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Okay, we'll get started. So, thanks for joining again. This is a tour hosted by the Widening Participation Medics Network in conjunction with I M G T U K. And this series is specifically focused on preparing people for the PAP exams and for practice in the NHS within the UK. And this series is sponsored by the Medical Protection Society as well. Today, we have Doctor Nadia Brody Steadman who is a S T two in emergency medicine training in the Northwest currently and she herself sat and passed up lab about five years ago. And so before we get started, just some quick housekeeping, um if you have any questions at any point in time, just pop them into the chat and we'll get to them at the end and uh I'll hand you over to Nadia now. Hi, everybody. Thanks to introduction Mukesh. Um Today we're just going to be talking, we're going to cover medical ethics and how it relates to plow big zam, but also how it comes up in the membership exams for the various specialties as well as heavily heavily on the situational judgment tests that you sit um for applying for foundation program then also again for a specialty recruitment. So we're going to cover these topics today. We're going to talk about the G M C good medical practice, uh patient capacity, uh the deprivation of liberty safeguards, which mostly referred to as dolls when you're in hospital. Uh D N A C P R decisions and the paperwork involved with those very quick glance on end of life care, we'll talk about confidentiality and the laws that govern this within the NHS will briefly go over how to deal with angry patient's and where you should direct complaints and also report instants when you're in hospital. So this is basically as soon as you get registered at the G M C, um the G M C good medical practice guidelines apply to you. And it's, it's set out quite nicely in this 38 page document sounds quite long, but it is quite easy to read. It basically sets the guidelines for doctors in the UK to ensure that they are providing the best care whilst maintaining professional standards. So it aims to ensure safe, effective and compassionate patient care and it upholds ethical and professional standards. So they use this as a framework when they're assessing doctors practice and also make a lot of guidelines based around this. If you read this document, a lot of the ethical scenarios that come up in plaid and other exams are sort of based, the answers are based in this guidelines. So it just gives you a good idea of what they care about and what they test. Um So there's four, it's based on four main principles uh to put patient's interest first. So you're meant to always act within the best interest of the patient's and make their care your top priority. They emphasize communicating effectively. So you're meant to have clear and effective communication with patient's. Uh The patient's are meant to be heavily involved in patient decision making and meant to work collaboratively collaboratively with colleagues, being effective team member and help with other healthcare professionals and provide optimal care through collaboration as well as to maintain trust, act with honest, honesty and integrity and preserve the trust of patient's and the public in the medical profession. So it's all quite worthy, but it's good to have an overview of it. So you know, which sort of category these stations are fitting into. This is just a screenshot of what the actual document itself looks like. So it's relatively easy to read, if not a little bit heavy, this just goes into more. This has the contents. As you can see, it's all listed in the four domains and within the G M C website as well. They have some pretty good case scenarios where they go through individual situations that you're likely to come across in hospital and also in exams and explain to you how you should address this and how how it is linked in with the good medical practice guidelines. So it's definitely worth a look through even if it is a bit dry. So we'll go into cases, I'm going to do four cases today. Um and we'll look at the different elements of it, how it relates to medical ethics and just talk through how you would address these. So the first cases, a 77 year old female present to the emergency department after being found on the floor at home and was brought in by an ambulance. She is confused has bruising around her eyes and a lacerations to the head. When you assess her, she is refusing treatment and and is insisting on being discharged from hospital. So she wants to leave. How would you go about managing this patient? We've got a couple of polls that you can answer the questions as well. So if you just click through what you think you'd do, there's no wrong answer, we'll just discuss them all. Okay. Slipped out your did pretty well on that. So just going through the other options quickly, you obviously can use pharmacological sedation on people. Um You do sometimes use it but you've got to do it in a specific case and you will talk about the sort of assessments and acts you need to do before you do that call next of kin to ask if you can, if you can keep her in hospital. This all depends on whether the patient themselves has capacity to make the decision. So we'll go into that assess whether she can understand way up retain and communicate her decisions for those of you that already know. Um That's part of the two stage Capacity Act that we do to determine whether somebody can make their own decisions or allow her to leave. So if you assessed her and you gave, deemed that she did have capacity, then you would allow her to leave. Even if you think it's an unwise decision that's all protected within medical law. So capacity and how you assess it is all based on the Mental Capacity Act. It has five main principles. We actually use, we use it a lot in hospital and it comes up a lot in exams. So it's important that you know what these are um three or about the person in question and tour about what you do with the person. So the first one is that you should always presume that a person has capacity. So basically that means until you have good information making you making, you question their capacity, the assumption is that they can make their own decisions and you don't even start investigating capacity unless you have a good reason to um the individual should be supported, to make their own decisions as much as possible. So this includes representing the information in a more understandable manner, allowing them to have somebody with them who can help explain it to them more effectively than you can. Um people are allowed to make unwise decisions. So, for instance, in this case, if the patient had capacity and they still wanted to go home, even though they had a big lacerations that was bleeding, you'd have to allow them to because they're allowed to do that. And the last two principles are all, if you deem that somebody doesn't have capacity, you active in their best interest. So you've got to think as the medical professional, what this person would want and what would be in their best medical interest and act on that. And you should do it in the least restrictive option for and basically don't want to be restraining them necessarily for a very minor procedure that doesn't really affect outcome, that sort of thing. So these are all, all parts of the mental capacity act that just goes, this slide just goes over again, the five principles. And this is a really important point because you see this, this sort of abused quite a lot is that people can have, have capacity is judged on of specific decision at a specific time. So a lot, we kind of throw around the turmoil that patient doesn't have capacity. But actually that can't be true. It's got to be they don't have capacity. So this lady, she doesn't have capacity right now to make the decision about leaving hospital. So it's always decision dependent. And every time that you have to assess it again, it has to be towards that exact situation. So she might not have capacity to decide if she should leave or stay, but she might have capacity to decide whether she wants a blood test or something like that. But that's just all assessed individually. So when you're carrying out a capacity assessment, which you'll get asked to do quite a lot. And also as long exams a lot use the two stage test. So this diagram here is from the Royal College of Emergency Medicine. I think it's really good at just representing what both stages are. So the first stage is, does the person have an impairment or disturbance of the functioning of their mind or brain? So more specifically, they give examples of that, but this isn't inclusive of everything. There could be situations where that's true and they're not in this list. So for example, patient's with mental disorders, dementia, learning disabilities, brain damage, confusion, delirium, or drug and alcohol intoxication. So if you answer yes to that question is this patient, does this patient have one of those things? Then you go on to assess whether does the impairment or disturbance of their mind or brain mean that the person is unable to make a particular decision? So this goes back to it being decision dependent and for them to be able to make, to be able to unable to make a decision. If they cannot, you've got to assess for things whether they have understanding. So do they understand the information that you're giving to them? Can they retain the information? So they have to be able to keep it in their mind. Can they weigh up the pros and cons and the alternatives available? And can they communicate their decision back to you? That doesn't have to be verbally, it can be by any means sort of written or could have clearly insinuated through their actions. If they can't, if they can do that, then the patient patient still has capacity. Even if you think they have a disturbance of uh of thinking. If they can't do that, then the patient lacks capacity to make that decision. And that's how you go about assessing it in the hospitals is quite often forms that you print out or using the computer that have specific things that you check off. So when a patient doesn't have capacity, this sort of start to make you think, okay, what do I do with that information? I know that they can't make this decision that I'm trying to get them to make. So what do you do next? Sometimes people have advanced directives, which is a legal document they've prepared whilst having capacity that says gives an idea of what sort of things that they would like or not like and what they want their future to look like. So you can refer to that document if they have one, a lot of people don't, if they don't have capacity or an advanced directive, then it goes to the health care professional, treating the patient to make the decision. So in this case, you'd have to look at what would be in the person's best interest. Um You can consider whether it's safe to wait until the person has capacity. So if you think it might be a transient delirium or something like that, or elderly patient who's more delirious in the morning, but maybe um has more capacity in the in the afternoons. So you could wait if the decision wasn't immediately needed. A lot of the time we talk to family members to, to gain an insight into what the person would have wanted. So this gets a bit confusing cause a lot of family members will express to you what they want and what they think that should happen. But you really have to pry out of them. What sort of things would your family member, who's the patient value? And what decision would they likely make in this situation? If there's no family member or friends available and you can't communicate well with the patient, then you should, it's mandated that you must assign an independent mental capacity advocate who is basically a third party person to help. In this scenario, it helps advocates for the patient's rights whilst you're making this decision. So a common one we get, especially in A and E is you judge somebody to not have capacity and they're insisting on leaving. So they want to leave or they're trying to actively leave the hospital if so, in some of these cases, because we haven't had a chance to see the patient yet. So they might be, they might be in the department but has not been formally assessed. Um But there's still sort of either very chaotic or acting dangerously and are saying that they want to leave, then you can rely on common law doctrine of necessity. So this is where, where a formal capacity assessment has not taken place. So you haven't done a two stage capacity assessment, but you suspect that they might either be, do you suspect they might like capacity even though you haven't assessed it and there might be a risk to them or others if you don't intervene and sort of intervene in that and detaining them still in the least restrictive way is protected under common law. It's a bit of a gray area that and I think it's always best to know about it, but it's important to involve seniors in that decision. The next one is you've judged them to have no capacity formally, they still want to leave. So you can put in a dolls. So you hear this quite a lot in hospital, they do it a lot for dementia patients' and uh and the sorts. So dolls is a deprivation of liberty safeguard. It's designed to allow hospitals or care homes to legally restrict patient's into a care situation uh in hospital. So trusts can put in an urgent dolls that lasts for seven days. So we quite often do that on admission, their form, they're, they're continually reassess. So if the patient gains capacity to make certain decisions, then you can remove it, but it lasts for seven days. And at that point, it has to be escalated to the safeguarding teams to, to look up further Axion. So there's some exceptions. I know there's lots of sort of different terms and acts and laws there all the way throughout this lecture. But it's just important that you sort of know, you have to know the details of them, but know when to use which one and just have an idea of what they are. So if there are some except exceptions to the Mental Capacity Act, if the patient has a mental health problem that is affecting their capacity, then they should be assessed under the Mental Health Act. So I'll give you a scenario to help sort of conceptualize this. Quite often, we get presenters to people presenting to A and E with a sort of acute psychotic episodes or where it's clear that they don't have capacity, but they still can't be formally detained with the Mental Capacity Act alone. You have to apply for Mental Health Act assessment. Then what normally happens is you detain them on what's called a section as like a very, there's different types of sections, but there are short acting ones. So you detain them on that section that you've put in place and then you fall, you call for a formal mental health assessment and that's done by a psychiatrist. So they come and decide whether the person needs detaining and whether they need a different sort of section put in place that allows treatment or allows admission to hospital and everything like that. So it's just important to know that if capacity is impaired by sort of a mental illness, then that's a different act. But in reality, it's sort of the initial parts of it for you as a doctor are similar, you just have to know where it goes next. Additionally, Children are not covered under the mental capacity act, they're covered under the children's act. That's probably you don't really need to know much about that. It's a bit, it's obviously more nuanced and okay. So back to our initial case now that we've discussed those things. So most of you were right that the first thing you would do is assess capacity if you could. Um Yeah, so you'd be assessing capacity. If she was deemed to not have capacity, then you would put in her dolls and make sure that she was always under supervision and that you were protecting and looking after her best interest while she was in the hospital. And part of this is that you could, you could um get scans and start treatment and all that sort of stuff. If they, if she would become, if she became very aggressive or was very, very agitated and deteriorated and you need to do something urgently, then you can start looking at using other forms of um restraint, either pharmacological or physical. But that's obviously like the last resort of all these assessments is using restraint goes back to you meant to use the least restrictive options. So if there's any other option available, you use it before you restrict them physically. Okay. So the next case, so this one, an 85 year old male presents to a and E from a care home with worsening shortness of breath and a productive cough for the last four days. His new score is 14. I don't, he might have already covered new scores, but that's basically all the obs collated into an early warning score. 14 is high. It means he's very unwell. He is hypotensive and hypoxic despite initial resuscitation with IV fluids IV, antibiotics and high flow oxygen. You look at his medical records and they show that he has severe COPD and has been labeled to severely frail. What are your next steps in management? I think we've got another question here. Yeah, we do have a, have a read through and see what you think. Yeah. Yeah. Mhm. Yeah. I think this is a really hard question. I'm just reading through the answers now. Basically depends so much on the other information that you're managing to get and it can vary very, depending on all the such all the other information that's available to you. But I think basically the gist of this is, is this man is very unwell. You've given him the initial treatment that you'd expect somebody to improve and he's not. And on the background of that he is has a bad baseline, so severely frail and has COPD. So I think the first option intubate for respiratory support, admit to I T U obviously with his COPD and the fact that he's very unwell as it is I T you would be very unlikely to accept him and it would be, it would probably be deemed as too invasive for the prognosis. That would, that would have um do you continue current treatment and admit to hospital? So that's definitely an option you can do. But at that point, you really would need to be thinking about what would be the next step if he continues to not only get any better, do you just continue indefinitely until something happens or do you escalate back to I T U? So you need to have a D N A R discussion with the patient and the family. Do you complete a DNA CPR stop all treatment and admit to hospital? So that option is sort of an end of life care decision, which else in this case might be the most appropriate. He certainly wouldn't do well with CPR. So that would probably be filled out. That would be a good thing to do is to fill out DNA CPR that might continue treatment a little bit longer to see what would happen. But also would be a valid reasoning after further discussion, to stop treatment and to preserve patient's dignity and comfort and go for end of life care. Do you discuss the wishes of the patient's family and carry this out? You certainly would discuss with the family. Um But you need to make sure, like I said before, that you're thinking about what the patient would want and not just what the family would want, discuss the wishes of the patient and carry this out. You definitely would want to discuss the wishes with the patient if you could, you wouldn't necessarily need to carry it out. So if so if a patient is saying that they would like to be resuscitated, but you were in your medical, your medical decision, think that that's really not a good idea. It would have a very bad outcome. Then you don't have to do resuscitation and you can fill out a D N A R for, we'll go into a little bit more detail about all of this. But basically this represent sort of the nuances of these decisions that you make in hospital and kind of a combination of a lot of these would still be a correct answer, but it depends on the situation, it's always good to involve seniors in these sorts of decisions. So, here's another question who decides if a patient should have attempted CPR, should the heart stop? Well, okay. So a lot of these could, could decide whether A D N A C P R could be put into place. But in this exact scenario, assuming the patient doesn't already have a D N A C P R. It would be, it would be the responsibility of the junior doctor who's looking after them. So in most cases, a junior, so I think mostly above F one, normally, first years can't because they've got full um G M C. But once you have that, you can put in a D N A C P R no matter what your grade is, as long as you have good reason to and you justify it and then it normally has to be confirmed within 24 or 48 hours by a consultant or a registrar just that they agree with the decision. But even before it gets confirmed, it's still in place. So you still wouldn't perform CPR, even if you only a junior doctor assigned it, um All these other people, the patient can request a DNA CPR. And most of the time you put it into place, even though it's a medical decision, you put it into place. If it's the wishes of the patient and you explored that fully family or next of kin, can't really decide about D N A C P R decisions. They can guide what if the patient doesn't have capacity. They can try and let you know what they think the patient would want to do, but they can't make the decision. A cardiology consultant obviously could about their own patient's, but you certainly wouldn't get the cardiologist down to see every patient that needed A D N A C P R, palliative care consultants equally can put in D N A C P R s. But you'd hope that a lot of these have been done before they get to that point. And the patient's general practitioner can put in D N A C P R S as well. And a lot of the time, they're the best people to do it because obviously when were in hospital people are very poorly, everybody's very stressed. It's a difficult time to have DNA CPR discussion's, it's much better to have it in the community when you've got a lot of time to think about it and discuss it. And it can be introduced gradually rather than in an acute emergency. Well done everybody. So D N A C P R obviously stands for do not attempt cardiopulmonary resuscitation, specifically refers to the cardiopulmonary resuscitation. But so it basically means if a person has a cardiac arrest, we don't try to restart their heart. As I said, this is a medical decision. It's signed by doctors. I know in a lot of other places, the patient's or the next of kin signed the DNA are. But in the UK, it's the doctors make the decision and make, do all the paperwork. You base it these decisions, a complicated decision but you base it on the patient's wishes. Um They're pre morbid health. So what's their baseline? What are they likely to get back to if the heart stops and you managed to resuscitate them? What sort of, what sort of life will they have after that? And the likelihood of surviving the current illness? Although it's a medical decision, you are required by law to communicate the decision with the patient if they have capacity, if they don't have capacity, you have to tell the next of Kim. So there's quite a big scandal about this during COVID because there was a lot of D N A C P R s being put in, even in the community and in hospital and the, the the appropriate people were not being informed. So this is sort of big in the learning points at the moment is that you have to make sure that people know that they have a D N A C P R in place. And don't just find out either afterwards if the family find out or they see it on their medical records or something like that, they can still. So it really does just, it just refers to cardiac arrest and doing CPR everything else is not included in a D N A C P R. So you can still have somebody who has a D N A C P R but is still in I T U. They can have full escalation. You can do all the treatments, they can have intubation ventilation, they can have everything. It does sometimes effect. If somebody does have a D N A C P R, it does sometimes affect how high you will escalate their treatment if you think that's how it's going to end. But yeah, just by the legal framework of it, it doesn't include anything else other than chest compressions and oxygen support and that sort of thing. So where D N A C P R only includes CPR quite often. Now they're moving towards having treatment escalation plans put in place. These can be decided by the patient's if they, if they not decided, but they can be guided by the patient. They can express wishes of where, how, how high they would like their treatment to be escalated. They can be done by the doctor who's admitting the patient or the doctor in a, any with a discussion with the medical team. But it basically it's not a legal document and it's putting the patient's notes as a guide for everybody who's treating that patient. It is much more nuanced than A D N A C P R. So it can include all the, all the different combinations of you can say like the patient should be for everything. So they should be for full active treatment, full escalation to the highest resources and includes CPR. So that can all be included an escalation plan. They can be not for CPR but for full active treatment like I described before. So no chest compressions, but up until that point, everything goes for ward based ceiling of care. This is a common one that we use for people who we don't think would survive an intensive care stay. So this includes everything that can be administered on a general medical ward, er and acute medical ward, all medications IV fluids. It normally includes non invasive ventilation, but doesn't include intubation. That's just an intensive care thing. All the other side of it is for comfort care only and that's really, that really just involves the end of life care plan. So we give people medications to make them comfortable, give them oxygen to make them comfortable, but we don't give them any active treatment. So it normally includes uh sub cut morphine, oxygen, um can include stuff first respiratory secretions and stuff like that basically just to keep people calm uncomfortable whilst they're dying. So these are what these forms look like. The red one. They, they do change from trust to trust and from region to region. But the D N A C P R forms are almost always red, they're always red around the perimeter. So you can find them easily an emergency if they're on paper, they quite often come in with these from home as well. So the ambulance will bring it in. Um That's what said it's just for CPR, doesn't include anything else. Respect form is there's a big move towards having this sort of form now where it's a lot more nuanced. It includes, it includes what sort of escalation would be appropriate in certain situations. So for example, with a person who has multiple exacerbations of COPD, they're coming into hospital for five times a year. Um, it could say on there for ward based ceiling of care, noninvasive ventilation only. And that would mean that there wouldn't be a candidate for intubation and generally, it has just more specific criteria of what would and would not be useful. I see what else we got. It's quite a common lab scenario and exam, general exam scenario is to have to discuss DNA CPR decisions with patient's something that you do have to do in real life from being relatively junior as well. So it's important that, you know, sort of getting your head about the way that you would like to do it. Everybody does it slightly differently, but a good sort of guide of how to do it is to first give a warning shot. So that would be something like, um, before you sort of jump into the full discussion, just let somebody know that they're very poorly and you'd like to talk to them about what sort of the next steps would be and what they would want if they were to get more poorly. So you can give them that warning shot. Give them some time to think about it and then go back and have the full discussion. A lot of people, I think through television have a really unrealistic idea of what CPR is and the outcome, I think the data shows that TV. CPR almost always works when we know in reality that in hospital it has about 50% chance of working and less taught for people surviving until discharge. So it's important that you assess what they understand CPR is including what the physical act is as well as what the outcomes are likely to be. You can discuss their ideas on this um and explain to them the value of it in their specific case or, or if, if you don't think of it's going to be of value in their specific situation. Why don't you think it's going to be of value? Um You got to let them know that a lot of the time they think that you're just going to give up on them. That's a common thing as well. You're just giving up on them completely and you got to make sure that you, they know that they're going to get the rest of the treatment. So you continue the IV antibiotics, the IV fluid and you're still going to treat them all the way up to that point of the heart stopping. Um People sometimes, although it's, it does feel quite abrasive sometimes when you say this to them, people of are quite often relieved when they find out it's not a decision that they or their family have to make and it's in fact an informed medical decision. So you're kind of taking that responsibility away from them, just let them know that it's not their decision to make. And it's, and it's going to be decided by a team of professionals for them. And like I said before, you must inform the patient of the outcome of the decision or the next of kin if they don't have capacity. Okay. So back to this case, kind of discussed it mostly already. I think obviously there'll be scenarios where you would do other things for this. But I think more than likely this is an elderly frail man who's very unwell and not responding to treatment. The most appropriate thing would be to discuss a D N A R C D N A C P R. If the consultant is around, you can involve them in the decision, but you can certainly have the discussion with the patient or their families. And then you may decide to continue doing the treatment for a little bit longer to see how it goes. Sometimes it's sometimes you admit people for 24 hours of active treatment to see how that goes and see if they improve or if it's looking like it's not going to approve and they continue to deteriorate. You would make an end of life care decision and just prioritize comfort care with those things that I said before. Okay. So we're on our third case. So this is patient. He is a 65 year old female who has been investigated for suspected colon cancer. So they have a ct thorax, abdomen pelvis and it suggests stage for metastatic disease, but this is not being communicated with the patient yet. So the patient doesn't know of this. Patient's son has asked to talk to you privately. He requests that you tell them what the scans have shown, just tell him what the scans have shown. Um He says he's a consultant surgeon and suspects that the patient has cancer. The sun states that he would prefer that the diagnosis of cancer not be communicated with the patient. Um If it were the case as he does not think so. So it basically requesting that you don't tell his mom that she has cancer as he thinks that she won't handle the news. Well, this is another common Noski case. So what would you do have a read through the options? Yes. Okay. It looks like you've all done really well on this one, we'll go through the options quickly, but it looks like you kind of get the gist of it. So the first one do not inform the patient of the diagnosis as per the son's wishes you have a duty to tell the patient. So that would be against the law to do that. Um explore the patient's wishes about being informed of bad news and do not tell the sun about the results. So this protects, protects the patient's confidentiality because you're not, not divulging anything without asking her consent first. And then you're also exploring whether she wants to hear the results because the sun might be right and she might not want to hear anything about it, but you need to know that to explore it with her before you make any decisions. And before you tell the sun anything, um explain the results to the sun, encourage him to discuss them with the patient. This would breach this would breach confidentiality because you haven't asked, you haven't asked for her if you can talk to the sun. And it also wouldn't be appropriate for a family member to break bad news like that unless the patient has stated specifically that that's what they wanted. Consult other family members to explore their wishes. I think that would just be breaching confidentiality further. So it's still not a good idea. Do nothing escalate to a consultant. It's not a bad idea to inform a consultant, but you should be able to deal with this situation at least the initial stages of it by yourself. So you should be able to let the sun know that you can't divulge any information to him and you'd have to get consent from his mom and then discuss the findings of the scan with the mother. If you thought any, if any part of that was being particularly difficult or you were having trouble with, then yeah, by all means escalate to a consultant, but you should at least be able to try and manage this by yourself. Okay. So now we're going on to confidentiality. I know all these topics are quite dry, but like I said, they just come up a lot all the time. So it's really good to get a good grasp of it early on and then it helps you in all your exams. So the G M C good medical practice has its own guidelines on confidentiality that are included in that summary, I showed you at the beginning. But basically that patient's have the right to expect that their personal information will be held in confidence by their doctors. And they can say they can say uh if they want their information to be shared with other people, but it should not be presumed that they want to share their information with other people. And the next of kin doesn't have a right to information unless the patient has given consent or doesn't have capacity. So in this case, if the mother, if in this back going back to our case, if it was deemed that the mother didn't have, didn't have capacity two, make decisions on what to do next about this cancer diagnosis. Then it would be appropriate to talk to her next of kin who might be the sun. But until you know, she doesn't have capacity, you can't really talk to the sun without asking if he, if he can be spoken to. So, confidentiality, the guidance, um good medical practice guidance has eight main principles. I'll go through these quickly, but I think they're all quite self explanatory. So you're meant to use the minimum necessary personal information when you're recording everything or share ing anything. Um It's the trust responsibility or the doctor's responsibility, manage and protect information. So you've got to make sure that there's good practice in place that there's not going to be data leaks or papers lost and all this sort of stuff as a medical professional, you're meant to be aware of your responsibilities in regard to confidentiality. You've got to comply within the law and we'll talk about a couple of those in a second. Share relevant information for direct care. So that goes back to share in the minimum amount possible between health professionals only, only share what is directly needed with somebody who directly needs it. So you have to ask for explicit consent to disclose identifiable information about patient's 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. So we'll sort of go into a little bit of what that means because that's quite obviously quite complex. Tell you have to tell the patient about any disclosures of personal information you make that they would not reasonably expect. And if to support patient's to gain access to their information that's stored about them, we'll kind of go through some of those. So most of the, the guidelines from this are based on the Data Protection Act of 2018. The Data Protection Act is a law that governs how personal data should be processed used and protected by organizations in the UK. So this does apply to the NHS, but it applies to all sorts of organizations who hold personal data. It includes the individual's right to access, correct and erase their data if they wish to establishes rules for obtaining consent for data processing defines the roles and responsibility of data controllers and processes and mandates the reporting of data breaches if any questions. So if you have any questions about this, then the best people to contact in the trust are the data protection officers. And I mentioned that because in all ski situations, if they're asking you about confidentiality and you're not sure you can say that you would contact the data protection officers in your trust for further guidance. And that's what we do in practice as well when you're doing audits and stuff like that. If you're ever unsure about anything, the data protection officers are who to contact. So as well as the trust's maintaining their own data for that they collect within the hospital, the trust themselves, there's also within the UK, the shared health records. So those can be accessed by anybody around the UK with a caring role for the patient where it needs to be accessed. So it's basically a centrally stored data base with patient identifiable information. Mostly it just includes diagnoses that people have been given and the medications there are and you can basically access those from anywhere through certain portals. This is all of this is still governed. It's important to know about this because it's something we use a lot and this is all still governed by the Data Protection Act and the Caldecott principles. Um for patients' too, give you access to their health data, they have to give consent. So when you open this up on the computer systems and you try and access the shared record, it will come up as a poppers have this patient given consent. So basically every time you want to access this, you ask the patient, they say yes and you just click yes and you gain access to the health records, but that consent is required for you to do this. Um The patient's have a right to access their own data. This doesn't include patient's just asking to see it like if they come into hospital and see you on a computer and say can I read it? That doesn't include that they have to go through official channels to gain access to this. So it's all documented and everything. But you don't have to show somebody their data immediately if they ask for it, but they do have access to it in the long run. They can, they can read it and therefore have inaccuracies corrected. So if there's something that they don't feel represents them or that has been disputed, then they can get it removed should only be shared with authorized individuals for a specific purpose. So we commonly use this, for example, when people come into A and E for various medical things, um, then you ask them when you're assessing them, is it okay if I look at your GP records just to get some medicate with the medications you're on if they don't know it and they almost always say yes and then you go and look for it. So we use it a lot. It's just important to not use it unnecessarily. So say if you're, if you're not involved with the patient's care and you just want to have a flick through, then obviously inappropriate has to be something that you need to do to continue confidentiality. There are some exceptions. This is the bit that loves, they love to examine the exceptions when you can breach confidentiality. And I think it's something that's going to require some independent study as well because it's just quite there's a lot of it, but hopefully this will guide you where to look and what you need to look into further. So, confidentiality must basically always be protected with the Data Protection Act. You don't disclose anything unless you have consent to. You may disclose relevant personal information about a patient who lacks capacity to consent if it's through the overall benefit from the patient. So for this, it's basically if, if the person that you're treating doesn't have capacity to give you to give you the information to doesn't have, sorry, let me say this again. So if say if the patient is very unwell, you can't discuss with them about, about what the next step of treatment would be or explain what's going on. You don't have to get that person's consent to talk to a family member. If they lack capacity in this sort of sense, then you can talk to the next of kin without it explicitly being stayed stated that is protected by law. Um You can break confidentiality rules if it's justified in the public interest. So this is normally if the patient poses a risk to others, such as if they told you or you strongly suspect that they're gonna commit a crime or have the intent to harm somebody or themselves, then you can, you can break confidentiality and inform the appropriate body. Most wind criminal and criminal access is normally the police. So you let the police know and it's also for reportable communicable diseases. There's certain, there's certain diseases, there's a list of them that if a patient is diagnosed with them, we tell them, we have to report it and then we report it to the, to the correct authority, including the patient's name and data so that if they need to be traced or they need to contact tracing, then that's that can be done. Sometimes it's ordered to your order to breach confidentiality by law. So a court can order order this to investigate a serious crime or road traffic accident. So this is sometimes given us the scenario as somebody comes into a and e they told you they've been in an accident, they have a big lacerations on their head. So you treat them as if they're in a car accident, there's not necessarily anything you have to report in that, but then the police come to you the next day and say we're trying to find a man who has been in a dangerous car accident and he's killed somebody in this car accident and we're trying to look for him. Have you had any patient's who fit this sort of injury profile? And in those cases, they can order you to divulge patient information to investigate that crime. All gunshot wounds and injuries that have been sustained in an attack with a knife blade, sharp instrument must be reported to the place. So there's no exception to that if somebody has been stabbed in any sort of incident other than being by accident or them self harming, then you have to report it. Um This is a big one. You should look into this. The D V L A which is the driver driving licensing authority need to be informed. So patient has a legal duty to inform the D V L A of certain medical conditions and that will affect their driving license. So for example, if somebody has a seizure, they are told by the doctors on staff that they cannot drive and they need to report it to the D V L A if they then come back in for a follow up appointment three months later and you have suspicion or you ask them and they tell you that they're still driving, then you can breach confidentiality and tell the D V L A yourself, you're meant to give patient's the option to do that first. But if you suspect that they're not going to or they haven't done, then you can, you can break confidentiality and tell them you should look up the specific scenarios that people have to stop driving because they ask about it a lot. It normally it normally to do with seizures and it varies in length depending on whether it's one seizure or multiple seizures or they have diagnosis for epilepsy. And also for people who have T I S. So one T I A, for example, you are meant to stop driving for three months. But you don't have to tell the D V L A if you have to T I s, then you have to stop driving for six months and you do have to tell the D V L A. So it's just quite a good idea to read through this. We can post a link to it just so you have an idea of when and how long people should stop driving for because it's our responsibility as physicians to warn them of this when we diagnose stuff. So back to our case, you guys got it. Alright. Anyway, you can't tell the sun any information about scans. You can't give him what the information that he's asking for. And additionally, you're not going to tell him to not tell the mother. So you have to tell the mother assess what she would like to know. And if she consents to you talking to the sun, you can talk to the sun. Okay. This is our last case. Now doing okay for time should be quite quick. This one. So a 22 year old male patient has recently had a kidney biopsy to help determine the cause of his declining kidney function. You're a junior doctor on the service and when you call the lab to chase the results, they inform you that they have never received a sample and therefore there's no result available. So in this case, you normally have to break this news to a patient or any bad news. And then quite often they get very angry and you're sort of left to manage that part of managing it most of it, how I look at these cases is to just explore what they're angry about. So you've got to tell them you got the duty of candor to tell them what's happened. And then after that point, let them talk, get an idea for what they're really upset about. If, if there is a genuine error, you can apologize, be empathetic with them. And then equally you want to sign, post them to the right destination, like for the the right services to help them progress this further if they want to and tell them what you're going to do about this specifically. So that's sort of the framework I use for all of these. But in general and angry you get angry patient slash relative. It's important to recognize that the patient is angry and react accordingly. It's best good to adjust your communication style. So sound more relaxed and calm, stay composed and professional, always professional, never let that break. Um Even when they can obviously be getting quite a rate and it can be quite distressing. You've got to stay professional, you can acknowledge their anger. So I can tell that you're upset by this and, and there's a lot of phrases like that you can work on that just acknowledge that doesn't diminish their feelings and let's them know that you understand what they're telling you and you're gonna act on it. Um You can respond to patient relative with empathy. So you say, given everything you've told me, it's understandable that you feel this way. So I apologize if an error has occurred and thank the patient and encourage further questioning. So these are all sort of just little tidbits that will help you deal with an angry patient case. The important bit that I'm going to talk to you next is quite often they don't calm down in these cases, they might calm down slightly and it's important to be able to tell them what you're going to do and what the hospital is going to do about this and then where they can go next to escalate this fervor. So, so one of the things that you're gonna do, the hospital is going to do is called an incident report. So all hospitals have these and it's basically in a way of reporting patient safety issues. So patient safety instants are any unintended or unexpected incident which could have or did lead to the harm of one or more patient receiving healthcare in general reporting them supports the NHS to learn from mistakes and take actions to keep patient safe. So important thing I take out of that is that it doesn't harm, doesn't have to come to the patient for you to have to put in a patient incident report. Um It could just be a potential harm. So even if it was caught in time, if there was any step of the way that that could have caused a patient to be harmed, then you have to, you have to report it. There are often local systems for this. Sometimes they call different things like date X and stuff like that, but just know them as instantly reporting. So within your trust, you can incident report and it gets escalated to the appropriate management and then it's the trust's responsibility to then sit through those and send important ones to a national system. So that as a whole, these can be monitored. If there's a common trend in something, then it can be addressed. So they will say that the aim from these is to learn rather than blame. Although when you're doing them, you do have to put in sort of who, who's involved in this case. And it does feel quite blame me when you're pulling them out. They're meant to be, they're meant to be a case for what can we do to improve the service rather than to punish somebody who's done something wrong and said earlier as a duty of candor to inform patient's when an error has been made, even if no harm is caused. So say if a, a, a nurse accidentally gave the wrong drug to a patient, there was no adverse effect that it weren't allergic to it and it wasn't a strong drug. So they had no reaction. You'd still have to inform that patient that an error had taken and what you're going to do about it. So if the, so you tell the patient all of those things, you sort of empathize with them, you talk to them, you tell them you're gonna interest and report it. If they're still very angry and want to pursue things further, then you could point them to two pals services. So Powell stands for patient advice and liaison services. All hospitals have them. Um And it's whole role is to offer confidential advice, support and information, health related matters to patient's. They provide a point of contact for patient's, their families and their carers. So anybody can contact pals about any specific thing to make a complaint or even to complement the service. They're not commonly used for compliments, but apparently they do do it, mostly it's complaints. Um And then the pals team will sort of look into it. They might gain more information from the doctors and nurses involved. And then if they feel like something needs to be doing, it gets escalated to management and sometimes change happens. But you can explain all that to a patient and direct them to the pals service. That's always a good way to sort of end these angry patient scenarios because then the patient feels like they're gonna, they have something to do next so they can escalate this further and it's not just stopping if they're still angry about it. Okay. So that's everything I wanted to cover today. Look good places to look for further information. And these are sort of what I've used to make. This is mentioned already the G M C good medical guidelines, good medical practice. The Royal College of Emergency Medicine has really good guidelines and all these issues and they are normally focused towards what to do in the emergency room for these sorts of things. But it's pretty applicable to the rest of the hospital as well. The Medical Defense Union has some good resources and obviously took a lot of the cases from the lab blueprint. So that's everything. Any questions I can't hear you. The cash are the confidentiality principles. The eight ones that you mentioned are these the Caldecott principles or is that something different? It's something different. But there are, they're basically all the same. So they're not technically the same thing. They've, they've made the sort of G M C have made their own confidential two principles, but they're based on the Caldecott principles. They're very similar. If there any think you just pop them into the chat, I'll say I'll talk about the next session while we're waiting for anymore. Thanks everybody for listening. That's, I know it's quite a lot of dry material and yeah, it's not really a huge, there's not a great way to learn it or make it very interesting, but it's important to know, and if you, even if you just recognize the different frameworks and when they used, and that will be really useful. Um because you want to talk about the next one. So if you enjoyed that and you thought that it benefited you, then please sign up to our next event which will cover some internal medicine topics and it's on May 20th at the same time. So I'm just posting a link to sign up to this event in the chat and it's the, it'll be on metal as well. Um, in addition, if you enjoyed that or if you didn't, then please complete a feedback form. And I've also posted that into the chat and this will be helpful, of course, for Nadia. Yeah. All right. Okay. I can't see any more questions now. Yes. So I think we can wrap it up there. All right. Thank you. Nervous.