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Good Medical Capacity Liberty Safeguards Practice (DoLS) T opics for DNACPR End of Life care Confidentiality T oday Angry patients Complaints Incident Reporting• 38 page document • Sets guidelines for doctors in the UK to ensure they provide the best care while maintaining professional standards. • Ensures safe, effective, and compassionate patient care. • Upholds ethical and professional standards.Principles of GMC Good Medical Practice 1. Put patients' interests first: • Act in the best interests of patients. • Make patient care the top priority. 2. Communicate effectively: • Clear and effective communication with patients. • Involve patients in decision-making. 3. Work collaboratively with colleagues: • Effective teamwork with other healthcare professionals. • Provide optimal care through collaboration. 4. Maintain trust: • Act with honesty and integrity. • Preserve the trust patients and the public have in the medical profession. A 77-year-old female presents to the Emergency Department after being found on the floor at home and was brought in by an ambulance. She is confused with bruising around the eyes and a laceration Case 1: to head. She is refusing treatment and wants to self discharge. How would you manage the patient in this case?How would you manage the patient in this case? 1 2 3 4 Use pharmacological Call her next of kin Assess whether she Allow her to leave assess hero you can keep her in hospital weigh up, retain and thoroughly communicate her decisionCapacity: The Mental Capacity Act (2005) • The 5 Principles: • Physicians must assume capacity unless there is evidence to suggest an assessment is required • A person must be given all reasonable support to make decisions • A person is not to be treated as unable to make a decision merely because he or she makes an unwise decision. • Best interest of the patient • Least restrictive option • Capacity is related to a specific decision at a specific timeAssessing Capacity: The 2 Stage T est (Royal College of Emergency Medicine, 2017)A Patient Lacking Capacity: • What to do when patient does NOT have capacity or an advanced directive • Decision about whether to go ahead with the treatment will need to be made by the healthcare professionals treating them • Person's best interests must be considered • Consider whether it is safe to wait until the person has capacity • Talk to family members about what factors would have affected the patient’s decision (not what the family members would want) • If no family members or friends, then an independent mental capacity advocate (IMCA) must be consultedA Patient Lacking Capacity: • What to do when patient does NOT have capacity and wants to leave hospital • Common-Law Doctrine of necessity • Where lack of capacity is suspected but not confirmed common law can be used to protect their right to life. • Deprivation of Liberty Safeguarding (DoLS) • Designed to allow Hospitals or Care Homes to legally authorise restrictive care situations for those who cannot consent to them • Trusts can authorise an urgent DoLS lasting for 7 days • Then gets assessed by the safeguarding team for further action if requiredA Patient Lacking Capacity: Exceptions • If the patient has a mental health problem that is affecting their capacity then the patient should be assessed under the Mental Health Act (MHA). • If the patient is under the age of 16, then the MCA does not apply. The Children’s Act (1989) would be applicable. A 77-year-old female presents to the Emergency Department after being found on the floor at home and was brought in by an Case 1:lance. She is confused with bruising around the eyes and a laceration to head. She is refusing treatment and wants to self discharge. An 85 M patient presents to A&E from a care home with worsening shortness of breath and a productive cough for 4 days. His NEWS score is 14. He is hypotensive and hypoxic despite initial resuscitation with IV Fluids, IV antibiotics and high flow Case 2 oxygen. Past medical history include COPD and Severe Frailty. What are the next steps in management?How would you manage this case? 1 2 3 4 5 6 respiratory support treatment and admit stop all treatment continue treatment the patient’s familyf the patient and carry and admit to ITU to hospital and admit to hospital and admit to hospital and carry this out this outWho decides if a patient should have attempted CPR should their heart stop? 1 2 3 4 5 6 The patient The patient’s The cardiology The responsible The palliative The patient's family and next consultant junior doctor care consultant general of kin practitionerDNA CPR • Do not attempt cardio-pulmonary resuscitation • If the person has a cardiac arrest, we don’t try to restart their heart • Medical decision – signed by doctors • Based on the patient’s wishes, their pre-morbid health and the likelihood of survival of the current illness • Required to communicate the decision with patient or NoK • Still can have active treatment including ICUTreatment Escalation plan • More detailed than a DNA-CPR • Not a legal document but documented in patient’s notes • For full active treatment including CPR • Not for CPR but for full active treatment • For ward-based ceiling of care (not for intensive care) • For comfort careDNA CPR: Communication • Warning shot • Assess understanding of CPR • Discuss their ideas • Explain its value • Let them know its not something they have to decide but a medical decision • Must inform patient of the decision or NoK if no capacityAn 85 M patient presents to A&E from a care home with worsening shortness of breath and a productive cough for 4 days. His NEWS scCase 2 14. He is hypotensive and hypoxic despite initial resuscitation with IV Fluids, IV antibiotics and high flow oxygen. Past medical history include COPD and Severe Frailty. Patient X is a 65-year-old female who is being investigated for suspected colon cancer. CT TAP findings are suggestive of stage 4 metastatic disease, but this has not been communicated with the patient yet. The patient’s son has asked to talk to you privately. He requests that you tell them what Case 3 the scans have shown. He is a consultant surgeon and suspects that the patient has cancer. The son states that he would prefer that a diagnosis of cancer not be communicated to the patient if it were the able to handle the bad news.at she would beWhat would you do? 1 2 3 4 5 Do not inform the Explore the patient’s Explain the results to Consult other family Do nothing. Escalate to patient of the diagnosis wishes about being the son encourage him members to explore the consultant. as per the son’s wishes. Do not tell the sons. the patient.hem with their wishes. about the results.Confidentiality: GMP guidelines • Patients have a right to expect that their personal information will be held in confidence by their doctors • They can have a say in who their information is shared with. • NoK doesn’t have a right to information unless the patient has given consent or doesn’t have capacity to give consentConfidentiality: 8 principles 1) Use the minimum necessary personal information. 2) Manage and protect information. 3) Be aware of your responsibilities. 4) Comply with the law. 5) Share relevant information for direct care 6) Ask for explicit consent to disclose identifiable information about patients for purposes other than their care or local clinical audit, unless the disclosure is required by law or can be justified in the public interest. 7) Tell patients about disclosures of personal information you make that they would not reasonably expect, 8) Support patients to access their information.Confidentiality: The Data Protection Act 2018 • law that governs how personal data should be processed, used, and protected by organizations in the UK. • Includes individuals rights to access, correct, and erase their data. • Establishes rules for obtaining consent for data processing, defines the roles and responsibilities of data controllers and processors, and mandates the reporting of data breaches. • If any questions NHS trusts have data protection officersConfidentiality: Shared Health Records • Governed by Data protection act 2018 and the Caldicott principles • Patients must provide consent for their health data to be shared • Have a right to access their own data • Can have inaccuracies corrected • Should only be shared with authorized individuals for a specific purpose. • e.g When a patient presents to A&E you can ask and gain access to GP recordsConfidentiality: Exceptions • You may disclose relevant personal information about a patient who lacks the capacity to consent if it is of overall benefit to the patient. • Talk to family members to try and get an understanding on what the pt’s wishes would be • Justified in public interest • Pt may pose a risk to others (has expressed intent to commit a crime) • Reportable communicable diseases • Ordered by law • Court ordered to investigate a serious crime / road traffic accident • A gunshot wound or injury sustained from an attack with a knife, blade or sharp instrument, must be reported to the police • Drivers who should no longer be driving (TIAs/ Epilepsy) but continue to do so. Patient X is a 65-year-old female who is being investigated for suspected colon cancer. has not been communicated with the patient yet.tatic disease, but this The patient’s son has asked to talk to you privately. He requests that Cyou tell them what the scans have shown. He is a consultant surgeon and suspects that the patient has cancer. The son states that he would prefer that a diagnosis of cancer not be communicated to the patient if it were the case as he does not think that she would be able to handle the bad news. A 22 year old male patient has recently had a kidney biopsy to help determine the cause for his declining kidney function. Case 4: When you call to chase the result the lab inform you that they never received a sample and therefore there is no result available.An Angry Patient / Relative • Recognise that the patient is angry • Adjusting your style of communication when a patient is angry • calm tone and remain composed, professional yet relaxed posture • Acknowledge the patient’s anger • “I can tell that you are upset by all of this” • Try to understand why they are angry • Respond to the patient/relative • Empathy ‘Given everything you’ve told me, it’s understandable you feel that way’ • Apologise if an error has occurred • Thank the patient and encourage further questionMedical Error - Incident Reporting • Patient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare. Reporting them supports the NHS to learn from mistakes and to take action to keep patients safe. • Local systems à national system • Aim to learn rather than blame • Duty of candour to inform patients when an error has been made even if no harm causedPALS (Patient advice and liaison services) • Offers confidential advice, support and information on health-related matters. • They provide a point of contact for patients, their families and their carers. • Can compliment or complain about serviceReferences • Good Medical Practice - GMC • RCEM guidelines • Medical Defense Union • PLAB BlueprintQuestions?