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Let's get started then. Yeah. So, hi, everyone. Thanks for joining this eye MG Tuk webinar. We're going to be focusing on some important concepts within medical ethics today that will help you prepare for the plaid exams as well as for UK Clinical Practice. Um This series is hosted by Widening Participation Medics Network, which is a national charitable organization that aims to make the medical workforce of the UK more representative of the population that we serve. Uh And uh the series is also sponsored by the Medical Protection Society, which is a leading medical exam initi provider that offers services specifically tailored to international medical graduates working in the UK. Today, we have um doctor now media Brody Steadman. She's an ST two in emergency medicine in the north west of England. Um I'm pleased to say that I've actually had this talk or a similar talk from her in the past and it's really helped me a couple of years ago, so I'm really excited for her to be given the talk today. Um uh Just before we get started, I'd like to remind everyone that if you have any questions at any point, please feel free to put them in the chat. Hopefully they'll be answered along the way. But if not, we'll probably get to them at the end. And at the end of the session, we're going to be sending out some feedback forms for the teachers today. And, uh, we'd really appreciate if you complete these because they help us out a lot to help us kind of understand um how to guide our future talks. Um So thank you and I'll leave the floor with Nadia. Thanks for sure. So as Bashar already said today, I'm going to cover some medical ethics scenarios. So it's not restricted to the classical medical ethics, but also covers um difficult uh scenarios where you have to work on your communication or whether trying to test your knowledge of specific UK guidance and framework. So we'll go through a couple of those, these commonly come up on Plavix, well as as a multiple choice questions in sort of the specialty recruitment exams as well as our skis for run training. So it's certainly worth knowing about and will also help you practice in day to day medicine. So we're going to cover safeguarding abuse, domestic violence, gonna talk very quickly about sick notes or fit forms as we call them here and talk about how to approach a scenario where you have a difficult discussion with a colleague or other challenging workplace situations as well as the framework we use for breaking bad news to patient's and talk briefly about the laws and sort of guidelines around organ donation. So I'll get started, got quite a lot to cover. So I'm going to be going in case I've got five cases and I've got some multiple choice of Clifford questions um sprinkled in that we can have as a bit of an interaction and we'll talk through the results. So the first case, the 78 year old female presents with limited mobility to a and E after accidentally fallen down the stairs, she says she lost her balance. But on physical examination, you notice that she has multiple bruises, they look at different stages of healing. You also think that for her age and sort of her living situation, she looks quite malnourished and unkempt. She told you that she lives with her son, know live with her husband who has dementia and also the sun. So this is a fairly common presentation to A and E that we see. So this is the first question just to get us right in there, get us thinking. So neglect is defined as a failure to provide needed care. Which of the following are examples of neglect. Is it commercial coercing them to transfer finances, restricting access to family members, failure to provide adequate food or clothing or hitting, slapping, kicking or punching. Give you a little bit of time to answer that. Okay. So it looks like you got all that right. So yeah, failure to provide adequate food and clothing. All the other options, obviously, still forms of abuse but not specifically forms of neglect. So I'll go through the different types of abuse, especially how they relate to elderly people and look at some of the things you need to look out for as well as the different presentations of those. So it's a bit of a bit of a heavy topic today to start with. But basically, obviously we've got an aging population, a big proportion of the presentations to acute services, whether that's in hospital or Toujeo acute GP appointments are elderly people. So it's something that we all have to look out for the signs of elderly abuse. Um It's quite common, shockingly common one in full vulnerable older people at risk of abuse. Um We use safeguarding as a way to try and watch out for this and flag it up when it comes up. Safeguarding, aims to uphold and adults fundamental rights to be safe. So I'll talk to you a bit more about sort of the safe, how you contact safeguarding. And what that means is also recently been made a criminal offense under the mental capacity Act willfully neglect a person without capacity. So that basically means that it's not only illegal to sort of physically abuse somebody as we'd consider that sort of crime, injury, crime, but it's also uh illegal and can be prosecuted if you neglect somebody who, whose under your care, who doesn't have capacity. I just wanted to point out we've recently had World Elder Abuse Awareness Day. So I think it's awareness is picking up, but it's obviously enough of a problem that it has its own day. So it is something that you need to be aware of. Um This is just a overview of like saying it's quite common. So this is about older people in domestic abuse. We often think of domestic abuse as intimate partner violence, but it also includes elderly people and people who live with them. So victims, you can have a quick look through this but basically shows that victims age 61 or over are much more likely to experience abuse from an adult family member or current internet party other than those 60 years and under. So, although we think the classic abuse scenario of sort of a couple, it's also really prevalent among the elderly population is something we need to be aware of their also less likely to flag this up to professionals. So I think I read that it was less than 1% will actually report it themselves. So it is part of our responsibility of healthcare professionals to notice the signs of it and deal with it accordingly. So I'll go through I say quickly, but it is quite big types of elder abuse. So we already mentioned neglect in the multiple choice question. But as long as that, as well as that there's physical abuse emotional abuse, sexual abuse, neglect and financial abuse. So all of those come under sort of the cover of elder abuse, we'll go through what to look out for. So, physical abuse I think is the most obvious and the easiest for us to come like identify as healthcare professionals because we do physical exams and they often present with injuries. But it's basically attempts can be made by the uh so it's basically an injury that you find that doesn't either fit with the presentation or the story they're giving you or there's a repeated pattern of multiple injuries. Sometimes the person who's with them could be the abuser. So they make attempts to try and cover it up like they'll put them in loads of clothing or they'll tell you that they get very distressed when they're examined and all these sorts of things. So that's just something to be wary of. Um, all those are injury, just general injuries that can happen from abuse. But I think I don't need to go through those, you'll know them, um, can also present as poor skin condition or hygiene. So signs of breakdown of skin, like they haven't been moved frequently or bed ulcers, all those sorts of things can be dehydrated and malnourished because they're not being fed and watered properly. Um, obviously loss of weight is something that we look for lots of medical causes for. But if you can't find those and it's still suspicious, then always think of this as an option. Um, it's illegal to restrain elderly people in all ways and that includes locking them into rooms and everything and, uh, to keep them safe, that's still castles restraint and it's illegal. So you need to look for signs of being restrained. So it can be wrist abrasions or things like that. They can have damaged their property. So sometimes they come in with broken glasses or hearing aids that have been broken, just things that look like they've been damaged, that should have been replaced. Um And rarely we see that they've been inappropriately dosed with their medication. So they're either been prescribe something and they've not been getting it. So you're not seeing the therapeutic benefit of it or they've been overdosed on it. So sometimes, um we've, they can be used as a sedative and things like that. So it's just something to be aware of psychological abuse is probably the hardest to spot and is the most common. Unfortunately, a common situation is that the person who's doing the abusing will take something that the person cares about that the patient cares about such as access to family members, to access to their grandchildren and they'll use it as a threat to um to get them to do what they want or to behave in a way that they want obviously harder for us to pick up as health professionals. But they can quite often present this quite withdrawn have some unusual behaviors or comforting behavior such as sucking, biting or rocking, can have unexplained fear or like I said, just extreme withdrawal. So all things look out for and this is often linked with financial abuse, which is another one that I will recover in a little bit. So financial abuse. This is occasionally you come across this in hospital, but it is more of a sort of an issue that the police will pick up once it's already flagged on the safeguarding team. But basically, it's a sudden cash withdrawal. Um or suddenly family turns up who have not been involved in this person's life at all when they're unwell and they seem excessively concerned about the care costs or the ongoing costs of caring for them when they go home, they often don't want them to go to a care home after discharge because it costs a lot of money and drains the assets of the house and things like that. Um They can also have lack of possessions so they turn up and they haven't got any pajamas or clothes and there's, there's no access to get them. Um and sometimes it can be as part of the picture of psychological abuse and they're deliberately isolated from other people. So this is not flagged up. So sexual abuse is more common in elderly than I think people think. Um it presents, I think in a similar way to sexual abuse at all ages, but it's just not something that people automatically consider but still happens. So again, they present as distressed or fearful and then the physical signs that you can catch as a medical professional sort of bruising around the breast of genital area. Unexplained sexually transmitted diseases or genital genital infections, unexplained, vaginal or anal bleeding can have difficulty walking or standing. And obviously, when you're examining them, you should always look out for torn, stained or bloody under clothing. If you suspect sexual abuse, it is important and we have all sexual abuse in elderly and everybody else. It's important to not um clean the patient or do anything that could jeopardise it as a crime investigation. So you don't, you don't have to make them sit there for ages in soiled clothing or anything. It's just important that you leave them as they are for now immediately call the specialist services that all hospitals have a link with uh sexual assault unit and they will come and do all the examinations and everything like that. They're just more highly trained in dealing with sexual abuse survivors. So it's not something that we have to do, but it's something you have to be aware of. Okay neglect. So this is what recovered in the question. Also very common a form of abuse, but basically they can come very unkempt so they can have dirty clothes, they can smell strongly of urine or faeces. Um sometimes they get lice or scabies and other things like that, that indicate that they have a poor living environment um can be inadequately clothed. So come in in the middle of winter with something that's completely inappropriate. Um uh they might have not presented before to medical services and just presented in this acute scenario. So they could have untreated medical conditions, hygiene. We've already covered. You can note that they've had lack of assistance with eating or drinking. So quite often when people are getting sort of advanced dementia, they need help with their feeding and they present as either been malnourished because they haven't been getting that all. They've been trying to feed themselves and had lots of difficulty thinking with lots of food and everything all over, all over them. Um It's also important to be aware that sometimes people can present with these symptoms or present like this, but it's still a personal choice. So people can choose to live like this as long as they have capacity and they're not being coerced to do so. So if you're, if you're unsure about whether this is a form of abuse or neglect or if they're just choosing to do so themselves, this is their lifestyle, they're choosing, then you can enact the mental capacity Act tests. So you can check their capacity for this specific situation. And if you're happy, they have capacity and they just tell you and you're quite reassured by it that they just, this is how they live. And they're happy with it and they don't want any help. Then that is a decision that people can make. So they don't have to accept care or referrals if they don't want to. Okay. So, in this situation, I guess that covers the types of neglect. But what do you actually do as a doctor? Obviously, I'm an A and E doctor. So I see them with quite limited information. Sometimes with families, sometimes not. Um So the question comes, you're concerned about this adult, this elderly adult, what do you do? Whose responsibility is it to get this sorted and refer them to safeguarding? What do you need to do immediately to protect the safety of the patient as well as potentially the safety of the staff in the department. If you're concerned about the abuser doing something there, what to do if you're not sure or if the case is sort of borderline, sometimes you're not, you're not convinced, but there are some signs and also who needs to be notified in these situations. They're all things to think about and I'll go through in a sec but basically to answer quickly whose responsibility is everybody's responsibility. So this is a image that I got from one of the safeguarding adults websites and it just shows that basically anybody can refer to safeguarding and it's everybody's responsibility to flag these issues up if you come across them. So other health professionals are just one small, small piece of this much larger picture. But it's important that we don't assume that these other people are doing it because it might be that that were the only ones who have noticed this aspect of it that were the only ones who noticed, been able to examine them closely, or it builds a bigger picture of what other people have reported. And so they can take more Axion. So basically, if in doubt, everybody needs to refer to safeguarding as a team, you can decide who from the team should refer, but you need to make sure that it is happening. It's your responsibility to do that. So that takes me to safeguarding teams. So every hospital GP or regional trust will have a safeguarding officer. So they're normally a team that are based within a region that handle all the safeguarding referrals for that specific area. So these, they obviously have full staff during the day, but they always have an on call duty officer overnight. So you can usually reach somebody even if you're concerned about discharging somebody in the middle of the night and that sort of thing. So every hospital have an arrangement with local social services, police and other agencies about how to notify to safeguarding. Um for example purposes, you just need to say that you're referred to safeguarding. But once you're working, it's always good to have a look at what your local policy is. So you know who to contact and how to contact them already mentioned that it's everybody's responsibility and that yeah, there's specific people in the hospital that can help you make assessments and they can also help you refer. So the very useful contacts they then refer onto social services, usually all the relevant people. So again, actions back to what do you do immediately, we've talked about the safeguarding referral. But at the end of the day, you're a doctor, you're working well, I work in A and E but you're working wherever you need to do, you need to attend immediately to the patient's medical needs. So sometimes you can suspect a case of abuse, but they've actually come in with quite serious injuries. So at the end of the day, your main priorities to keeping that patient stable. So treating the injuries as well as keeping them safe. Um So that might involve having them in a safe place where there, where there, where the relative that you're concerned about doesn't have access to them. Um You can get hospital security to help you do this if the relative is being quite combative or anything like that, if you suspect a crime has been committed. So I'm talking sort of case cases of where you suspect sexual abuse or there's evidence in front of you that they've been assaulted or you suspect that then you need to report it to the police as well as safeguarding. So that's important that you do that. So if you suspect a crime is committed, then you need to refer to the police as well as safeguarding. Um, sometimes you're in a situation where you're worried about somebody, they're quite stable medically. They could go home if you weren't concerned about their home situation, but you're concerned about their safety, their general safety, who the person who's looking after them, you're not sure that they're, they're doing it properly and you maybe can't get access to the safeguarding team immediately, but they're still ready for discharge. But in this case, it's always best to admit them or admit them to a place of safety. So sometimes it's just add means emitting them to the medical ward overnight or for a few hours whilst all these checks can be taken into account and more information can be sought. So don't be afraid to admit people just for social reasons. Um So it's important that everything that you've discussed with the patient and your concerns are fully documented in the medical notes. Um You can document your referrals and the time of your referrals, but just important that everything is documented clearly and quite comprehensively because these could be used a later date if, if it turns into a criminal prosecution or the safeguarding teams might use it as evidence that the person is at risk. I said before, it's also important to consider capacity of a patient. So especially in the cases that are a bit that are a bit put more gray, not as clear. If the adult, the elderly person still has capacity, it's important that they're involved in this decision. And this discussion, you can't, you can't automatically um refer them without getting their permission first. So if you do a mental health Act Capacity assessment and talks that talk all the discussion through of them, then that always um leads to start having more information as well as the patient understanding what's going on and can express to you they're wishes of what they want to happen going forward. So I guess that's quite a lot of information. I'm just going to quickly cover as well. So we've spoken about different types of abuse and safeguarding referrals for adults. Um But it's also important to remember that Children can be involved in these as well. The rules, the presentations are different for Children in terms of the nonaccidental injury presentations and things like that. Some of them are similar, but some are different. And also it's important to note that Children don't have capacity. So it doesn't matter about capacity assessment in them, it automatically gets referred to safeguarding whether the child asks for it or not. Basically. So I've, I've split them into two here just to go over it again quickly. If there's an adult without capacity or a child, then if the risk is posed to child under 18 or a vulnerable adult without capacity, you must break confidentiality, break confidentiality, even if they don't want you to and inform social services that's part of our safeguarding rules. If they're not fit to be discharged, then admit them and refer to the safeguarding team who then referred to social services and out of our contact are usually available. And then for adults with capacity, you need to explain to them the risks as you perceive them and what help is available to them. You must encourage them to accept help from you and or allow a referral onwards, safeguarding. However, if they have capacity and they do not consent, you cannot disclose their situation to anyone else or make a referral. So you can document it in the medical notes and you should do, but you can't breach confidentiality if they have capacity. Um Again, if they, if they agree to it and they want help, you can admit them to hospital if they are not safe to go home. Um and you must all this is also really important, even if the parent has, even if the adult has capacity, if you think that another child or vulnerable adult in the household is at risk, then you still need to refer to self teeth guarding for that vulnerable adult or child. Let me know if that's confusing. I mean, that's quite a lot. Just again to summarize if you so always suspect abuse, have a high index of suspicion, use decision aids if required if it's more subtle and involves seniors early treat a medical emergent medical needs. Don't leave the patient alone with a suspected abuser and contact the police. If there's a crime committed, assess the capacity. If it's an adult with capacity, then you need to discuss through what options they have and what they want to do next. If it's an adult without capacity or a child, then they get an automatic referral to safeguarding. Um You can refer to safeguarding teams, social services directly if you wanted to please, if it's a crime and if it's a domestic abuse situation, there's always a local domestic abuse service. So my apologies, I know that's a bit heavy and a bit complicated. But yeah, the general principles is no, no about the safeguarding team who she should refer to and the relevant risk assessments you have to do this is I won't go through this because it's big. But this is when I said you can use a decision making tool. This is one from the uh Cumbria Social Services and they basically, they take a type of abuse. So this is physical and they tell you what things would be cast as high risk and reportable. So this just that gives you information on what sort of things to look out for and what the next steps would be to take. So each, each region has these that you should look at if needed. Okay. So second case, so you in GP for this 1, 35 year old female comes books an appointment saying that she has insomnia. She states that she thinks it is due to troubles in her relationship, but doesn't want to give you any more details. And when, as she is reluctant to allow a physical exam, so this is in the Oscar situation, you obviously need to use all your communication techniques to offer reassurance and reassure about confidentiality and the commitment you have to them as a patient. And then after that, they often open up to you a bit more. Um She allows you to examine her and you notice that she has multiple bruises and then she confines you that her long term boyfriend has been hitting her. Uh And uh so it has been hurting her. And after more asking about the situation, she confirms that they don't live together or have any Children. So it's always important to ask about Children in the household or vulnerable adults in the household because of what I said before that they would warrant their own safeguarding referral. So time for another quiz. So which statement is most correct about the situation? So this is not domestic abuse that it is not happening within the home. You should report it to the police, regardless of the patient's wishes. You have an inclusive talk with the patient about what help is available and what she would like to happen next or as there are no Children at risk, it does not meet the threshold for referral to domestic abuse services a little bit of time to answer and read them. Yeah. Okay. So again you did. Well, it was the third option. So have an inclusive talk with the patient about what help is available and what she would like to happen next. So about it happening within the home. So in this case, the partner didn't live with the patient but they were still partners. So this still clusters, intimate partner violence, it doesn't have to be within the same household for it to still be um domestic violence. You should report it to the police regardless of the patient's wishes. So this is another thing about the patient having capacity. Unless there's a really obvious crime that's been committed, like they've come in with a stab wound or something like that, then that needs reporting. But other than that, if you just suspect that they're in a domestic abuse situation, you have to talk to the patient as long as they have capacity about what next steps should be taken. Um And then, and this fourth question is just wrong because basically anybody can have a refer referral to domestic abuse services. If you suspect abuse, regardless of the situation, the living situation that they're in. Okay. So it's just more, some more stats that are a bit depressing. So one in four woman or one in six men will experience or have experienced domestic abuse in their lifetime of some form, um, 74% of women and sadly, two women are killed a week by current or former partner. So this is in the UK. Um, it's just kind of highlights how, how frequent is. And sadly, as we get a lot access to a lot of vulnerable people in hospitals and in GP practices, we might be the only person that they're seeing or the only time that they can have a moment alone away from their partner to discuss things. So it's important that we are aware of it and know what to do next. So approach to these scenarios for a Noski or yeah, or for your future practice, it's just mostly communication. You've got to reassure the patient offer, supportive environment, tell them about their rights and their confidentiality. Make sure that they know their privacy and their safety. You shouldn't be afraid to ask them flat out about if they're being abused. I think it's easy to want to skirt around it cause it feels quite confrontational and you don't want to scare them anymore. But a lot of the data says that you should just ask people directly about this sort of thing if you feel able to, it's quite obvious but make sure that the potential abuse it is not round. So in a GP, I guess it's more easily controlled because there's a separate room. But in hospital try and get them away out of a far out of a cubicle because obviously you can hear a few que uh, you can hear through the, they're just, sometimes just curtains. So you need to make sure that they're far enough away that the patient feels comfortable that they can talk to you openly. Sometimes it helps if you get a nurse to take the partner away, to ask to discuss something with them or something like that. So, you know that they're far away and the nurse is keeping an eye on them. So every time you do this, you've got to perform a risk assessment for the patient and any Children involved. So you need to think about whether the person you're talking to, is that an immediate risk of harm to talk to them about whether they feel safe if they can go home. And also if there's any Children that they think are at risk or any Children in the household and that will sort of guide how you deal with this later on offer formal support. So I'm talking about referrals to domestic health, domestic violence services and a common thing I think is that you should always assume that they want to leave their partner. I think instinctive, they just want to support them and you want to give that. You feel like you want to give them encouragement to leave and get themselves out the situation. That's not always what people need. Sometimes they just need somebody to listen to them or they need to know where to go if something does escalate. So it's important to communicate properly with the patient and listen to what they're telling you and what they want. Sometimes that's just coming up with risks like plans of Axion if they feel like it's escalating and things like that. Okay. So I'm not going to go through all of this, but this is called the dash risk checklist. So you fill this out with the patient if you suspect that they're at risk of domestic violence or they've told you they are you have the conversation and you fill out this checkbox, this then informs of what to do next in terms of referrals. So I think some of these are pretty obvious, like, do you feel isolated? Is there conflict of a child contact? Are you pregnant or recently had a baby? But it's basically just a long checklist that you can go through. That's the end of it there. And I think an important bit to highlight is that um there's a section for where even if they don't check many of the boxes. Yes, you as a clinician or healthcare professional can still feel like they reach the threshold for being at risk and therefore referral. So the reason we have this checklist is if they check more than 14, yes, is that it generally meets the criteria for what we call a Maric referral and I'll go through American a sep separate, but it's basically a regional committee that, that meets, it's a multidisciplinary team and it meets and discusses the people who are at high risk of domestic violence and sort of progress is in the case and the current situations and they normally meet monthly. So it's more, it's more for the high risk domestic violence referrals. So it stands for the multi agency risk assessment conferences. They're regular meetings of professionals who discuss how to help individuals who are most at risk of serious harm due to domestic violence and abuse. So if they are visibly high risk on the dash risk assessment score, then they can be referred if from your own professional a judgment, but you haven't been able to do a dash risk assessment score, then you can still refer them if you think they're high risk. All the police refer them as well has been reported three crimes from a perpetrator in a 12 month period. So they get a maric referral. You don't need to know too much about it, but it's just good to be aware of. So you know that what the dash assessment actually leads to. Okay. Um Next case, I think I'll go and no somebody's got a question but we I'll go through them at the end if that's okay. So 24 year old male re attends with a complaint of ankle injury and requests that their medical notes be altered. Um After further questioning, the patient reveals, they initially said that they got the injury while playing football and would like to change the history that they sustained the injury whilst at work, they say that this change of history is due to them being in pain at the time of the initial assessment. So what's the next best course of Axion for this patient? So again, somebody's had an ankle injury, they said they got it playing football and then say a week later they came back and said they wanted you to change it to say that it happened at work. So do you want delete the initial notes and complete a new assessment, cross out the initial notes, leaving them still visible and complete a new assessment. Do you leave the original documentation and add an entry stating what the patient is telling you now? Or do you tell the patient? They are lying and you cannot document anything they are telling you. I don't think the quiz quiz things not popping up. There we go. Give you a little bit more time to answer. Okay. So I've obviously made these questions too easy. Well, too good at them. Um Yeah. So leave the original documentation and add a new entry stating what the patient is telling. You think it's obvious you should never delete medical notes or remove them if they're paper. Um You can cross out notes. If you think if you've made a mistake, you can cross it out and date it and sign it but in this situation it wouldn't be appropriate because it wasn't incorrect at the time. That's what the patient told you at the time. Um Tell the patient they're lying and you cannot document anything that they're telling. You said men, although that's obviously could be true, it's probably not the best way to handle it, just annoy them. Okay. So, very quick about medical documentation. Um I think we probably all do this anyway. It's a little bit different between paper notes and um computer systems because the computer systems normally have a proper audit log. So even if you go back and edit stuff, it will still have what's originally there. So there's not really any changing anything but um it's all pretty obvious, but medical notes are a legal document. If you make a mistake, like I said before, you just cross it out with a clear single line and sign and date the amendment so they know who's changed it. Um Can't give any misleading information in the notes and you can't even really leave out stuff. If you think it sort of fits the clinical picture better or anything like that, it needs to be complete thorough and easily, easily read. You can, that's what I said before about the scenario before you can add notes later. So if a patient changes their story or you think a clinical diagnosis changes or investigation gets re reported, sometimes they get amended. It's important to just add in the amendment, you don't need to go back and change anything. It's just a, a chronological order of what, you know, at that time, obviously, they're extremely important for medical legal cases. And I think it's a good habit to get into to always remember that everything that you document is, is legally accountable to you. So just be careful. Um I don't really need to go through this next bit. That's just a jumble it sample of sort of how we document in hospitals. It's obvious stuff just always include the name, your date, the date, the time, the patient's details and what's going on. So the Royal College of Physicians have got standards on general medical record keeping. Um There's quite a lot of them, so I won't go through them. There's 12 of them. Um It's worth looking at because they're quite specific guidance like about where numbers need to, where how many page, like how you need to date and time and keep pages and whether that's continued or a new note and things like that. So it's worth looking at just to help when you start working and to be aware of, but I won't go through them in detail. Now. So in this scenario, in this Osti scenario, we're talking about about the patient who wants to change the medical record, there's obviously comes up with an ethical dilemma of, do you do what the patient is telling you and do you change the medical notes or do you sort of have a bit of a discussion with them about how you can't change them and find out why. And quite often this develops into the, it's some form of them wanting sick leave for some reason. Um, but thinking they can't because they're self employed or something like that. And sometimes they will have a Noski scenario of where you have to fill out a sick note. So, just good idea to be aware of them and what they are in the UK, we call them fit forms and they're standardized in every hospital. So like it's a government document. So it's called the med three form. And it's for any health care professional to fill out. So it used to be just doctors could do it. But now I think pharmacists and some senior nurses can as well. It's not job specifics. Although we always ask them about what job they do. It shouldn't really matter that much because we're meant to be saying generally, are they fit to work? Are they not fit to work? Even if there, I mean, even if they're like a lorry driver and they've had a fit, you can write a form that says that they obviously can't drive, but they could do admin work in the base in the back at the lorry base and things like that. So it doesn't have to be specifically about or they can't do that job because they've got this injury, it can just be more general than that. Um That's what said you can make recommendations. So you basically say whether they're categorically not fit to work at all, like they need to be at home resting or they might be able to turn out to do um specific duties such as light admin work and things like that. They're pretty self explanatory, have to have to fill them out. Um Also for the clinical scenario is important to know that statutory sick pay in the UK is available for zero hour contracts. If you don't know what that means at all, I apologize. I'll try to explain it quickly. Basically, a zero hour contract is, it's one way you're working, but you're not guaranteed any number of hours. So basically at any time, the employee can be like, I want you to do eight hours today and then the next hour you could do the next day. They would not want you to do any hours. And quite often they didn't, they didn't used to come with any sick pay entitlement or anything like that, but that's changed. And as long as they're working sort of consistently and earning a minimum out a month, even if they're on a zero hour contract, they're still entitled to sick pay. If you're unsure about this stuff, when patient's are asking you questions about it, just refer to get them to seek advice from the Citizen's Advice Bureau. It's called and they're the people who, um, give advice to people about sort of sick pay and their entitlement and all that sort of stuff. But as a doctor it doesn't matter if you think that they couldn't work, you can fill out a fit form. A person can self certify for seven days. So if they say they think they're only going to be off work for five days, you don't need to do a form. You can just tell them to self certify for that amount of time. If they want it after that, then it has to be a medical professional to give them the form. Okay. That's a bit of a dry one but still worth knowing about how we do. So case four. So you're working in a medical specialty ward alongside an F one doctor, a medically fit patient is very angry and as recently complains that they have been awaiting discharge documentation and take home medications for several hours and it is delaying them from go hurt from going home, discuss the situation with the F one doctor. I think this one obviously leading you into having a conversation with your colleague about sort of uh not being able to deliver what's expected of us as junior. So obviously, it's kind of ham hammered into us that we need to be doing discharge documents in a timely manner so that the whole flow of the hospital can work properly. So in this scenario you're just about approaching a colleague and finding out what the issue is seeing if you can help them with that and just being sort of open and supportive with your team. Sometimes in these situations after you dig around a little bit, something else comes up and that gives you a situation to deal with that as well. So in this case, the F one reveals to you that they're extremely burnt out, they're not coping with their job and their feeling depressed. Um And because of this, they're struggling to keep up with their clinical duties such as their documentation and they're doing the discharge letters on time and things like that. So this is about challenging situations in the workplace. So in this case, we're assuming that the sort put, this is sort of a similar level to use their still a junior doctor, you might be a year or two more senior some, but there's still a similar level if able to. So if you've got capacity, you can say that you'll help them with their duties. So if, if you've got time, then you can help them do their discharge letters and support them with the actual general running of the ward, if there's no capacity for that. So if you're also run off your feet or you're also not managing to keep up your commitment, that it's important that you, this is a patient safety concern and you recognize that you escalate it immediately either to your registrar or your, your, your consultant who you're under. So they are aware of the situation and they can sort of chip in or pull people from other specialties. If they need to explore for all these situations, when you're talking to a colleague about difficult scenarios, explore their concerns, the reasons why this is happening and offer support the best that you can. There is I'll go through in a second how you escalate stuff like this. So how if you're struggling as an individual, how you escalate it or if somebody else is struggling and you don't think they are escalating it, but it needs to be escalated how you go about it. I think it's good practice that you always encourage the person you're talking to, to escalate it for themselves. So it's so they talk to their supervisor rather than you talking to their supervisor about them because that obviously creates a complication amongst your dynamic as colleagues. And I think being supportive in helping them escalate it themselves is always going to be a better outcome for everybody. Um You can sign post people to places of support. So we've got occupational health departments in every hospital and they've got health and well being services. So if you're if you yourself are struggling or if you notice that one of your colleagues are struggling with anything like burnout mental health issues, um any alcohol or drug issues that get flagged up, you can, you can refer them or often tell them that they can get support from these places. Obviously, the next, the next people who need to be aware while still keeping people's confidentiality as much as you can is educational and clinical supervisors as well as the consultant on duty that day. So this is just about the, I went through last time I did one of these in the first Ethics lecture. I went through the GMC Good clinical Practice and they've got a whole domain for communication, partnership and teamwork. So even within our portfolios, when we were in specialty training, I've got a whole learning outcome about challenging, dealing with challenging scenarios and workplace encounters. So it's something that you need to be aware of is going to be a part of your medical education and your job throughout and something that is sort of formally reflected on. I just wanted to point that out. Actually, I have to put something there. This is important as well as that patient safety is always the primary objective of these encounters. So it's important that even though you're exploring your colleagues concerns and worries and everything like that, if there's a patient safety concerns such as they're not going to be enough doctors or you're worried that your colleague is using substances or anything like that, then it has to be a patient safety concern first and be escalated accordingly. So this is about, this gets off asked quite a lot on when you do situational judgment tests for your exams, they ask for your specialty recruitment exams. They ask you who you should escalate things too in certain situations. And it's just good to have a general idea. So this is for a training doctor. So all junior doctors, um you have you initially as a trainee and then obviously you've got the people you can turn to, to support for your own issues such as your GP colleagues, peer support or the occupational health department and things like that. Health services above you, you've got your supervisors. So this includes your the consultant who's in charge for you that day. So they're in charge that day that if you have any concerns, you can escalate it to them. But also generally you have your clinical supervisor who is usually who's usually your supervisor for all clinical things to do with that specific placement and your educational supervisor who more overlooks your general training and your educational needs. So you have those three people at any one time that you can escalate things to above that is depending on what training program you're in. There's a training lead. So in foundation program, there's the foundation program director or in the other training programs as a training program director. So they oversee all the training for a region and they would be the next tier up and then the final tear up would be sort of the deans and associate deans and heads of schools for your specialty or for your training. So if you're not getting the help from your educational clinical supervisor, you can go up to your TPD. If you feel like that's not working or you're not getting what you need from them, then you go a step higher and then there's all these different services on the side of this thing here such as occupational health hr health and well being services. So just it's mostly just the educational supervisors, TP Deeds and then Dean's heads of schools that you need to know about. Okay, so this is another question for most professional situations that you encounter, which is the most appropriate escalation path. So this is just what I covered just now. Okay. Okay, most of your right first consultant on duty, clinical supervisor, educational supervisor training program director. So the second option, depending obviously on the scenario, these might change a little bit or if any of those people are involved in the scenario that you're concerned about. For example, sometimes they, they have a rosky situation where like you, you suspect that your clinical supervisor has been drinking and obviously, then you'd skip that as an option and go straight to a different consultant. But in general, that's the, that's the thing. Okay. Final case, I'll go through this quite quick. We're running out of time a little bit. So 58 year old male presents with sudden loss of consciousness at home and was found to have a massive intracranial hemorrhage. He was previously fit and healthy and has a guarded prognosis. So they think that he's unlikely to wake up. How would you discuss this with the next of kin? That's just for you to think about. And here's a specific question at what point is the most appropriate to refer to the organ donation team? So is it only once the patient has been declared as brain dead, once the family has given consent for organ donation, once organ support has been withdrawn. So such as when ventilators have been turned off or filters have been turned off or something like that or as early as possible, if the patient has likely brain deft which is absent, cough, reflex on suctioning or fixed dilated pupils. Yeah. Okay. So most of you got the rights, the fourth option as early as possible, you meant to refer so that things can be considered the first one. So by the time the patient has been declared brain dead, it's normally a little bit, you can, you could still refer them. But by that point, it's normally a bit late. These things take a couple of like a like a little bit of time to sort out. And the organ donation teams, it's not an automatic sort of you refer them and they automatically become organ donors. It's, there's a lot of talking with the family and sort of consent and things like that, that go into it takes as much time as it will take. Basically. So as early as possible as best um once the family is given consent for organ donation, so it doesn't necessarily have to be you as the doctor who gets consent from the family. That's something that I wasn't aware of before I started working on a bit of itu is that you can actually refer to the organ donation teams and then they get the consent, they prefer it that way normally. So they can be involved in the conversation. So this is another as well as the questions about organ donation. This is about breaking bad news in a Noski situation. Um And one of the Pneumonic sui use for this is spikes. So settings, perception, invitation, knowledge, emotions, and pathway and strategy and summary. So I'll go through those briefly, but it's worth looking up because it's a really useful tool so that you sort of approach these in a, in a way that feels like it's got some structure because they can obviously get quite emotionally heated and it's nice to have a structure to go back to. So setting, make sure that it's always inappropriate space such as a quiet private room. It's obviously sometimes difficult in A and E but for our skis, that's what you want, that's what you want. Quiet and private room. Um make sure you have comfort stuff available. So tissues, some water, that sort of thing and always check who's there. So you can ask people if they prefer to have a family member or a friend there. Um for support perception. So this is where you explore what the patient understands or what they're expecting to happen. So you can say I have the results here today. Would you like me to explain them to you now? Um So the new, it's sort of as well as knowing what's going on. It allows allows you to assess what, what the patient understands. So invitation, that's kind of the same as before, the same phrase. Yeah, this is a warning shot. We call it. So you got to ask people and that's the warning shots. The next one, sorry, I'm getting a bit muddled up with these slides anyway. So the invitation is you got to ask people what if they want to hear bad news because if it's about the person you're talking to. So if you're telling a patient that they have got cancer of some sort, something they might not want to know and they have the right to not want to know. So you ask them, um, you ask them what, like how much they would like to be divulged and whether they want to hear the results now, whether they want to hear them later with family members, that sort of thing, that's all their decision. Now, this is the warning shot. So knowledge, so we can start with a statement saying as you know, we took a biopsy, unfortunately, results were not as we hoped. So that short statement, it sort of allows the patient to know that you're leading into something that's a bit distressing. But without giving them so much information that it doesn't give them time to react. At that point, they can say actually, I don't want to hear anymore until my family members here or something like that. So, emotions and pathway so recognize and respond to the motions with acceptance, empathy and concerns, important to not lie or give false hope. Um And this is especially true for our skis. If you don't know yet the questions, the answer to the questions that they're asking you, then just tell them that you don't know and that there'll be more a more appropriate person to discuss that with you. So you can reassure them that says, I actually don't know the answer. But what I'll do is I'll get in touch with your consultant oncologist and we'll discuss that further and I'll get them to come talk to you that sort of thing. So strategy and summary. So this is the final step in spikes, make a plan together and inform them of what the next steps are including specialist referrals. So it's a good opportunity to sort of summarize everything that you've discussed briefly check their understanding. So you can get them to repeat it back to you if you want. And decide together what plan is best to take next. So who they need to be referred to and what further information they would like to know. Yeah, sorry, I got a bit confused on that but spikes is a really good thing to look into a bit more in practice using. So I just wanted to finish off with organ donation. So we had that question about it before and it is a little bit of confusing topic because um the laws that we have in the UK are slightly different to a lot of other places. So in the UK, the reason is quite recent that this has changed, I think in 2020. Um but we've turned into an opt out system. So now anybody who's over 18 and has capacity is technically an organ donor, registered organ donor unless you decide to opt out. So if you as an adult decide you don't want to be an organ donor, it's your responsibility to go and let people know there's a government website where you, where you specifically opt out. So that's sort of changed it from where people would sign up to be an organ donor. Now, you have to sign up not to be an organ donor. So technically, there's a lot more organ donors in the country now. Um in reality, the way that we approach this in hospital is still pretty much the same. So we don't just cavalierly say two families that what it doesn't matter what they think about whether they're relative was an organ donor or not, they didn't opt out. So they are an organ donor. There's a lot more, still sort of emphasis put on what the person would have wanted. But in general, I think it's meant to open things up so that you have the, you have sort of the baseline that everybody is an organ donor. I think it's shown that it increases how people feel, how confident people feel with their family members, organs being donated in the first place. So basically anyone, anyone can potentially be an organ donor, sort of regardless of age or, or anything like that, except there's only four things that sort of completely contraindicate. It is um Creutzfeld Jakob Disease, Ebola, active cancer HIV. So they quite often like to ask that on multiple choice questions, which one cannot be an organ donor? And they're the only four that can't, obviously, there's a lot of other considerations that are put into this. So even though some people might not have those things, they might still not be an appropriate organ donor, but there are the only complete contraindications. Um It's usually considered as part of the end of life care planning. So most frequently, this is something we deal with on intensive care. And it's patient's most frequently for patient's who've had catastrophic brain injuries with the absence of one or more cranial nerve reflex such as and the GCS of four or below. So, cranial nerve reflexes, like I said before, it's like if you do suction on the endotracheal tube and they're not coughing or they've got fixed and dilated pupils or lack of corneal reflex, then it's a sign that think the prognosis is not good if that's not the criteria for complete brain death, but it's a good indicator that they're not going to do well or the intention to withdraw life sustaining treatment um is expected. So for that, it's not sort of so much as a brain injury, but a different thing that's causing them to be very unwell and the withdrawal of that treatment is likely to cause death. So they're the two situations we do it in, there's always an organ donation team. So like I said before, the earlier that you can refer to them, the better they have in my hospital, they have a policy that they would like to be referred. Everybody who is 85 and under who has been considered for end of life care. Obviously, in a lot of those cases, I mean, you as a physician know that that person is absolutely not going to be fit for organ donation, but it's still a standard that they like to keep. So we refer and then they do the assessments and decide whether they'd be fit for it. Um It's much more common than I see you, but in a lot of medical words, you do the referral and there's really, um there's not much, there's not much that could be donated in lots of people. But it's important to know who you can refer. Um You can as the doctor, you can approach the topic with the family and explore the wishes that the patient would likely like. It's always good to mention it. But at that point, you can do a referral right away and get the organ donation team involved. So this is from, these are the nice guidelines. They're a little bit older, but they're still quite good early identification of potential donor. So the following criterias that I spoke about is the donation after brain stem death, which normally to do a big intracranial injuries or hemorrhages and lack of reflexes or somebody who is critically unwell and is likely to die if you withdraw organ support. So that's donation after circulatory death, refer the patient to the organ donations, referral line which are called snobs. Um then you clinically stabilize the patient in an appropriate critical care setting. And whilst the assessment for donation is being performed, this is why most organ donations come from intensive care because it's the only way you really have the ability to keep people who are dying alive for a period of time that can be considered um provided that delays in the overall best interest of the patient life sustaining treatment should not be withdrawn or limited until the patient's wishes around organization have been explored and the clinical potential to donate has been assessed in accordance with legal and professional guidance. So that's about, yeah, that's the organ donation sort of guidance that we have that we use in our trust like.