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Uh um yeah, so it's very informal. So really do if there's anything that it's not clear as are some sort presenting, please just sort of um, put your hand up, put question in the chat bar. Um, feel free to come off the mic and ask the question. I'm very conscious that I'm talking about UK medical practice and ethics. Although it's certainly there, there will be elements I'm talking about that will resonate foot in internationally as well. But if anything, it's not clear, pleased to just shout out and ask, ask questions, I'm going to um start sharing my screen now. Hopefully. Okay. Can everyone see my screen? I'm gonna uh extend this so I can okay? And have we, I'm going to try and get the chat with your fantastic. So I've got the chat up. So if you've got any questions, um, as I said, do just shout out as well if you want to. So I'm gonna give, um, has she Hannah? Can, can you see my screen? Ok. Yeah, that's great. It's not full screen though. Okay. Right. Oh, say what's going okay there. Is that better? Yeah, that's great. Perfect. So I'm gonna talk about medical ethics in the UK. There will be elements that will resonate with, with other um countries, approach to medical ethics. A lot of things we feed into the world medical associations. There's lots of international general kind of standards and approach just to medical ethics as well. So this is very much focused on the UK. That's where I'm based and where my expertise in terms of providing guidance and supporting doctors and medical students and their practices. But there will be certainly elements that will be, may be familiar or be helpful in terms of approaches elsewhere. So, has anyone heard of the British Medical Association? Put your hands up if you have um thumbs down if you haven't or put some problems on in the chat bar, has anyone heard for the British Medical Association? Okay. So how do I pronounce your name as? Oh, is that correct? Ok, apologies. Yeah, it's easy to Hamza. Fantastic. Okay. So you get for the other two who he, he may not be familiar with British Medical Association with the Trade Union and Professional Association for Doctors in the, in the UK. We have over 100 and 70,000 members across the all grades and specialties and over two thirds of practicing doctor our members. So we are distinct to the General Medical Council who is the regulator for doctors in the UK. So if, if, if the doctor wants to practice in the UK, they have to be registered the G M C and they step very high level standards in terms of professional expectations and ethics. Um They will set education incentives. I know in some countries, the role of a professional association and a regulator is combined into one organization. But within the UK, we are, we are distinct entities. So we have negotiating rights with the UK government to negotiate terms of conditions of service. But we also have professional side that, for example, has a library to support our members was, has an international section that provides um advice, um policy work on immigration rules. And then we have the ethics section which is what I worked for uh in medical ethics and human rights. And I've been a special advisor and I've worked for the department for, for nearly 20 years. Um um we do a range of things in terms of ethics. So we influence policy and promote best practice. Um We monitor legal developments particularly within medical law. There's been huge changes in the last stage, two or three decades, real development in terms of detail and scope of legislation that guides and dictates how, how ethical conduct is um conducted. Um We also support the medical ethics Committee. So we have a committee that meets four times a year. It has elected doctors and medical students on the committee, but we also have lane members. So we have professors of law, we have professors of ethics who also contribute and develop our policy. We also promote human rights and healthcare for clinicians and patient's domestically and internationally. So, for example, yesterday, we marked the coup in Myanmar um to show solidarity with healthcare workers who are based in Myanmar, Myanmar because there's, you know, in the last two years since the coup, there's been a lot of attacks on health facilities and individuals. So ourselves along with other health organizations in the UK, marked and express solidarity by light illuminating our buildings. So we do all sorts wide range of things. We also provide a ethics advice service. So if doctors encounter ethical dilemmas, they want some advice or sign posting to relevant uh guidance, we also support members um in terms of their ethical enquiries. So when I be I'm gonna, I'm gonna start with philosophical approach is to ethics. Um And if you look at ethics guidance in UK and actually internationally, the doctors, there is not one philosophical approach that is adopted in terms of developing the expectations and standards that except the doctors and medical students, but philosophical approach that approaches can be quite helpful sometimes in terms of approaching an ethical dilemma. And also you can see elements within guidance um in, in, in terms of you can see elements of the different philosophical approach is within that, in terms of what the rules might be. So the first one is consequential is um so it's a philosophical approach that when you think about an ethical dilemma. You're looking at the outcome, you're not looking this process, you're looking at the outcome. So very commonly known one is utilitarianism. So it's, it's, it's approaching an ethical dilemma by looking to do to maximize uh maximize the greatest, good for the greatest many. So it's looking very much at consequences. The second approach is d ontological and this is where it's believed that there are some universal obligations. So you'll see this, for example, in say human rights legislation, um there are certain duties and obligations and rights that are just are the case. That's that the approach. One approach that often sort of excited and methodology that's often cited with their medical practice is four principles approach. So someone approaching ethical dilemma breaks down to the four principles of autonomy and autonomy will come up throughout this session. Autonomy. So it's about respecting an individual's ability to weigh up and make decisions for themselves, their, their self determination. So that's where the locus of ethical to solicit and making rise. It's also about beneficent second principle. So about approaching um an issue to maximize benefit. It's worth about non Eliphas since so about not causing harm. And then there's also the fourth. So it's either expressing sort of justice or equality. So it's when doctors or medical students are approaching an ethical dilemma is breaking down and thinking about the situation in terms of autonomy, beneficence, non maleficent and justice. We also have virtue ethics, which certainly in the UK has probably got a little bit more coverage more recently. And virtue ethics is not necessarily what the uh looking at ethical issue in terms of thinking about in terms of the outcome or in terms of there being particular principles or particular sort of, right? It's about virtue. So it's focused on what the doctor is like. Are they honest? Are they acting with compassion? So the Locusts in terms of sort of ethical practice is about how that individual is? What qualities they're expressing? Are they honest? Are they compassionate? So any questions on, on those philosophical approach is put your hand out for in the sidebar, whatever you feel comfortable doing? Yeah. Okay. So I'll go on to just to um the medicated to the UK. So we have these philosophical approach is but, but life is a little bit messier than that. And actually, there's not some neat philosophical approach in terms of approaching an ethical dilemma and certainly within UK and this will, there will still probably resonate in other countries and internationally. The development has been influenced by a number of factors. The first is up to the 19 sixties practice was very doctor lead in terms of ethics. So it was doctor knows best. So it's very paternalistic model of ethics. So what was right to do was basically what the doctor thought was, right? We've moved very much away from that now in terms of ethical practices about a partnership as a partnership between doctor and uh the patient. So a real shift in cultural attitudes and also the ability to question decisions are shared decisions. Generally, there's the impact of technology and that's particularly acute when we look back in the last few decades, in terms of the beginning of life and end of life, what's possible has really kind of stretched the sort of limits and parameters, what is feasible and it's raised many ethical questions. So for example, around um embryo research in terms of IVF, in terms of neonatal care, in terms of um end of life care, in terms of being able to sort of preserve someone on a ventilator. And it's raised lots of ethical questions. And I think we're still saying, you know, we can, we will continue to see the impact of technology if we, even if we just look at current debates around, for example, artificial intelligence about the ability now the technology to, to amass huge amounts of data and to sift through it and extract information on what might be a useful way to uh in terms of clinical practice to the impact of technology is certainly develop medical ethics for where we are now today. But also going forward, continue to sort just when you think you everything's wrapped up and everything's need new, develops, new questions arise again. Another one is genetics in terms of what's possible in terms of um breaking down the genome understanding, uh the potential impact of that raises huge ethical questions. There's also the impact of law and I've, I've mentioned that there's been a huge amount of development in the last few decades. Um So in the U K, a huge amount of law in terms of say statute, which is the high level um sort of setting out the principles and direction of travel in terms of medical law, but also a huge amount of case law. But that's where it kind of interprets statutes and sets down more uh detailed parameters in terms of practice. We also in the UK, with devolution, we have UK wide legislation that affects medical aw, but we also have devolved nation. So um in the UK, we have England, Wales, Scotland, Northern Ireland and certainly with devolution where powers have been devolved, the nation's. So particularly say that Northern Ireland and Scotland, we've seen more of this in terms of medical law. We see those, those countries, those nations developing slightly different legislation that guides medical practice. The approach is generally the same, but there are different points of legislation. So for example, one aspect is how decisions are made around uh when someone when an adult lacks capacity to make decisions. So in, in England, we'll focus on best interests. It's about what's in the best interests of that individual. That's how, that's the guiding principle in terms of decisions and best interest, not just clinical interest. But also for example, things like that privilege, privilege to express wishes in Scotland, there is different, generally, destruction is very much the same, but it talks about in terms of the decisions made, the benefit and benefit the patient. So we see some differences and have developed and I and and will increasingly sort of developed the general sentiment and approach is very similar. We also have the impact of high profile enquiries. Um We have the COVID inquiry going on at the moment which is at which will go on for for some years, which is analyzing how decisions were made when, when the pandemic came to our shores, what we did, how decisions were made, what decisions were made. So we have and that they will will out of that inevitably be some sort of recommendations going forward in terms of safe. We look at ethics in law. Another example where in the past this happened, we had a huge inquiry in the late nineties um around the retention um and disposal and use of human tissues including children's organs. And a result of that inquiry inquiry which highlighted the fact that consent and permissions haven't been sought. Following that in cryo, we have huge amount of guidance and legislation that it's very clear that for example, say in the case of a child, that consent discussion's I had um consents are obtained to ensure that people know what's happening to their nearest and dearest human tissues and organs. So there's, there's been several hyper impacts inquiries over the years. There's also the reorganization of medicine and multidisciplinary approach. And in a way it goes back to this doctor led ethics. Whereas previously, you know, particularly they say if you go into a hospital in the UK, the consultant at the top of the kind of hierarchy was the decision maker. What said, you know what that individual said went? Um We've, we've also as well as taking away from doctor led and more doctor patient partnership. It's also more multidisciplinary approach. So it's not just the consultant who makes decisions, it's different people within the team will have perspectives. So league, league nurses will make uh in some circumstances to make decisions about CPR um you have social care workers, it's far more multidisciplinary and discursive in the discussion amongst the team rather than it just been one individual who made that just makes that decision. And finally, it's about changing societal values and expectation and we'll see this everywhere. It's about people's expectations, what you know, uh And I'll say again, autonomy, autonomy is very key and it, it's um I think that reflects changing societal values and expectations. Now, people expect to be told things, people expect to be able to make decisions about their body and what happens to them. So that's one key element where we've certainly seen an influence in terms of medical ethics. Has anyone got any questions put your hands up or take, go off your mites or, or you can pop it in the chat bar any questions? Okay. The MRI from so as a as a result of this and there's no expectation or on doctors in the UK to, to know absolutely every piece of legislation we're not expecting people to be many lawyers um law and these developments will be reflected in a whole raft of guidance that's readily available for doctors and their clinical practice. So top right. General Medical Council, I mentioned there, the regulator for doctors, they have a huge amount of ethics guides which will reflect all of the legislation that uh doctors are expected to follow. And they will also set the high level principles they expect doctors to follow and doctors will be held up against those high level standards and reflected in their guides will be things that doctors should do and also things that doctors must do. And if there are any questions in terms of uh and doctors ability to practice and be on the register referrals would be made to the G M C. But the G M C has a huge amount of ethical guidance. The BMA mentioned, we've got a huge amount of ethics guidance and our ethics guidance is is publicly available, are guidance tends to be not less top level, but uh sort of more reflecting the kind of inquiries that we get in. So it has a farm all sorts of F A Q approach to the guides that we produce. Um It's all publicly available if you're interested in this area, do have a, do you have a wander around the G M C and the B M A Ethics materials? They're all publicly available and you can, you can get sort of real sense of what the approach that's adopted. Also Royal College and Interleague Collegiate guidance. So Royal Colleges will have uh reflect specific specialties and they will have guidance that will affect the ethics and law within that particular specialty. So you'll get, for example, guidance from Royal Commission, Oppositions and Gynaecologists, you'll get guidance from the Royal College of Child Pediatric Health, which again will reflect the the ethical principles and the medical law that guides practice. There's also statutory guidance. So I talked about the laws, we have acts of Parliament that the statutory at the top level know underneath that sometimes the statutory guidance that goes into a bit more detail about how, how practice should um approach ethical delivers. Say for example, one of the pieces actually going, I've worked on the past is multi uh multi agency statutory guidance on female genital mutilation. And that sets out expectations and also obligations on doctors in terms of state information share ing if if, if a girl or woman is felt to be at risk of FGM or has undergone FGM and also ensuring that there's care pathways and, and it's a very uh the focus is centered on the individual who is at risk or undergone FGM. So we have safe, we have it. That's one example, statutory guidance, also government health departments who set out legislation, I think probably less. So now we used to have more government health department's guidance. So we used to have, for example, the department, how it used to set out guidance on, on consent. Um um they still have lots of guidance on information sharing, but guidance also comes from these bodies and it, as I've talked about before devolution, you'll get different health, government health department's um that set for example, UK wide guidance, but also devolved nations. So you'll get guidance from, for example, the Scottish Health Department or, or the Northern Ireland's Health Department, we also have defense bodies. So in the UK, um doctors can be read it with the defense bodies. They, they have a more medical legal approach to sort of ethics and law and they may be called in people. Uh individual doctors will be members and they will um provide uh legal cover, for example, in cases of clinical negligence or so on. Um Sometimes the B M A and the defense bodies rolls over that BMA tends to focus in terms of sort of representing doctors interest in terms of employment issues, in terms of contract issues. Um But sometimes when you get into things like performance issues where there might be uh it might be multifaceted. Uh and the doctors, clinical practice might be uh uh being questioned for, for uh multiple reasons there might be enabled up between defense bodies and the BMA in terms of what they do. Another area where um doctors in UK can get ethics advice, a clinical ethics committees and research ethics committees. Now research ethics committees well established and fairly uniform in their approach. But their focus is very much on research that's being conducted and whether it's been conducted ethically, you know, other right consents being attained is the right information being given to, to research participants. We also have clinical ethics committees, they're less well developed in the UK and a little bit more. Uh there isn't a uniform approach but particularly say some hospital trust, they have clinical ethics committees and what they will do is they will consider um ethical issues that arise in that organization and that might come from individual health care practitioners give flag dick what might be because they're being asked to review a particular hospital policy and look at the ethics of that. So there's, there's many places where um doctors and medical students can seek advice that and and there will be guidance. Is anyone if anyone is not familiar with UK? Or actually, in fact, if there's anyone who is, who is in the UK, but it's not familiar with these, they're ready questions and again, you can put your hand up, shout out or put questions in the sidebar, whatever you feel comfortable doing okay. I'm hoping that was all clear. So we talked about the General Medical Council GM see the regulator. Um and if you're interested in UK Ethics Practice or you're going to practice in the UK, what I would say if you read nothing else in terms of ethics, read good medical practice, good medical practice is the key high top level uh guidance for doctors in terms of the expectations, in terms of the ethical practice. And there's a link there, I can put it in the sidebar later as well. So you can easily access it and it sets top level principles. And I think if you look at it, you'll see that there are elements of the difficult different philosophical approach is that I I mentioned earlier. So it's broken into four domains, it's knowledge, skills and performance. So there's an emphasis on, on you have a professional obligation to make sure that you're competent to do your job, that you keep your skills and your knowledge up to date the safety and quality. So if you see that there are issues uh in terms of save the system, system of problems that raise concerns about patient safety, there are percent obligations to act and take proper action to try and address that and make sure even if it's, it's, it's not within your gift but sort of escalate that to the authorities that can make decisions. There's obligations in terms of patient safety and quality of care. There's also an emphasis on communication, partnership and teamwork and that brings in those elements we talked about in terms of joint decision making. Multidisciplinary approach is there's an emphasis on people, you know, doctors being able to communicate and communicating with their colleagues to ensure that patient patient remains a focus decision making and they receive optimal care. And then finally, it's about maintaining trust and this is about acting in a way. And I guess this taps into about that virtue, ethics that we talked about acting in a way that maintains trust in the profession. They're probably there are expectations of doctors that there aren't for other sort. Uh There will be for some but many other professional borders. There are expectations and doctors in terms of how they act and actually outside their clinical practice as well that they maintain the trust within the profession. Um said in the UK, uh medics are one of the, you know, was highly regarded and trusted professions um within the UK and, and it's uh the G M C is very keen to ensure that that trust is maintained. So the patient's feel confident to come uh disclose the most minimized thoughts in terms of uh you know, going so they can receive best clinical care. It's incredibly important that we maintain 10 trust in the profession. So that's the fourth amendment, as I say, if you, if you are going to practice in the UK and you haven't already read it or if you're interested in this, if you read nothing else. Really good medical practice is a share of parents. Has anyone read good medical practice or been? It was aware of it before this? Put that, put your hands up, okay. I'll put, I'll pop it in the side. I linked to it in the sidebar as well. So, one of the things that it's quite, I've mentioned that I've worked in ethics for, for, for a very long time is um sometimes the inquiries we get, it was clear that it wasn't, you know, individuals hadn't or the doctor's medical schemes hadn't identified that something that was an ethical issue. And, you know, it may be really straight forward sometimes, but sometimes it's not clear and particularly in very pressured environment where there's lots of competing clinical obligations. Sometimes it can be, I, I appreciate them sometimes be very high to actually identify that there is an ethical issue that might need to be given some thought. So when we talk about ethical issue, um it's generally um where concepts such as interest have been engaged. So for example, individual patient interest or family interest or those close patient's interest or public interest, it's about things about values. What do you know what, what values have been engaged? It's about right, and it's about autonomy. So it's being alert to, into clinical practice that there might be an ethical issue. Um And sometimes it's very straightforward, sometimes it's not so straightforward within the UK. Um Even if I can't sell that the importance of being aware of ethical issues in terms of the moral imperative of it, there's an imperative to be aware of it because difficulties and complaints cannot rise if, if uh those issues aren't thought about giving you consideration, so you might, it might be sort of complaints made to the General Medical Council. There might be some legal complaints made where for example, there's been poor communication where appropriate consent wasn't obtained from a patient where confidentiality was breached. So you will see uh sort of fitness to practice proceedings. So their proceedings that the regulator might take uh if a complaint is made about doctors, for example, um I know two doctors talking about patient's care in a public list where people can overhear the conversation where um communication hasn't been good and consent hasn't been appropriate. So someone goes into surgery and something else has done that didn't need to be done at that time, but consent wasn't obtained. So it's really important to be aware of ethical issues because it could potentially in the UK lead to a complaint being made about practice. And when addressing ethical dilemma, need to consider the law talks about how the law has been, is really shaped things in last few decades. Gm see guidelines and I've mentioned good medical practice, but there's also guidance on consent confidentiality. Um No, 2, 18 year old's mental capacity, there's a huge amount of resources from G M C website. And, and if a complaint made gm see about doctor, they'll be held up against that guidance. And also it's considered good practice guidelines out there. And that will be maybe from statutory guidance, it might be from uh all colleges um bits to have that awareness. Are there any, any questions? Um Eva. So when we've done analysis and then this is analysis outside the pandemic because the pandemic throughout particularly, I think, unique and greater emphasis on, on ethical dilemmas that weren't, weren't the case prior. So if we look at the sort of data prior to to the pandemic, the kind of issues that we mainly got inquiries about were around confidentiality, access to health records, consent, the doctor, patient relationship, mental capacity and how decisions are made. Refusal of treatment, conflict of interest. So for example, if a patient, uh if the doctor has uh delivering state care NHS care, but then also has a financial interest in, in another health organization that that might have a relationship with the NHS one um end of life care. So Children, personal belief. So what doctors can conscientiously objective in this country? And uh doctors can't conscientiously object to um organ donations, safeguarding are any of those? What do you think that uh these are surprised? Is there anything you're expecting to, to to be a bigger issue in the UK. What, what do you think or what are the main ethical issues that you faced in our clinical practice? And what one or what ones you expecting to face, man? If you just type in the, in the chat bar, if you already get to get your reflections of what the key ethical issues might be for you? Okay. Okay dot Okay. So is anyone surprised I'm going to go two thumbs up or thumbs down then is anyone who was expecting to see confidentiality and consent as such big issues? Okay. All right. Um So what, so when we get inquiries and general guidance and then we are going to produce, be producing a standard piece of guidance on approaching an ethical dilemma the next few months that will be publicly available on our website. This is a suggested approach. It's not obliging anyone to approach this way, but this is a suggested approach if to sort of support people's thinking and how they might break down an issue that if they face one in their clinical practice. So the first one is the highlighted for is recognizing that situation races an ethical dilemma. Um So it's being mindful of, yeah, decision. Get, have I ask the right questions? Have I got consent? Do I need consent to this? Does the consent I have covered this? Is there an issue around patient's privacy and confidentiality? So it's thinking um it's being mindful in your practice about whether a situation is raising an ethical dilemma, it's then breaking down the the situation to its component parts. So the inquiries that we often get, um it might be it that there's not just one element looking uh being raised by the issue, but it might multifaceted. So for example, if you had uh something around situation about clinical decision for a 15 year old, it might raise issues about. Um does that individual have competency to make decisions? Um Do other decision makers need to be involved but then other questions about confidentiality, about who needs to be involved. So it's consent confidentiality. Why raise issues around safeguarding? So there can be different elements. So it's recognizing it and then breaking it down into its component parts, the Sikh, then they're seeking additional information, including the patient's view. So we'll get choirs and, and it'll be very sparse at the very top level, but many, many ethical. Um it's, it's very, it's very the response and how you deal with it will be very um tailored to the individual circumstances of the situation. And one thing that's really crucial to sort of feeding into that this image in that you're making is the patient's views and wishes. Um they are, they are autonomous, generally, are not always but autonomous beings. You can make decisions for themselves and nephews are incredibly important. That might not have been the case so much. Um say 50 years ago where, where it was more so the case where things were done to patient's and it's identified relevant legal professional currents and I highlighted some of the sources of fat in the UK and in the earlier slide. So it's just a result. Sometimes it's really straightforward. Um Can I show this information? Yes. No. Um So it's not just that it's, if it can be easy resolved, it's not just always about saying this is what I do. It's being able to justify that. Sometimes, sometimes there could be challenges. Sometimes documentation is really important in terms of say our medical records actually documenting how a decision has been made. I've seen junior doctors in, in the court's in the UK where um the outcome may have been no different clinically, but the way the decision was made that the one I'm particularly thinking about is a do not resuscitate decision. It's about how, how the decision, what discussions were had with the patient with the family. It was incredibly important. The outcome may have been no different. The individual patient would not have been resuscitated but how that decision was made um was really important and certainly asking, you know, doctors channel is saying, well, if it's not a medical record that you had this, this conversation, how you know, what's your proof? I'm saying that you didn't have this conversation. So it's be able to justify and also document some particularly important decisions about how they were made, the issue isn't resolved, subjected to critical analysis, go to organizations like the GM CBM. A medical defense body, remember and maybe get different. Uh get some guidance and buy some on the particular circumstances and just analyze it and try and bring in all the facts to think about what factors you need to consider. And within the UK. Um if it is an irresolvable conflict with the law is unclear, it may be necessary to seek court declaration. It's not a failings that happens. There are some situations that irresolvable and need to go to the court's for decisions to be made. We've had particularly last. You were quite a few high profile cases around decision making and with the withdrawal of life sustaining treatment for, for Children with terminal illness, those cases went to court, I don't think they could have gone anywhere else. They need to, to resolve them. Are there any questions on this slide? Anyone again, you can pop your hands up, turn your mic off, it'll turn your mic on or proper questions in the sidebar? Any questions? Nice. Okay. So some of the challenges uh in terms of uh situation that medics can face are is who is right, who is wrong. And sometimes there isn't a right or wrong answer, there is the least worst option. Um But the nature of ethical dilemmas are sometimes that there, there isn't, there's no right or wrong. It's, it's um it's just the way it's then that the process is very important about how you think about it, how you justify how you reason decision. But sometimes there is not, it is not the right or wrong that one might hate for life is not black and white. Another challenge is who decides who is the decision maker. So uh talk about doctor patient uh partnerships, um who decides that sometimes depending on, on the capacity on the individual and the particular circumstances who decides can, can change? Is it the clinician? Is it the patient is, it's so close to the patient? So some of the challenges is working out who, although it's very uh approach is very collaborative and good communication. Sometimes there's an ultimate decision maker and it's understanding who that individual is within particular circumstances, then there's the challenge of individual relationships. And what about the rest of us? There might be uh ethical approaches that are best for the individual but may not be the best option generally. Uh If we took take into account public interest and I guess we talked about everything about the pandemic. There was a lot of those challenges and tensions when you've got very limited resources um about how you, how you uh make the decisions. What ethical framework, as you say, for example, on if things were very, very stretched, who gets access to ventilators, how you prioritize them. So they might be individual relationships with patient's, but how much doctors need to take into account if they're, for example, very limited resources, the bigger picture and public interest in terms of those things. Another challenge is is dependent on context. So for example, you could have a patient who the clinical picture is exactly the same. Um the clinical options might be exactly the same. But what happens after that point might be very different because the context say, for example, if your or it's part of the decision making, feeding in the sort of weighing up the thoughts, feelings and views of the patient, they might be very different. You might have a patient who, who says, I don't want any heroics. I don't want intervention in X Y or ZED circumstances might have another patient who's never expressed the wish you might have a patient whose family saying I want everything possible done. And so even though the clinical picture might be very similar, the clinical options might be similar that the potential for clinical success might be very similar. Um The challenges that actually because we have very patient focused approach and sends and sort of and taking into account patient's previously expressed wishes and thoughts and and their, their wishes and thoughts. If they're autonomous at that point in time, the outcome could be very different depending on the context. And then the challenge is open to interpretation. I went to a very interesting session a few months ago where actually was kind of thinking about those issues about uh clinical presentation of the same uh presentation by two different patient's um very similar clinical presentation and options. And even within that the clinical context, there can be different interpretations by different individual doctors in terms of what's the best clinical approach you then factor in um having to wait up with, with the views and wishes that threatens individual patient. You can see how sometimes there can be different interpretations in terms of clinical factors. In terms of um taking into account more holistic factors. In terms of patient wishes, there can be different interpretations about what the best outcome, these things, these, these concessions can be very finely drawn. And that's why it's really helpful to uh think about whether you can rationalize the decision you make, particularly if it's very fine line between what is or what isn't done. And finally, and some of the challenges sports do when there's two values that conflicting and, and there's a lot of tensions and actually raising before is um say values in terms of privacy, but then it tends to say public interest. So for example, if uh if it's identified that I have a particular contagious disease, that's really detrimental to people around me or something to find in my sort of uh genetically, there's a value in terms of my privacy. But then there's maybe the value in terms of the public interest, those people next to me who may be affected, particularly if they're affected, it has the potential threat to that in a very serious health consequences or to their life. So there can be values and it's about where you draw the line in terms of those values. So, are there any, any questions, any questions shouts out? Is it all, is it all clear? Are you all feeling confident to go out and, uh, you feel confident to address ethical issues in your practice? Okay. So I did so um said before, if this is an area that you want to find out a bit more about uh medical ethics in the UK, do go on our website, books and the gmc's website, there's a huge amount of guidance that's available that will hopefully bring to life a bit more, some of the issues that I've flagged before. Um But it's been lovely, lovely talking to your. Uh thank you for coming and I hope you have a good, oh, here we go. Question who decision about whether do not attempt CPR should be a cake. So the decisions around do not attempt resuscitation, I will pop in the sidebar. We have National Guidance on do not attempt resuscitation lines. And that's been brought together by British Medications, the body. I work for the Royal College of Nursing and also the Resuscitation Council of the UK and decisions around D N A C P R. So that's what we abbreviated to in this country is. Um would be dependent on another factor. So actually, that kind of illustrates there's not necessarily a simple, straightforward um answer who decides it will be, it will be dependent on context. So it will depend on the age of the, of the patient. It will depend on whether they have uh capacity if their adult or if their competency, if they're a young person, um it will depend on whether the clinical decision is such that it's believed to be futile if to attempt CPR. So healthcare professionals need not obliged to provide care um that they think will be futile, but it's not to say that discussion still doesn't need to be had. We've particularly in the past had cases where a decision is being made by clinicians because it will not be successful not to attempt CPR. And then patient's had do not attempt resuscitate, put on their healthcare records without the patient or the family knowing and then patient's of the family of seeing this and being very distressed about it. So, um I mean, that's one example where, you know, we've had to really sort of reflect the need to have discussion's and communicate these decisions within national guidance. So when we say about decisions, it depends on, on capacity, it depends on uh the clinical presentation of the patient and whether they're likely to, whether it's like to be futile. Um It depends who's delivering the care and it also covers things like. Um um so a decision might be made not to resuscitate, but does it apply to the particular circumstances? So, for example, someone might have a decision might be made and communicated that they will not be resuscitated. But then if they say choke on a piece of food, it's not to say that nothing's going to happen. That's, that's not the circumstances that would envisaged when do not resuscitate decision was made. Um I think this could become more complicated when it's not that it will be completely futile. But it's a fine line between whether it be successful and there's maybe, you know, they will be admitted to I T U post resuscitation. There is a the probabilities and chances of them, them being say, for example, ventilated, dependent afterwards. And then a in terms of decision, one would hope it was the shared decision. Um but it will be navigating that discussion. So actually, what I'm gonna do, I'm gonna pop, if I, in fact, I stop sharing my screen now, I will get you the Euro and I'll pop pop that in. So actually, the CPR guidance is quite a useful one to illustrate generally the approach to medical ethics in the UK because it brings in consent brings in privacy. It brings in capacity, it brings in what happens under 18 year olds. Um um And the guidance, it's changed that it's the guidance is and it's on this fourth edition or something. It, you know, I've, I've been following it to say 20 years or so. It's changed over that time because of cultural expectations because medical law has changed. So if I just stop, no, I don't. OK, stop showing. I will pop that one. Is there any other kind of um are there any other issues that people are particularly interested in that I can maybe identify and post? So, so Abdullah, does that answer your question in your person view? Do you wish uh do not resuscitate yourself? You're admitted to hospital. It's one of those things I, I, you know, I uh I, I wouldn't want to, I think it would be very much dependent on the particular circumstances at the time. And I hope that you don't think I'm, I'm uh avoiding the question, but I am, I think it was very much depend. Uh there's thinking about something in a very sort of theoretical and abstract way. And I think then there's a reality of the situation. I think that I think thoughts and feelings can change depending on a particular time if I just want to CPR. Okay. So the, the, so this is the National Guidance on how decisions made um to do not resuscitate orders for the UK. We also now have a, there's been quite a lot of use of over tool called respect, which is not just about CPR, which is more generally one of the one things that comes out in the National Guidance and do not resuscitate decisions. Is it, if a decision made? It is just about CPR, it's not about anything else. It's not, it's not to say because I think there is sometimes a concern in the past, there was a perception of someone's would do not resuscitate, it had indications for other decisions being made. Like do they receive IV antibiotics and some, and this is, um, I think the one thing that we've tried to do international clients is to make it very clear. It is just about CPR it's not about other decision, clinical decisions being made. It's not that someone is being given up on. It's just this is because it will be a very acute situation where very clear direction needs to be given and, and still it's guidance. It's not necessarily binding an indicator about whether someone should be resuscitated, a very acute period of time where decisions when you need to make quickly. It's just about that. That's why it's, it hasn't had a particular focus and guide, but there is now something called respect, which is a more is more degenerate, disc intensive generally about um the variety of decisions that might arise take in end of life care in terms of what and having those conversations with, with patient's and those close to them to make sure that they are explored in advance for an acute situation. So I'm very um I'm very conscious of time and understand that you have another session, 11 o'clock, some of you. So I've finished their, it's been lovely to talk to you. Um Thank you very much for coming and I hope you have a good rest of the day. Thank you very much. Bye. Thank you, Rebecca. Um, before everyone leaves, please do fill in the feedback form and I will put the open the certificate in the chat. Now, uh the certificate is in the chat. So please download it if you can. Um, otherwise, um, take a note of it and hopefully we can address the issue of certificates. Um, people can't down and certificates from the chapel address that issue, hopefully for the end of this term, but the certificate is in the chat if you can download it. And uh, so is the link for the feedback form. So please do that quickly and um, I'll end this meeting in a minute also. Thank you.