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ALL OU NEED TO KNOW ABOUT ETHICS AND LAW by: Elena Boby Nidhi Rege Here’s what we do: ■ Weekly tutorials open to all! 18:00 every Thursday ■ Focussed on core presentations and If you’re new here… teaching diagnostic technique from a clinical perspective ■ Reviewed by doctors to ensure W elcome to accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats!TOPIC ONE Elena BobyWhat this tutorial will cover ? ■ Capacity assessment ■ Advanced care planning (advanced directive + advanced statement) ■ DNACPRMavis is a 74 year old lady recently diagnosed with metastatic breast cancer . She has come to terms with the news and expressed a wish to opt for symptom management only, she has no other medical history of note and lives independentlyWhich of these statements is the best answer regarding her capacity to refuse treatment A) Mavis needs a capacity assessment as she is refusing potentially life saving treatment B) Mavis is within her rights to refuse treatment but needs to have a capacity assessment due to her age C) Mavis can refuse treatment and no capacity assessment is required D) Mavis should discuss with her family as they know her baseline capacity the best E) Treatment can not be refused, only requested, so she is required to have chemotherapy for the management of her conditionA) Mavis needs a capacity assessment as she is refusing potentially life saving treatment B) Mavis is within her rights to refuse treatment but needs to have a capacity assessment due to her age - in itself, age is not a factor that deems someone incapacitous C) Mavis can refuse treatment and no capacity assessment is required - every adult is assumed to have capacity unless there is a reason to think otherwise D) Mavis should discuss with her family as they know her baseline capacity the best - family should be involved but ultimately the decision is the patient’s E) Treatment can not be refused, only requested, so she is required to have chemotherapy for the management of her condition - in no circumstance can treatment be requested but it can be refused Capacity rules (in adults) EVERYONE IS ASSUMED TO HAVE CAPACITY UNLESS THERE IS A REASON TO THINK OTHERWISE! How do we assess capacity (with the example of undergoing chemotherapy)? 1. Can they understand what chemotherapy is and what it will do? 2. Can they retain what the doctor has communicated about chemotherapy? 3. Can they weigh-up the pros and cons of undergoing treatment ? 4. Can they communicate their final decision ?Mavis’ wishes are respected by the team and she now wants to start advanced care planning…Which of the following would be a part of her advanced decision? A) Wanting extra pain medication as she nears the end of life B) Not wanting to be bathed or washed towards the end of life C) Refusal of IV antibiotics for a chest infection D) Not wanting to be fed any meat E) Not wanting treatment for a mental health condition she is sectioned forA) Wanting extra pain medication as she nears the end of life - measures designed for comfort can not be refused B) Not wanting to be bathed or washed towards the end of life - basic care can not be refused C) Refusal of IV antibiotics for a chest infection D) Not wanting to be fed any meat - this would belong in an advanced statement of wishes E) Not wanting treatment for a mental health condition she is sectioned for - treatment for a mental health condition the individual has been sectioned for under the the MHA can not be refused Advanced directive to refuse treatment For this to be valid the ADRT must have - Been made What is it? when the A legally binding document to ensure an individual had individual can refuse specific treatmentsin capacity and wad 18+ the future when they lack capacity - Be specific to the situation - Not been Life sustaining treatment can be refused but not coerced by basic care like washing, food or drink by mouth, other people measures for comfort like pain meds or mental - Be signed and health conditions the individual was sectioned for witnessed TREATMENT CAN NOT BE REQUESTED!!What if Mavis no longer wishes for the Advanced directive to be used in her care ? Given she has capacity, the directive can be withdrawn - written or verballyMany months later , Mavis’ condition deteriorates and she can no longer verbalise her wishes. Her children want to know if they can make decisions on her behalfWho is it? A person appointed Only applies when Mavis lacks capacity (just like to make decision an advanced directive) decision’s on Mavis’ behalf Lasting power of attorney - key points for So, can her children make OSCE (+ life) decisions on her behalf? They can ● If they were appointed make all as LPA after she decisions on her behalf or created her advanced just some directive then YES ● Between advanced directive and LPA - the latest one takes priorityAfter careful consideration, the doctors want to implement a DNACPR as she is now nearing the end of life but her children feel as though the team have given up on her . Which of the following is true regarding a DNACPR ?A) The DNACPR can only be issued if Mavis’ family agree with the decision B) Mavis needs to have expressed a wish for a DNACPR when she had capacity for it to be valid C) A DNACPR can be put in place even if the family disagree D) A DNACPR applies to all types of resuscitation - for example fluids + oxygen therapy when sats are decompensating E) Only the primary consultant is involved in the decision of implementing a DNACPRA) The DNACPR can only be issued if Mavis’ family agree with the decision - DNACPR is a medical decison B) Mavis needs to have expressed a wish for a DNACPR when she had capacity for it to be valid - DNACPR is a medical decison C) A DNACPR can be put in place even if the family disagree D) A DNACPR applies to all types of resuscitation - for example fluids + oxygen therapy when sats are decompensating - it applies specifically to CPR E) Only the primary consultant is involved in the decision of implementing a DNACPR - the decision is influenced by all the members of the team and usually discussed in MDTDNACPR rules ■ Patients and families wishes are always respected + they will always be involved in the process ■ But ultimately, the decision is MEDICAL and can be put in place for the patient's best interest without the patient’s and their family’s consent What if the family feel the DNACPR is unjustified? They are entitled to a second opinion if this is the caseWhat if Mavis never made an advanced directive or appointed an LP A? A best interest decision would be made : ● Only done if the patient lacks capacity ● Mavis’ previously expressed wishes and her family’s wishes are taken into account ● If there are no close family or friends, an IMCA (independent mental capacity advocate) can be appointed ● The advanced statement will also be taken into accountAdvanced Statement (of wishes and care preferences) Not legally binding but must legally be taken into consideration when making a best interest decision It can include things like ■ Religious or spiritual views, and those that might relate to care ■ Food preferences ■ Information about your daily routine ■ Where you would like to be cared for (in a hospital, at home, in a care home etc.) ■ Any people who you would like to be consulted when best interest decisions are being made on your behalf (however this does not give the same legal power as creating a Lasting Power of Attorney) Ethic and Law Part 2 Nidhi RegeIn this part we will cover… - DVLA rules - Breaking Bad News - Duty of CandorIn this part we will cover… - DVLA rules - Breaking Bad News - Duty of Candor But first……Lets practice some OSCE’ s Potential OSCE Station 1 Candidate instructions You are a 4th year medical student on the geriatrics ward. Scenario Steven is one of the nursing students who saw a 82 year old patient, Mr Dodgson, with early stage dementia. He gets very confused when he gets ill. The doctor advised Mr Dodgson that he considers ‘Advanced Care Planning’ in case he becomes very ill again, and he is no longer able to make decisions for himself. Steven would like toask you some questions. Task Please speak to Steven and answer any questions he might have.Potential OSCE Station 1 ‘Hi I’m (Y/N), I’m one of the medical students, nice to meet you’ ‘I’m Steven one of the nurses’ ‘What do you want to talk about today?’ ‘Yes, I saw a case… what is advanced care planning?’ ‘What happens if there’s no ADRT/LPA?’1. Opens consultation appropriately 5. Explains other agents ● Introduction - WIPER QQ ● Mentions court of protection/court appointed deputy ● Gains consent to have discussion ● Begins with open question ● Asks about current level of knowledge 2. Brief explanation of capacity 6. Clearly explains ‘best interests’ regarding decision ● Someone’s ability to make a decision regarding care making ● Presumed for over 16, time and decision-dependent ● Only if patient lacks capacity and no LPA/advanced ● Need to make sure informational needs are met decision etc. ● If patients’ lose capacity (e.g. dementia) then we look for other ways ● Takes into account previously expressed wishes and to find out way they want wishes of those close to the patient ● Advance statements can form part of this ● Can apply for an independent mental capacity advocate (IMCA) especially if there are no close people 3. Clearly explains ‘Advanced Decisions’ 7. Explains and puts into context relevant guidance. ● Apply to refusal of treatments only Information is understandable, clear and jargon free, given in ● Only applies when the person lacks capacity appropriate detail, clearly applied to role player’s ● Legally binding circumstances 4. Clearly explains ‘Lasting Power of Attorney’ 8. Ends consultation appropriately ● Appointed person who makes decisions on their behalf ● Invites questions, summarises ● Only applies when person lacks capacity ● Offers leaflet ● Can make all decisions, or just a subset ● Thanks and closesPotential OSCE Station 2 Candidate instructions You are a 4th year medical student on your respiratory placement Scenario Mrs Sullivan, a 63 year old woman has breast cancer which has metastasized to her bone and lungs. She was admitted 1 week ago after she had difficulty breathing. There are no further therapeutic options to treat the cancer. She accepts she is dying. The consultant has decided to fill a DNACPR form, which she is aware of. She has some questions about DNACPR Task Please respond appropriately to Mrs Sullivan’s questions Pass Borderline Fail Opens consultation appropriately ● Introduction - WIPER QQ ● Gains consent clearly and appropriately ● Establishes recent events and understanding of current health ● Establishes concerns and expectations ‘I’ve seen CPR on the telly, but I don’t know what DNACPR is?’ ‘Who makes the decision?’ ‘Does this mean my treatment will be stopped?’ Pass Borderlin Fail e Opens consultation appropriately ● Introduction - WIPER QQ ● Gains consent clearly and appropriately ● Establishes recent events and understanding of current health ● Establishes concerns and expectations Clearly explains cardiac arrest and CPR ● Explains cardiac arrest ● Explains CPR and the procedure ● Emphasises invasive procedure with many risks and low success rate Clearly explains ‘DNACPR ● Explains due to current health state, CPR is unlikely to succeed, will likely cause more harm ● Explains when having cardiac arrest, no capacity to consent, so this is form of advanced care planning ● Explains form is signed by doctor, after team decide CPR is inappropriate ● Does not apply to other treatments ● Can ask for 2nd opinion + review Explains and puts into context relevant guidance. Information is understandable, clear and jargon free, given in appropriate detail, clearly applied to role player’s circumstances Ends consultation appropriately ● Invites questions, summarises ● Offers leaflet ● Thanks and closesDVLA Rules How could they apply in OSCEs? DVLA rules Group 1 (normal licence) Group 2 (heavy goods vehicle licence) Diabetes Must meet certain criteria to drive (depends Must meet certain criteria to drive (depends on hypoglycaemia episodes, hypoglycaemia on hypoglycaemia episodes, hypoglycaemia awareness, glucose monitoring and awareness, glucose monitoring and complications) complications) First unprovoked seizure Must not have had seizure for 6 months 5 years After DVLA medical investigation approves Other seizure 1 year 10 years Stroke/TIA 1 month (don’t need to inform DVLA if no 1 year (tell DVLA) neuro deficit) Unexplained syncope 6 months (don’t need to inform DVLA if no 1 year symptoms) MI treated with stent 1 week (don’t need to inform DVLA if no 6 weeks (but need tests) symptoms) Alcohol misuse 6 months (of controlled drinking/abstinence) 1 year (of controlled drinking/abstinence) Alcohol dependence 1 year (free of alcohol-related problems) 3 years (free of alcohol-related problems)DVLA rules Group 1 (normal licence) Group 2 (heavy goods vehicle licence) Diabetes Must meet certain criteria to drive (depends Must meet certain criteria to drive (depends on hypoglycaemia episodes, hypoglycaemia on hypoglycaemia episodes, hypoglycaemia awareness, glucose monitoring and awareness, glucose monitoring and complications) complications) If applicable, patients have a legal duty to report their First unprovoked seizure 6 months 5 years condition to the DVLA. Other seizure 1 year 10 years If patient does not do it, Stroke/TIA 1 month 1 year doctors have a legal defence to Unexplained syncope 6 months (don’t need to inform DVLA if no 1 year symptoms) report this to the DVLA. MI treated with stent 1 week (don’t need to inform DVLA if no 6 weeks (but need tests) symptoms) Alcohol misuse 6 months (of controlled drinking/abstinence) 1 year (of controlled drinking/abstinence) Alcohol dependence 1 year (free of alcohol-related problems) 3 years (free of alcohol-related problems) DVLA rules Group 1 (normal licence) Group 2 (heavy goods vehicle licence) Diabetes Must meet certain criteria to drive (depends Must meet certain criteria to drive (depends on hypoglycaemia episodes, hypoglycaemia on hypoglycaemia episodes, hypoglycaemia awareness, glucose monitoring and awareness, glucose monitoring and complications) complications) First unprovoked seizure Must not have had seizure for 6 months 5 years After DVLA medical investigation approves Other seizure 1 year 10 years Stroke/TIA 1 month (don’t need to inform DVLA if no 1 year (tell DVLA) neuro deficit) Unexplained syncope 6 months (don’t need to inform DVLA if no 1 year symptoms) MI treated with stent 1 week (don’t need to inform DVLA if no 6 weeks (but need tests) symptoms) Alcohol misuse 6 months (of controlled drinking/abstinence) 1 year (of controlled drinking/abstinence) Alcohol dependence 1 year (free of alcohol-related problems) 3 years (free of alcohol-related problems) Potential OSCE Station 3 Candidate instructions You are a 4th year medical student in the neurology clinic. Scenario Mr Gosling is a 52-year-old man who has epilepsy and had a seizure 2 months ago after missing a dose of his medication. He is concerned about how his seizures can affect his job as an uber driver. Task Take a social history and sensitively address his concerns You have 10 minutes for this stationHow do I remember the different parts of social history taking? life occupation ADLs alcohol smoking drugs/diet exercise travel Any lifestyle changes? life Uber Driver - very important occupation ADLs alcohol smoking drugs/diet Any exacerbating drugs? exercise travel Are thours?avelling longPotential OSCE Station 3 Candidate instructions You are a 4th year medical student in the neurology clinic. Scenario months ago after missing a dose of his medication. He is concerned 2 about how his seizures can affect his job as an uber driver. Task Take a social history and sensitively address his concerns You have 10 minutes for this station Pass Borderline Fail Opens consultation appropriately ● Introduction - WIPER QQ ● Gains consent clearly and appropriately ● Establishes recent events and current understanding of situation ● Establishes concerns and expectations Pass Borderline Fail Opens consultation appropriately ● Introduction - WIPER QQ ‘I’m going to ask you some questions about your ● Gains consent clearly and appropriately lifestyle and then we can address your worries one ● Establishes recent events and current understanding of sby one and see how we can make changes to help ● Establishes concerns and expectations you.’ Pass Borderline Fail Opens consultation appropriately ● Introduction - WIPER QQ ‘I’m going to ask you some questions about your ● Gains consent clearly and appropriately lifestyle and then we can address your worries ● Establishes concerns and expectations understanding oone by one and see how we can make changes to help you.’ Mr Gosling’s concerns: ● ‘I heard there were some rules about not being able to drive when you have seizures, what are they?’ ● ‘I have to work, me and my wife are already struggling with paying bills’ ● ‘What happens if I don’t inform the DVLA?’ Pass Borderline Fail Opens consultation appropriately ● Introduction - WIPER QQ ● Gains consent clearly and appropriately ● Establishes recent events and current understanding of situation ● Establishes concerns and expectations Appropriately takes social history ● Asks about job - whether work can make adjustments ● Establishes who lives at home, dependents - whether anyone can help ● Asks about whether he is able to do activities of daily living ● Alcohol/smoking/recreational drugs ● Diet/exercise ● Travel - long driving hours ● Anything making it difficult to take medication/acting as a trigger Demonstrates clear knowledge ● Sensitively explains that can’t drive because group 1 vehicle ● Needs to inform DVLA and stop for 12 months from most recent seizure. ● If he doesn’t inform DVLA, obliged to tell supervisor who will inform DVLA Demonstrates professional behaviours/communication skills ● Breaking bad news - signposts appropriately (consultation setting, other family members present) ● Warning shot, allows time for patient to process/ask questions, etc. ● Displays empathyEnds consultation appropriately ● Offers leaflettions/summarises ● Offers to get nurse/relative to sit in with patient ● Arranges follow-up ● Closes/thanks patient No matter how far you end up getting in your histories, counselling or communication stations MAKE SURE YOU ALW A YS FOLLOW UPBreaking Bad NewsBreaking Bad News Role plays during CPP sessions can be quite intense but unfortunately they do represent how it will be in clinical practice. However in 10 minute stations where you may be expected to do other things as well, breaking bad news is slightly different…. THE ALGORITHM STAYS THE SAMEBreaking Bad News WIPERQQ ○ Comfortable, quiet, private space? ○ Set up room appropriately, make eye contact with patient Setting ○ ‘Would you like anyone present?’ Invite ○ Explain what you will do, and consent for discussion ○ Take a quick history - ‘what do you know so far?’ Perception ○ ICE ○ Give warning shot - ‘Unfortunately, we’ve found something worrying’ Knowledge ○ Deliver information short chunks ○ Pause, give them time to respond Recognise ○ Offer a tissue ○ ‘Take your time/I can tell this is tough/ I can only imagine how difficult this is’ emotions ○ Next plans - ‘I can give you some time to think about it…can arrange Summarise follow-up…leaflets…websites’ ○ Check patients understanding - ‘Can you tell me what you understand + Close to make sure we’re on the same page’Potential OSCE Station 4 FBC Results Patient Values Reference Range Hemoglobin 10.5 g/dL 12.0 - 15.5 g/dL Hematocrit 32% 36% - 46% Candidate instructions You are a 4th year medical student in a GP surgery Mean Corpuscular 72 fL 80 - 100 fL Volume Scenario Mrs Johnson is a 75-year-old woman who noticed 4,000 - 11,000 White Blood Cell 9,500 cells/mm3 spots of blood in her stool 2 weeks ago. As part of cells/mm3 her investigation she had blood test investigations and a FIT test. She is extremely worried about 320,000 150,000 - 400,000 what her results might mean. Platelet Count cells/mm3 cells/mm3 FITTest Results Task Please interpret these results and sensitively Positive explain their meaning to the patient You have 5 minutes for this stationPotential OSCE Station 4 FBC Results Patient Values Reference Range Hemoglobin 10.5 g/dL 12.0 - 15.5 g/dL Hematocrit 32% 36% - 46% Candidate instructions You are a 4th year medical student in a GP surgery Mean Corpuscular 72 fL 80 - 100 fL Scenario Volume Mrs Johnson is a 75-year-old woman who noticed 4,000 - 11,000 spots of blood in her stool 2 weeks ago. As part of White Blood Cell 9,500 cells/mm3 her investigation she had blood test investigations cells/mm3 and a FIT test. She is extremely worried about what her results might mean. 320,000 150,000 - 400,000 Platelet Count cells/mm3 cells/mm3 Task FITTest Results Please interpret these results and sensitively explain their meaning to the patient Positive You have 5 minutes for this station Pass Borderline Fail Opens consultation appropriately ● Introduction - WIPER QQ ● Gains consent clearly and appropriately ● Establishes recent events and current understanding of situation ● Establishes concerns and expectations Demonstrates clear knowledge ● Sensitively explains results show iron-deficiency anaemia + blood in stool ● Says needs to have a colonoscopy + 2WW referral ● Reassure that it may not be cancer, this is to rule it out Demonstrates professional behaviours/communication skills ● Breaking bad news - signposts appropriately (consultation setting, other family members present) ● Warning shot, allows time for patient to process/ask questions, etc. ● Displays empathy Ends consultation appropriately ● Invites questions/summarises ● Offers leaflet ● Offers to get nurse/relative to sit in with patient ● Closes/thanks patient What’s brought you in today? Pass Borderline Fail Opens consultation appropriately First I want to get an idea of what you know ● Introduction - WIPER QQ ● Gains consent clearly and appropriately so far, then I’ll talk about your results and what this means. Is that okay? ● Establishes recent events and current understanding of situation ● Establishes concerns and expectations ICE - update me on what has Demonstrates clear knowledge ● Sensitively explains results show iron-deficiency anaemia + blood in stoolppened, your concerns, ● Says needs to have a colonoscopy + 2WW referral expectations? ● Reassure that it may not be cancer, this is to rule it out Don’t scare the patient - Demonstrates professional behaviours/communication skills ● Breaking bad news - signposts appropriately (consultation setting, other familyarm members present) ● Warning shot, allows time for patient to process/ask questions, etc. Use your sandwich ● Displays empathy Ends consultation appropriately Take a brief social history, ● Invites questions/summarises can you talk to someone ● Offers leaflet ● Offers to get nurse/relative to sit in with patient else, is there someone that ● Closes/thanks patient can help you? Duty of Candour Duty of candour ● HCPs must be honest with patients when mistakes in care are caused or where there are treatment failures. ● HCPs must: ○ Tell patients when something has gone wrong ○ Apologise to the person ○ Offer an alternative treatment or provide support ○ Explain fully the short and long-term effects of the mistake ● HCPs and healthcare teams must also reflect on mistakes being made. They must: ○ Raise concerns where appropriate ○ Be honest with regulators ○ Support and encourage each other ● May come up in a breaking bad news station?? THANKS FOR W ATCHING! Tutor 1: Elena Boby Tutor 2: Nidhi Rege Please fill out the feedback form on Medall and see you next week!