the pass mark for the whole examination
2014 exam
75% passed OSCE and 75% passed SOE. 63% passed both.
• Weakest OSCE examination stations were those involving ECG and X ray interpretation.
• Need to convince the examiner that they are aware of the logical approach to reading an ECG or X ray and
assume that the examiners will require a thorough and systematic interpretation
• Issues around refeeding syndrome were answered poorly
Relevant curriculum domains
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Basic ethical principles: autonomy, beneficence, non-maleficence, justice
Ethical and legal issues in decision-making for the incompetent patient: incapacity
Difference between euthanasia and allowing death to occur: doctrine of double effect
Cultural and religious practices of relevance when caring for dying patients and their
families
Deprivation of Liberty
Safeguarding Adults/Children
Power of Attorney, Independent Mental Capacity Advocacy
Treatment limitations, withholding or withdrawing care
Organ donation
Ethical issues surrounding transfer
Define the standards of practice defined by the GMC when deciding to withhold or
withdraw life-prolonging treatment
Know the role and legal standing of advance directives in different UK legislations
Outline the principles of the Mental Capacity Act (Adults with Incapacity Act in
Scotland)
Day format
9 - 10am: Organ donation nurses - the practical aspects of organ donation/service set-up and delivery
10:30 - 11:30am: Dr S Raby - brainstem death testing and donation.
11:30 - 12:00pm: Enrico S - the mental capacity act
12:00-12:30pm: Ben G - journal review (two relevant journals)
OSCEs:
Explain reasons for a non-clinical transfer.
Refuse admission or intubation against family’s wishes.
If necessary ?Brainstem death testing procedure
(Other possibilities are : guide a family through the decision to consent to donation, consent for PM, explain
reasons for physical restraints.)
Then Viva practice:
Discuss the principles of the Mental Capacity Act in England and Scotland
Discus withdrawing ‘v’ withholding
(Others: discuss DoLS, safeguarding, advanced directives, DNAR)
Basic ethical principles: autonomy, beneficence, non-maleficence, justice
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Autonomy
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Beneficence
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Treatment should only be given if it is likely to benefit the patient. Best interests. Promote well-being.
Non-maleficence
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Right of a patient to have control over his or her own life, including decisions about how his or her life should end.
Competent persons should be able to refuse life-saving treatment in both current situations and future foreseeable situations
Treatment should not be given if it is likely to cause more harm than good. In codes of medical practice,
The principle of non-maleficence (“primum non nocere”)
It also underpins the doctrine of double effect.
Justice (distributive)
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Treatment should not be given if it deprives others of greater benefit
Sanctity of Life Doctrine
All human life has worth and therefore it is wrong to take steps to end a person's life, directly or indirectly, no matter what the quality of that life. But:
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‘should life be preserved at all costs?’
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no place for consideration of quality of life?
Doctrine of double effect
There is a moral distinction between acting with the intention to bring about death and an act where death is a foreseen but unintended consequence.
Performing an act that brings about a good consequence may be morally right, even if only achieved at the risk of a harmful side effect.
Acts and omissions distinction
There is a difference between actively killing someone and refraining from an action that may save or preserve that person's life.
Withholding is only permissible if the patient's quality of life was so poor, that it would not to be in the patient's best interests to continue treatment.
Confirming cardiac death (AoMRC 2008)
• The simultaneous and irreversible onset of apnoea and unconsciousness in the absence of the circulation
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Full and extensive attempts at reversal of any contributing cause to the cardiorespiratory arrest have been made.
Such factors, which include body temperature, endocrine, metabolic and biochemical abnormalities, are considered.
• One of the following is fulfilled:
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meets the criteria for not attempting cardiopulmonary resuscitation
cardiopulmonary resuscitation have failed
treatment aimed at sustaining life has been withdrawn because it has been decided to be of no further benefit, o is against patient wishes
• The individual should be observed by the person responsible for confirming death for a minimum of five minutes.
• The absence of mechanical cardiac function is normally confirmed using a combination of the following:
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absence of a central pulse on palpation
absence of heart sounds on auscultation
In hospital, you can use:
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asystole on a continuous ECG display
absence of pulsatile flow using direct intra-arterial pressure monitoring
absence of contractile activity using echocardiography
• Any spontaneous return of cardiac or respiratory activity during this period of observation should prompt a further five minutes
observation from the next point of cardiorespiratory arrest
• After five minutes of continued cardiorespiratory arrest
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absence of the pupillary responses to light, of the corneal reflexes, and of any motor response to supra-orbital pressure should be confirmed
• The time of death is recorded as the time at which these criteria are fulfilled.
Brainstem death testing – AoMRC and FICM
Caution !
1.
if testing <6hr of the loss of the last BS reflex
2.
<24hr in hypoxic injury
3.
Hypothermia – rewarm then test 24hr later
4.
Neuromuscular disorders
5.
Steroids given for SOL
6.
Prolonged fentanyl infusions
7.
Primarily brainstem or posterior fossa pathology
8.
Children under 2 months
Must have:
Irreversible brain damage of known aetiology
No depressant drugs – do levels if necessary,
No NMB
Allowed for long action in renal failure
Tell the SN-OD that you are doing the test
Aim for :
Temp >34,
MAP >60,
Normocarbia, normoxia,
Normal pH,
Na 115-160, K>2,
Mildly deranged Mg and PO4 allowed,
Glucose 3-20 mmol/l
Brainstem testing
SIgn
CN
BS structure
Pupils fixed (any size)
A-II , e-III
Midbrain
Corneal reflex absent
A- V , e-VII
Pons
Vestibulo-ocular reflex absent
a- VIII , e- III, IV, VI
Pons
Motor response (to somatic area
stimulation) in CN distribution
absent
A- V, e-VII
Pons
Carinal cough reflex and gag absent A and e - IX, X
Medulla
Apnoea
Medulla
Consent
Landmark decision from Montgomery v Lanarkshire Health Board, by the UK Supreme Court March 2015
Nadine Montgomery was a woman with diabetes who gave birth by vaginal delivery. Baby born with serious disabilities after shoulder dystocia during delivery.
Obstetrician (McLellan) did not mention 10% risk of shoulder dystocia. Admitted she routinely didn’t in case women would opt for a caesarean section.
Court ruled this was illegal.
Bolam test is out
“supported by a responsible body of medical opinion” no longer applies for consent.
Now “reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.”
Thus 3 questions:
1.
Does the patient know about the material risks of the treatment I am proposing?
2.
Does the patient know about reasonable alternatives to this treatment?
3.
Have I taken reasonable care to ensure that the patient actually knows this?
Of note
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Material risk = either a risk to which a reasonable person in the patient’s position would be likely to attach significance or a risk that a doctor knows—or should reasonably know—would probably be deemed of
significance by this particular patient.
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“this particular patient” . Material risks are therefore personal.
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Pro forma consent is ethically dodgy. Therefore a “dialogue” between doctor and patient is requisite.
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Give information in clear terms, avoiding jargon/technospeak
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Material risks should be forwarded. DO NOT wait to be asked.
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Document discussion fully
Exceptions
1.
The patient explicitly prefers not to know the risks.
2.
If telling would cause serious harm– “therapeutic exception” eg stress of discussion causing MI.
3.
No consent is needed in circumstances of necessity, urgent treatment, coma, lack of capacity.
The Law must impose some obligations “so that even those doctors who have less skill or inclination for communication, or who are more hurried, are obliged to pause and engage in the discussion which the law
requires.”
i.e. the pre-existing GMC “guidance” is now law.
Consent to donation
Reasons for refusal
Relatives not wishing surgery to the body/concerns regarding disfigurement
Feelings that the patient had suffered enough
Uncertainty regarding the patient's wishes
Disagreements among the family group
Religious/cultural reasons
Dissatisfaction with healthcare staff and process
Concerns over delay to funeral/burial process
Unable to accept death, lack of understanding of brain death
Concerns regarding integrity of process, e.g. unfair organ allocation, organ selling
Relatives had decided on their own that organs would not be suitable
Longstanding negative views on organ donation
Relatives were emotionally exhausted
Include in discussion
• Description of the what the organ donation process actually involves.
• Emphasis on the benefits of donation and the potential to help others.
• Reassurances regarding funeral and burial arrangements.
• Reassurances regarding the fairness of organ allocation.
Donor care
Incidence of physiological changes post BSD (%)
• hypotension 80
• diabetes insipidus 65
• disseminated intravascular coagulation 30
• cardiac arrhythmias 30
• pulmonary oedema 20
• acidosis 10
Causes of cardiovascular collapse after brain stem death.
• Peripheral vasodilation
• Hypovolaemia diabetes insipidus
• osmotic diuretics (mannitol)
• hyperglycaemia
• therapeutic fluid restriction
• Myocardial depression depletion of high energy phosphate
• mitochondrial inhibition
• possible reduction in T3 production
• electrolyte disturbance
Donor care 2
CVS targets
Mean Arterial Pressure 60-80 mmHg
Central venous pressure ~ 4-10 mmHg
Pulmonary artery occlusion pressure ~ 10-15 mmHg
Heart Rate 60 – 100 beats.min-1 and Sinus rhythm is desirable
Cardiac Output Cardiac Index > 2.1 l.min-1.m-2
Echocardiography – TTE if good quality images, else TOE
Clinical problem
Diabetes Insipidus
Maintain Na+ = 155 mmol.l-1 with 5% dextrose3
Maintain urine output about 1 - 2 ml.kg-1.h -1 with vasopressin 1 U bolus and 0.5-4.0 U.h-1 infusion.
PRN desmopressin may occasionally be required.
Hyperglycaemia
Insulin infusion to maintain plasma glucose 4-9 mmol.l-1. Maintain K >4.0 mmol.l-1
Hypothyroidism
Tri-iodothyronine (T3) 4 µg bolus then infusion at 3 µg.h-1
Inflammatory response
Methylprednisolone 15 mg.kg-1
Donor care 3
Respiratory targets
Normocapnia ·
Lowest FiO2 for PaO2 of >10.0 kPa. FiO2>50% probably toxic re lung transplant
PEEP > 5 cmH2O usually not required
Avoid high peak/plateau pressures
CXR
Other
Renal
Avoid hypotension
Haematological
Hb > 9.
Correct coagulopathy.
No antifibrinolytics
Temperature
Normothermia – usually have to warm
DCD notes
• Outcomes:
• kidneys: higher incidence of delayed graft function with DCD kidneys but
similar graft survival
• liver: lower patient and graft survival at 1 year
• pancreatic: similar to brain death harvesting
• lung: similar to brain death harvesting
• WARM ISCHAEMIC TIME
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time from withdrawal of treatment -> cold perfusion
the most important phase occurs when SBP < 60mmHg
liver: < 30 min
kidney and pancreas: < 60 min
lung: < 90 min
Donation after cardiac death
Ethical Considerations in Transplantation
• Altruism: the voluntary stated wish of the individual to make the ‘gift’ of donation of their organs upon death without expectation of
reward.
• Autonomy: the right of the individual to determine his/her own fate, including that of their organs after death.
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But approx. 7% of potential donations are blocked by the NOK.
In reality, not in law, their consent is required
• Dignity: complex to define, but in this context reflecting the unique and precious status of the human being and the ethical requirement to
treat it respectfully without inflicting harm in both life and death.
• Beneficence: act in the best interests of the patient and act to promote well-being.
• Non-malificence: the ethical principle that healthcare professionals should not cause harm or distress to their patients.
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Use the least invasive process
• Futility: the contentious principle that it is unethical to perform interventions which cannot benefit the individual receiving them; the
controversy focusing upon what does or does not constitute benefit.
• Equity: The concept of fairness or justice with respect to the way the organs donated are allocated and utilised
Predominant conflict =
Does an altruistic wish (Altruism) to donate allow treatment that is futile (Futility) for the patient, potentially undignified
(Dignity), and harms (Beneficence & Non-maleficence) their body for the sake of preserving organs for others (Equity?).
Death does not deny the individual ‘rights’ since this would conflict with ‘last will and testament’ laws.
Donation process
Category
Type
Circumstances
Typical location
1
Uncontrolled
Dead on arrival
Emergency Department
2
Uncontrolled
Unsuccessful resuscitation
Emergency Department
3
Controlled
Cardiac arrest follows planned withdrawal of life
sustaining treatments
Intensive Care Unit
4
Either
Cardiac arrest in a patient who is brain dead
Intensive Care Unit
Mastricht category - above
Discussion points with NOK when agreeing to go ahead
• Which organs could be donated and how they would be used benefit to others. Coroner may also disallow some
depending on circumstances.
• The time frames associated with the process of organ and/or tissue donation.
• Tissues and blood samples that may be taken and stored as part of the donation process e.g. HLA typing, biopsies, etc.
• The option for participation in research (e.g. organs and tissues donated solely for research, those donated for research if
they are unsuitable for donation, participation in research studies to support and improve donation outcome).
• The disposal of organs that are unsuitable for transplantation or discarded following participation in a research study.
• The appearance of an individual following the donation of organs and/or tissues.
• The need for virology testing and that results may be discussed with them if a test result were found to be positive.
• The past medical and social history of the potential donor.
• Following documentation of consent/authorisation as described above, the organ donation process can start
Consent for post mortem examination
Reasons for:
• Unexpected death
• violent, unnatural or suspicious, such as a suicide or drug overdose
• an accident or injury
• during or soon after a hospital procedure, such as surgery
• the cause of death is unknown
Procedure
Body opened
Usually organs removed
Tissue sometimes retained for prolonged (weeks) testing. Then returned.
Can request not looking at certain parts.
If hospital PM there may be a charge for the full report
Can request to go through the results with a doctor
Autonomy v authority
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If there is resistance and the coroner still insists then the only option is ‘judicial review’.
• Religion
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Object
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Muslim and Jewish
Generally accept
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Christian Scientists, Buddhists, most Christian sects, and Jehovah Witness doctrines do permit.
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Shinto, Taoism, and Confucianism do not object.
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Hindus have no intrinsic objection but all organs must be returned to the body
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Sikhs believe that the funeral must not be delayed.
Salford 2010 – offered MRI (for £500) instead of PM on coroner’s agreement
Part 2: Retention and future use of tissue samples
Consent for post-mortem examination of an adult
Name of deceased:
Date of birth:
Date of death:
Consultant / GP in charge of the patient:
Hospital number for deceased:
This form enables you to consent to a post-mortem examination of the body of the person
named above. Please read it carefully with the person obtaining consent from you. For each
section tick the relevant box to indicate your decisions and sign beneath each section.
As part of a full or limited post-mortem examination tissue samples and small amounts of
bodily fluids may be taken and used to determine the diagnosis and extent of the disease.
Bodily fluids will usually be disposed of following a diagnosis. However, the tissue samples
removed during a post-mortem examination can be stored for use in the future. The storage
of the tissue samples and their later use require your consent. These samples can be
valuable for the education and training of healthcare professionals, research and other
purposes. Please indicate whether you consent to this:

I consent to the tissue samples being stored for future use, and
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I consent to the tissue samples being used for the purpose of evaluating the efficacy
of any drug or treatment administered to the deceased, or for review on behalf of the
family if a need arises
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I consent to tissue samples being used for education and training relating to human
health, quality assurance, public health monitoring or clinical audit
I consent to the tissue samples being used for research that has been approved by
an appropriate ethics committee

I confirm that I have had the opportunity to read and understand the [insert name of
information leaflet].
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I confirm that my questions about the post-mortem examination have been answered
to my satisfaction and understanding.
If you decide tissue samples should not be kept after the post-mortem examination, further
diagnosis will not be possible and the tissue samples will be disposed of.
Signed by……………………………………..Name………………………………………………
[See guidance note 3]
Signed by……………………………………..Name………………………………………………
Part 1: Post-mortem examination
A post-mortem examination may be full or limited. The benefits and disadvantages of each
will be explained to you. Please choose one of the following options.
Option 1: Consent to a full post-mortem examination

As part of a full or limited post-mortem examination, it may be necessary to retain some
organs for more detailed examination. The person explaining about the post-mortem
examination will tell you what may be required. The retention of organs for more detailed
examination requires your consent. Please indicate whether you consent to this:

I consent to a full post-mortem examination of the body of the person named above.
I am not aware that he / she objected to this. I understand that the reason for the
examination is to further explain the cause of death and study the effects of disease
and treatment.
Option 2: Consent to a limited post-mortem examination

Part 3: Retention of organs for more detailed examination
I consent to a limited post-mortem examination of the body of the person named
above. I am not aware that he / she objected to this. I understand that this may limit
the information about the cause of death and effects of treatment.
I wish to limit the examination to (please specify) ……………..………………….
[See guidance note 1]
…………………………………………………………………………………………………
…………………………………………………………………………………………………
Disposal of retained organs
After more detailed examination of organs removed during a post-mortem examination, they
must be either stored for specified uses or disposed of in a lawful manner. You have the
option of donating retained organs for research or medical education. Please indicate your
wishes by choosing one of the following options:

I wish to donate retained organ(s) for research into related diseases, after which they
will be disposed of lawfully

I wish to donate retained organ(s) for education, after which they will be disposed of
lawfully

I wish the hospital to lawfully dispose of any retained organ(s), without them being
used for research and/or education

I will make my own arrangements for lawful disposal of any retained organ(s) [See
guidance note 4]
[See guidance note 2]
Signed by……………………………………..Name………………………………………………
I consent to the retention, for more detailed examination, of the following organ(s):
Signed by……………………………………..Name………………………………………………
Explain non-clinical transfer of patient
Usually out of necessity and a time pressured discussion.
Consider the ethics:
• Does the clinical team, or the institution, owe an equal duty of care to both
patients?
• If each patient is owed the same duty of care, should the aim be to maximise the
chance that both patients live, or minimise the chance that both patients die.
• In contrast to 2, should the sickest patient be given any greater priority in
receiving best possible care?
• If the patient in ICU is owed a greater duty of care, is this sufficient to justify the
decision not to admit the other patient, given the foreseeable probable
outcome?
• Is patient autonomy relevant in this situation?
• Keep in mind that it is not possible to provide the best care to both patients
http://www.ukcen.net/index.php/main/case_studies/who_should_have_the_intensive_care_bed
Withholding and withdrawing
1.
Explain the medical situation
2.
Elicit the patient’s values and preferences
3.
Provide emotional support to the family
4.
Begin to develop a trusting relationship
Appropriate when
• When the available medical interventions are unlikely to achieve the patient’s goals of care
• When the duration or invasiveness of treatment required to achieve the patient’s medical goals is known to
be unacceptable to the patient
Misconceptions
Abandonment – withdrawal of treatment is not withdrawal of therapeutic relationship
Violation of beneficence – ‘well-being’ and ‘best interests’ are not always best served by prolonging
life
Withdrawal NOT = withholding - not ethically different in law
Doctrine of double effect – intentions matter
Withholding and withdrawing – the law (&GMC)
A number of legal judgments on withholding and withdrawing treatment, mainly in English courts, have shown that
the courts do not consider that protecting life always takes precedence over other considerations
Case law
• Life prolonging treatment can lawfully be withheld or withdrawn from a patient who lacks capacity when starting
or continuing treatment is not in their best interests
• There is no obligation to give treatment that is futile or burdensome
• If an adult patient has lost capacity, a refusal of treatment they made when they had capacity must be respected,
provided it is clearly applicable to the present circumstances and there is no reason to believe that the patient had
had a change of mind.
• In the case of children or adults who lack capacity to decide, when reaching a view on whether a particular
treatment would be more burdensome than beneficial, assessments of the likely quality of life for the patient with
or without that treatment may be one of the appropriate considerations.
• Clinically assisted nutrition or hydration may be withheld or withdrawn if the patient does not wish to receive it; or
if the patient is dying and the care goals change to palliative care and relief of suffering; or if the patient lacks
capacity to decide and it is considered that providing clinically assisted nutrition or hydration would not be in their
best interests
• In the case of patients in a permanent vegetative state (PVS), clinically assisted nutrition or hydration constitutes
medical treatment and may be lawfully withdrawn in certain circumstances.18 However, in practice, a court
declaration should be obtained
• Responsibility rests with the doctor to decide which treatments are clinically indicated and should be offered to the
patient. The decision to provide treatment should be subject to the patient’s consent if they have capacity or, if
they lack capacity, any known views of the patient prior to losing capacity and any views offered by those close to
them
Refusal of admission to ICU
Reasonable topic for OSCE
Standard ethical principles but unlikely to incorporate this into OSCE.
Little literature – try:
• Ethical problems in intensive care unit admission and discharge decisions –
BMC Medical ethics 2015
• http://www.biomedcentral.com/content/pdf/s12910-015-0001-4.pdf
• Reasons for refusal of admission to intensive care and impact on mortality
• http://icmjournal.esicm.org/Journals/abstract.html?doi=10.1007/s00134-010-1933-2
Mental capacity act
What is mental capacity?
• Ability to make their own decisions, at that moment. Specifically judged using THE SIMPLE (4 point) TEST.
• What is the Mental Capacity Act?
• Single, coherent framework for dealing with mental capacity issues and an improved system for settling
disputes, dealing with personal welfare issues and the property and affairs of people who lack capacity.
• Delivered in the Code of Practice
• Explanation of how the MCA works on a day to day basis.
• Health and social care workers have a legal duty to have regard to the code.
• What changes did the Mental Capacity Act introduce?
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Presume capacity prior to testing
Use of a single clear test
Ways to influence decisions in the future – advance decisions, statements, LPA
Actions if lack of capacity
Obligation to consult carers and those involved in welfare
Advocacy service where none appropriate (IMCA)
Wilful neglect is a crime
Research safeguards
New court of protection
MCA 2 – 5 principles and 4 point test
The five principles of the MCA:
• Help to make decisions for themselves
• Information
1. Everyone (adult) is assumed to have
capacity
2. Everyone supported as much as possible
to make own decisions
3. Everyone can make ‘unwise decisions’
4. If capacity is lacked, act in their best
interests
5. If capacity is lacked, use the least
restrictive (re rights and freedoms)
actions
1.
2.
3.
sufficient,
understandable & tailored,
given with support.
• Assess capacity
• When should capacity be assessed?
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Specific and sufficiently complex decision, & reason not to have capacity,
• Stage 1 - Does the person have an impairment of the mind or brain, or is there
some sort of disturbance affecting the way their mind or brain works?
• Stage 2 - If so, does that impairment or disturbance mean that the person is
unable to make the decision in question at the time it needs to be made? Use
the 4 point test.
The test to assess capacity
1. Understand the information relevant to that decision, including understanding the likely consequences of
making, or not making the decision.
2. Retain that information.
3. Use or weigh that information as part of the process of making the decision.
4. Communicate their decision (whether by talking, using sign language or any other means).
MCA 3
• Challenging the result of an assessment of capacity
1.
2.
3.
4.
5.
6.
7.
The first step will always be to raise the matter with the person who did the assessment.
A second opinion may be useful in some cases.
Involve an advocate (not an IMCA) who is independent of all parties involved.
Local complaints procedures.
Mediation.
Case Conference.
If a resolution is not possible they can apply to the Court of Protection
• Best interests
1. Not on the basis of the person’s age or appearance, condition or any aspect of their behaviour.
2. Consider all the relevant circumstances relating to the decision in question.
3. The decision-maker must consider whether the person is likely to regain capacity. Can decision wait?
4. Must involve the person as fully as possible
5. If the decision concerns the provision or withdrawal of life-sustaining treatment the decision-maker must not
be motivated by a desire to bring about the person’s death.
6. The decision maker must in particular consider the person’s past and present wishes and feelings, any beliefs.
7. Must consult other people if it is appropriate to do so and take into account their views:
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LPA For health and welfare (separate from financial, administered by the Office of the Public Guardian (OPG), an agency of the Ministry
of Justice of the United Kingdom) has charge over personal and financial affairs.
Must consider appointing IMCA
Advance decisions / directives
Define advance decision (previously advance directive; avoid ‘living will’)
• Statement explaining what medical treatment the individual adult would not want in the future, should that individual 'lack capacity‘
(MCA 2005).
i) a directive, ii) the appointment of representative., iii) a statement of general beliefs: iv) a combination of any of the above
• Legally binding in England and Wales.
• Except in the case where the individual decides to refuse life-saving treatment (must be signed and witnessed), it does not have to be
written down, but is best to.
• A patient with capacity can override any directive at any time
• If you doubt the validity contact hospital law team or your indemnity organisation
• In Scotland and NI
•
•
governed by common law rather than legislation.
But it is highly likely that a court would consider it legally binding.
Advance statement
• This is an expression of the individual's desires and may refer to personal values, principles and religious beliefs. It is not legally
binding but may act as a guide to a doctor who has to make a decision on behalf of a patient who lacks capacity.
Cannot be used to:
Can be ignored if:
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Ask for specific medical treatment.
Request something that is illegal (eg assisted suicide).
Choose someone to make decisions, cf 'lasting power of attorney'.
Refuse treatment for a mental health condition (MCA pt4)
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The individual makes changes which invalidate the directive (eg
a change to a religion).
There have been (unconsidered) advances in treatment
There is ambiguity in the wording
Care act and safeguarding
Care act 2014
• There have been a number of high profile hospital scandals that have
highlighted the need for vigilance and action among staff and managers.
• Abuse and neglect are crimes
The statutory guidance enshrines the six principles of safeguarding
1. empowerment - presumption of person led decisions and informed
consent
2. prevention - it is better to take action before harm occurs
3. proportionality - proportionate and least intrusive response appropriate to
the risk presented
4. protection - support and representation for those in greatest need
5. partnerships - local solutions through services working with their
communities
6. accountability - accountability and transparency in delivering
safeguarding.
Acheived by:
• Sensible risk appraisal – are they a ‘vulnerable adult’
•
•
Takes into account the individual preferences as these alter the individual risk/benefit
balance.
Munby - "what good is it making someone safer if it merely makes them miserable?"
• Multi-agency collaboration (Police, NHS, others)
• Sharing of information
• Designated Adult Safeguarding Managers
The Care Act 2014 puts adult
safeguarding on a legal footing and from
April 2015 each local authority must:
1. make enquiries if it believes an adult
is at risk of, abuse or neglect.
2. set up a Safeguarding Adults Board
(SAB) with LA, Police and NHS
3. arrange for an independent advocate
4. cooperate with each of its relevant
DNACPR
1.
2.
3.
4.
Decisions re whether or not to attempt CPR, made early and in the wider context of
advance care planning, is an important part of good-quality care.
Personalized decision, never blanket policies.
Reassess as the clinical picture changes, or the patient changes their opinion.
‘Best-interests’ decision is made using the patient, or where that’s not possible, close
relatives.
• It is important to ensure that they understand that (in the absence of LPA) they are not the final
decision-makers.
5.
6.
7.
8.
9.
Refusal or an advanced decision to refuse treatment (ADRT), must be respected.
If the healthcare team is as certain that CPR would not re-start the heart and
breathing for a sustained period, CPR should not be attempted.
A decision not to attempt CPR that has no realistic prospect of success does not
require the consent of the patient or of those close to the patient.
But there is a presumption in favour of informing a patient or relatives of such a
decision. Effective communication is essential to ensure that decisions about CPR are
made well and understood clearly by all those involved.
There should be early clear, accurate and honest communication
Cultural and religious issues re death/dying/palliation
All varies between and within religions:
Dying/palliation
•
Suffering is part of life and leads to a better state of existence in the next life (some Christianity, Islam and Buddhism)
•
More, and prolonged, prayer may be needed
•
Family gathering may be needed
•
Anointing of the sick (Christianity, Islam)
•
Conflict of mind-altering drugs being prohibited but relieving pain to make the best of the remaining time (Several religions, particularly Islam)
•
Life does not end with death. The way in which you die influences your rebirth/afterlife.
•
Potential conflict with staff’s views on palliation/dignity.
•
All major world religions condemn suicide – extra layer of emotion for many families.
After death
•
•
•
•
•
•
•
•
Prolonged viewing of the body (Buddhism)
Lie/face towards Mecca (Islam)
Oil lamp lit near body (Hinduism)
Cremation within 24hr (Hinduism)
Whispering declaration of faith into the ear (Islam)
Recitation of Psalms and prayer (eg Shema) (Judaism)
Last sacrament (Catholic)
Avoidance of the body by pregnant women and children (Chinese)
Management
•
•
•
•
Open mind and accommodate as far as possible
Include family where possible
Call relevant leader/priest/minister
Allocate space for prayer, gathering etc
Duty of candour
• Joint statement from the Chief Executives of statutory regulators of healthcare
professionals (inc GMC) 2014
• This means that healthcare professionals must:
1.
2.
3.
4.
tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong;
apologise to the patient (or, where appropriate, the patient’s advocate, carer or family);
offer an appropriate remedy or support to put matters right (if possible); and
explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term
effects of what has happened.
Medical negligence
The patient, or other person bringing the claim, has to prove on the balance of
probabilities:
1. Breach of duty – that the treatment was such that no reasonable
practitioner would have delivered that care
2. Causation – that the breach of duty or negligence caused or contributed to
the injury, loss or damage suffered, and that the patient would not have
suffered that injury without the breach
The ‘clinical negligence pre action protocol’ aims to resolve claims without going to
formal court proceedings wherever possible. This usually is the case.
Deprivation of liberty safeguards – DoLS
History
MCA 2005
• Restraint (physical/pharmacological restriction to prevent harm)
• Deprivation of liberty is the use of restraint when the patient doesn’t have capacity to
consent.
Amended in 2007
• after the Bournewood judgement re a sedated autistic man who was not allowed to see
carers – deemed to have been deprived of human rights.
• Enacted 2009.
• DoLS is an administrative scheme to allow hospitals to refer potential cases.
• If restraint is necessary but DoLS can’t be used then the court of protection is invoked.
2014 New problems
• Cheshire West v Chester and P&Q v Surrey – al previous rulings overturned and
an acid test developed
DoLS 2
Acid Test (not yet a statutory definition)
“Anyone who is under continuous supervision and control, and is not free to leave”
If lacks capacity to consent to these restraint then DoLS authorisation needed.
Who to consider – anyone who passes the acid test and:
• Restraint is in their best interests and there is no less restrictive alternative
• Other exclusions:
• Informal consensus that if the lack of capacity would only last 7 days then ~overlook it. – not
‘legal’
• Patient consents to enter ICU, or have restrictions placed upon them,
• Life-saving treatment – the resuscitation period
• Outside England and Wales
Not relevant when considering whether deprivation of liberty is occurring:
the reason for treatment, compliance with treatment, lack of objection, family/carer’s agreement,
appropriateness or ‘normality’ of the treatment, lack of an alternative safe place for treatment
DoLS 3
Assessment procedure checklist:
1. Over 18
2. Mental health assessment, including delirium
3. Mental capacity assessment
4. No prior refusal to this treatment
5. Do they need treatment under the 1983 MHA
6. Best interests assessment
Be told why
Have ready access to court of appeal
NB
• Should NOT delay urgent care
• Apply for standard and urgent authorisation simultaneously in most cases (you can’t get
urgent authority without having applied for standard)
• Reassess if situation changes
• Family etc have no input
OSCE scenarios
• BSD testing
• Dalteparin was omitted from the drug chart in error for 5 days and the patient
now has a PE – discuss this with the NOK.
• Duty of candour
• A bung fell off the dialysis set and the patient exsanguinated into cardiac arrest.
Discuss this with the family.
• You need to transfer a patient out for non-clinical reasons. Discuss this with NOK.
• Your patient has had anaphylactic shock as a result of a drug error and is now
ventilated and on an adrenaline infusion.
• You intend to limit treatment for a patient, including a DNACPR decision. Discuss
with the family.
• After an unexplained death discuss the need for post mortem with a Muslim
family.
• The family are requesting transfer of an unstable ventilated patient to worldrenowned specialist ICU. Discuss this with them.
• Refuse admission to ICU
SOE possibilities
• Brain stem death – any aspect
• Mental capacity
• Consent
• DoLS?
• Safeguarding
• Duty of candour
• Diagnosis of death
• Withholding and withdrawing
• Advance decisions
• LPA, IMCA
MCQ brainstem
• In the diagnosis of brain stem death:• A. a neurological opinion is essential
• B. the EEG must be isoelectric for at least 24 hours
• C. the presence of convulsions rules out the diagnosis
• D. spinal reflexes may be present
• E. a blood screen for the presence of drugs must be made