450 SBAs in Clinical Specialties - Research, Ethics and Clinical Governance Flashcards Preview

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1. Consent and the Mental Health Act

A 32-year-old woman with paranoid schizophrenia is admitted for antenatal assessment at 36 weeks’ gestation with twins. Her pregnancy is complicated by intrauterine growth restriction and impaired placental flow. She has had no psychotic symptoms in this pregnancy. Her obstetricians recommend an early caesarean section and argue it is in the best interests of the mother and her babies and to prevent further fetal insult. She has repeatedly said that despite the significant risks, which she understands, she refuses caesarean delivery. What is the most appropriate action?

A. Detain under Section 5 of the Mental Health Act and deliver by caesarean section

B. Detain under Section 2 of the Mental Health Act and deliver by caesarean section

C. Determine that the patient lacks mental capacity and, acting in her best interests, delivery by caesarean section

D. Determine that the patient lacks mental capacity and, acting in her fetus’ best interests, deliver by caesarean section

E. Encourage volunatary admission to the antenatal and repeatedly explain the benefits of caesarean delivery

E. Encourage volunatary admission to the antenatal and repeatedly explain the benefits of caesarean delivery

1 E Demonstrating that ethics and law are truly alive in obstetrics and gynaecology, this case is drawn from the one author’s own experience (modified to protect confidentiality). There are two principal issues: one, the ethics and legality of treating a patient detained under the Mental Health Act and two, acting in the best interests of a patient who lacks capacity. It is not lawful to detain someone under the Mental Health Act for treatment of any disease other than a psychiatric condition. Therefore options (A) and (B) are incorrect. Section 5 orders are emergency holding powers to detain patients who are already inpatients and for whom there is no time to apply for another more appropriate detention order. Section 2 orders are usually used for patients in the community who require detention in hospital for assessment, although in practice they may also receive treatment (for the disease necessitating detention) as part of an assessment. In this case, the patient has not shown psychotic symptoms and it is unlikely that she would require formal admission. Options (C) and (D) imply that the patient lacks capacity. The question makes clear that this patient: (1) understands the information she is being given about risk, (2) retains the information, as she is repeatedly refusing care despite understanding the consequences of waiting, and (3) can weigh that information in the balance and communicate her choice. These three tests are met and the patient has capacity to make the decision about caesarean section. A patient with capacity can refuse treatment, even if that decision is irrational or against the advice of family or friends. The only option left is for the clinician to encourage engagement with the care team and recommended plan (E). She may require treatment – perhaps under detention – for the schizophrenia, but formal admission for this might deter her from accepting advice from all doctors and therefore reduce the likelihood of her accepting a caesarean section.

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2. Consent

Which of the following would be incorrect advice to give a woman requesting a caesarean section for non-medical indications?

A. You are twice as likely to have a stillbirth in a subsequent pregnancy

B. The risk of damaging the bladder is one in 20

C. There is an increased risk of placenta praevia in future pregnancies

D. 1–2 per cent babies suffer lacerations

E. The risk of infection is 6 per cent

B. The risk of damaging the bladder is one in 20

2 B The 2009 Royal College of Obstetricians and Gynaecologists’ caesarean consent guidelines provide guidance on how to counsel a women undergoing emergency and elective caesarean delivery. The only incorrect answer here is (B). The risk of damage to the bladder is one in 1000: it is highly unlikely that caesarean section would have become accepted modern day obstetric practice were there a risk that 5 per cent of all women had iatrogenic bladder injury at operation. Other risks include venous thromboembolism (4–16 in 10 000), significant haemorrhage (≈five in 100) and the need for hysterectomy (eight in 1000).

The risk of death for caesarean section is around one in 12 000.

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3. Ethics of life-saving care

A 24-year-old Jehovah’s Witness is brought to accident and emergency with a Glasgow coma scale (GCS) score of 3, BP 90/30 mmHg and pulse 110 bpm. Her husband reports that her last menstrual period was 8 weeks ago and she complained this morning of lower abdominal pain and vaginal spotting. Ultrasonography suggests a ruptured ectopic pregnancy. As part of the resuscitative measures employed before emergency laparotomy, a transfusion of group O-negative blood is prepared. Her husband interrupts and says that as a Jehovah’s Witness she would absolutely refuse all blood products even at risk of death, and has previously signed an advance directive stating this. What is the most appropriate option?

A. Avoid transfusion and volume-replace with colloids before emergency transfer to theatre

B. Avoid transfusion and use a Cell Saver auto-transfuser in theatre

C. Avoid transfusion and immediately transfer to theatre

D. Stabilize the woman in accident and emergency before transfer to theatre

E. Transfuse the woman with group-O negative blood and immediately transfer to theatre

E. Transfuse the woman with group-O negative blood and immediately transfer to theatre

3 E There are two principal ethical issues here. First is the concept of best interests in relation to a patient who is unable to consent themselves (in this case due to unconsciousness), and second is the idea of advance directives. This woman has been brought to accident and emergency in a life-threatening condition. It is likely that the transfusion of blood would be part of life-saving management of her condition. In an emergency, patients must always be given life-saving treatment unless they have made a valid advance directive declining such treatment. To be valid, an advance directive must be viewed by the treating clinician, signed by the patient who had capacity to make the decision at the time of signing, and be witnessed. The advance directive is not present in accident and emergency in this case, nor is there evidence of any discussion with her treating clinician. Therefore, in this case, a normative assessment of the patient’s best interests would err on the side of giving life-saving treatment, e.g. blood (E). Given this is the case, avoiding volume replacement entirely (B, C) or delaying surgery by filling with colloids in a patient with catastrophic haemorrhage is inappropriate. Anaesthetists are unlikely to be willing to anaesthetize an unstable patient without preoperative resuscitation (C).

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4. Abortion care ethics

An unbooked 26-week pregnant woman sees you at the hospital to request a termination of pregnancy. She says that if she leaves here today without a termination she will try and do it herself by stabbing her abdomen. Your consultant arranges an urgent psychiatric review which finds no grounds under which to detain this woman in regards to her mental health. Under these circumstances, if a termination was performed, which part of the Abortion Act would it fall under?

A. The continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated

B. The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman

C. The pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman;

D. The pregnancy has not exceeded the continuance of the pregnancy and would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing child(ren) of the family of the pregnant woman

E. There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

B. The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman

4 B Straight away answers (C) and (D) are not appropriate as they refer to pregnancies under 24 weeks. Answer (E) is not appropriate. If the child was born at 26 weeks there is a risk that it would have abnormalities but that is no different to any other case. Answers (A) and (B) seem to be the most appropriate. The psychiatrist is happy that she has capacity and is not suffering from any mental illness. You could argue that if she went home and stabbed her abdomen her life would be at risk. You could also argue that if she went home and carried out her threats this would have long-term effects on her mental health and possibly on her physical health. For this reason section (B) is probably more appropriate. This case is an ethical minefield. A lot of doctors would not be happy terminating a healthy fetus after 24 weeks. Theoretically, a termination is possible throughout pregnancy if the criteria on the Abortion Act form are met.

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5. Ethics in obstetrics

A 24-year-old woman in her first pregnancy presents to the labour ward in labour. She and her partner express an overwhelming desire to avoid a caesarean section. Her labour does not progress and after 9 hours her cervix is still only 3 cm dilated. Unfortunately, the fetal heart slows to 60 beats and does not recover after 5 minutes. Your senior registrar explains the situation to the woman and recommends an immediate caesarean section. She refuses and her partner tells you to stop harassing them. You explain that their unborn child will die if this continues. What options do you have?

A. Caesarean section under general anaesthesia (GA) under Section 3 of the Mental Health Act

B. Caesarean section under GA under Section 2 of Mental Health Act

C. No action. Allow fetus to die

D. Caesarean section without Mental Health Act application

E. Caesarean section under GA under Section 5(2) of the Mental Health Act

C. No action. Allow fetus to die

5 CThe Mental Health Act does not provide legal justification for operating or providing treatment for a woman who has capacity but who declines on that treatment. There is nothing to suggest that this woman lacks capacity. Section 2 (B) is a 28-day section that allows a period of admission for assessment. Section 3 (A) allows up to 6 months of detention for treatment. Section 5(2) (E) is a temporary holding order that lasts for 72 hours in which time a patient can be assessed for Section 2 or 3. It can be exercised by the doctor in charge of the patient’s care or ‘his nominated deputy’, which in practice refers to any hospital doctor attending a patient. It would, of course, always be prudent to involve the patient’s consultant with such decisions. It only refers to patients who do not have capacity. Even if you have to watch this fetus die it would be legally unjustifiable to perform a caesarean section without consent. Options A,B, D and E would amount to a battery and would put the doctor at risk of criminal prosecution.

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6. Ethics in gynaecology

A 16-year-old Muslim woman attends accident and emergency department with her father. She complains of a 1-day history of left iliac fossa pain and mild vaginal spotting. A urinary beta hCG test is positive. As part of your assessment the patient consents to a vaginal examination. She insists you do not tell her father that she is pregnant, and you consider her to be competent in her judgement. Her father becomes angry and says you must not perform a vaginal examination. How should you proceed?

A. Perform the examination with a chaperone present and tell the father that it is a routine examination

B. Perform the examination with a chaperone present and explain that parental consent is not necessary in this situation

C. Defer performing the examination and document the situation fully

D. Perform the examination with a chaperone present having assessed the girl’s Gillick Competence

E. Perform the examination with a chaperone present having assessed the girl’s Fraser Competence

B. Perform the examination with a chaperone present and explain that parental consent is not necessary in this situation

6 B The patient is 16 years old, and may therefore be considered competent, in which case parental consent is not required to perform any procedure or examination (B), although it is always preferable to have family members on board. Not performing a necessary clinical examination for a consenting patient would be negligent (C). You must respect the young woman’s request to maintain confidentiality regarding her pregnancy, so (A) is incorrect. Gillick competence (D) is irrelevant here, as the patient is 16 years of age and competent. Fraser Guidelines (E) are a result of English case law and originally related to the legality of a doctor to provide contraceptive advice to minors without parental knowledge. The Fraser Guidelines do not apply to those over the age of 16. A female chaperone should always be present for intimate pelvic examinations, regardless of the gender of the examiner.

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7. Ethics in the emergency setting

A 32-year-old woman is rushed to accident and emergency as the viction of a high speed vehicle collision. She is 35 weeks pregnant and unconscious. There is evidence of blunt abdominal trauma and she is showing signs of grade 3 hypovolaemic shock. The consultant obstetrician on call immediately attends the resus call and recommends immediate perimortem caesarean delivery in a resuscitative effort to improve the management of her shock. Her husband has been brought into resus by the police, and insists that she would refuse caesarean section under any circumstances. What is the most appropriate management?

A. Rapid fluid resuscitation until the situation regarding the patient’s wishes becomes clear

B. Replacement of the lost circulating volume with blood products

C. Admit to the intensive care unit and begin infusing inotropes to restore the cardiac output

D. Immediate caesarean delivery

E. Resucitation and transfer to the obstetric theatre for emergency caesarean delivery

D. Immediate caesarean delivery

7 DIn this case, the wishes of the husband are largely irrelevant. The patient is in a life-threatening condition and lacks capacity due to unconsciousness. In such circumstances, life-saving treatment must be given if it is in the patient’s best interests as judged by the attending clinician. This woman is likely to be bleeding into her abdomen from a ruptured viscus: she is gravely ill and close to cardiac arrest. A young woman can compensate significantly for blood loss, and the fact that she has significant signs of hypovolaemic shock indicates the likely massive loss of circulating volume. Replacement with fluids (A) or (B) will not stop the haemorrhage, though they will buy time. Transferring this peri-arrest patient (E), even to ITU (C), is unwise as she may arrest en route, for example, in a lift, where facilities are not available. In addition, inotropes may increase the cardiac output but they do not compensate for the lack of circulation caused by continuing haemorrhage. A senior obstetrician here has advised that delivery of the fetus in accident and emergency (D) would help with her resuscitation. Perimortem caesarean section is usually performed as a means of saving the life of the mother rather than the fetus. The gravid uterus reduces venous return and therefore preload on the heart, in turn reducing stroke volume and cardiac output. Moreover, the placental oxygen requirement is huge and reduces the ability of what little circulating volume she has left to perfuse her vital organs. Perimortem caesarean would remove these obstacles to effective resuscitation of this critically ill trauma patient. It is usually performed through a midline incision: such an incision would also then give access to the abdomen for a general surgeon to perform a trauma laparotomy.

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8. Valid consent

A 59-year-old woman has been admitted for a hysterectomy for endometrial cancer. She has not yet given her consent and the rest of the team is in theatre. You have performed a hysterectomy before so feel confident in taking her through what will happen and the risks involved. The General Medical Council (GMC) says that you should tailor your discussion to all of the options except which of the following?

A. Their needs, wishes and priorities

B. Their level of knowledge about, and understanding of, their condition, prognosis and the treatment options

C. The onset of their condition

D. The complexity of the treatment

E. The nature and level of risk associated with the investigation

C. The onset of their condition

8 CThe GMC have published extensive guidance about consent, in particular how to inform someone appropriately when asking for their consent. All of the above apart from (C) are crucial in relation to consent. (C) should read ‘the nature of their condition’. These are five very useful pointers to remember when asking for consent, even verbal consent for a blood test. Assess the patient’s understanding (B) of their disease, which enables the gynaecologist to tailor further information, and language, to the patient’s needs and can augment the patient’s understanding. Discuss a patient’s needs, wishes and priorities (A), which involves the patient in their care and allows them to take a lead in its direction. Explain the complexity of the treatment (D) and the risks associated with it (E), which is vital for consent to be valid: without the above the patient may be successful in proving in a court of law that they had not been properly informed in relation to the procedure.

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9. Improving patient care

A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. This is an accepted definition of what?

A. Audit

B. Clinical governance

C. Clinical research

D. Clinical effectiveness

E. Integrated governance

A. Audit

9 A This is the National Institute for Health and Clinical Excellence (NICE) definition of audit. Audit is an integral part of NHS care, allowing clinical and non-clinical staff to evaluate what they are doing and bench marking it against the best care possible. Clinical governance (B) is an umbrella term that can be defined as a framework through which NHS organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. Audit is part of this, along with research, education and risk management. Research (C) is a process to answer a clinical question. At its heart is the scientific method: a method of enquiry based on examining measurable evidence that can be tested. Integrated governance (E) is a term that refers to the combination of clinical and corporate governance. Clinical effectiveness (D) takes clinical research a step further by examining not only whether a particular intervention works but whether it is useful, acceptable to the patient and represents value for money.

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10. Paediatric and adolescent gynaecology

A 15-year-old girl attends the gynaecology clinic with her boyfriend, also 15, requesting the morning after pill 4 months after being circumcised during a family trip to Somalia. She understands your advice and the implications of her decisions to engage in sexual activity, is using condoms regularly and refuses to inform her parents. What is the most appropriate management?

A. Decline to prescribe the morning after pill and refer the patient back to her GP

B. Decline to prescribe the morning after pill, and inform her parents that she is having underage sex

C. Prescribe the morning after pill, give contraceptive advice and recommend that the girl informs her parents

D. Prescribe the morning after pill, give contraceptive advice and immediately alert your consultant and the Safeguarding Children Team

E. Prescribe the morning after pill, give contraceptive advice and inform her parents

D. Prescribe the morning after pill, give contraceptive advice and immediately alert your consultant and the Safeguarding Children Team

10 D There are two significant issues here: a patient under 16 years requesting contraception, and her circumcision. The girl meets the Fraser Guidelines for giving contraceptive treatment or advice to those under 16: she understands the advice; she cannot be persuaded to tell her parents; she is likely – given that she has a boyfriend – to continue having sex and her health will suffer if contraceptive treatment is not provided (pregnancy is inherently more dangerous than non-pregnancy). Prescribing the morning after pill is an appropriate correct course of action, so (A) and (B) are wrong. Informing her parents would be a breach of confidence and is not permitted under the GMC’s Good Medical Practice, so (E) is incorrect. Both (C) and (D) would be correct, but only (D) takes the further action that would be required given that she has had a female circumcision* abroad, a serious offence in the UK, contrary to the Female Genital Mutilation Act 2003.