Block 11 Flashcards
(167 cards)
1
Q
3 factors to be taken into account in reproductive ethics =
A
- Parents
- Future or existing children
- Third parties (e.g. the state)
2
Q
What autonomy to parents have?
A
Procreative autonomy
3
Q
Procreative autonomy =
A
Parent’s wishes regarding reproductive choices should be resepected with minimal interference from the state.
4
Q
What can override procreative autonomy?
A
Interests of future children
5
Q
ART =
A
Assisted reproduction technologies.
6
Q
Definition of ART =
A
Any treatment involving in vitro handling of human oocytes or embryos for the achievement of human pregnancy
7
Q
Arguments for ART
A
- Procreative autonomy
- Psychological health of parents
- Welfare interests
8
Q
Arguments against ART
A
- Involves destruction of embryos
- Harmful to parents: disappointment, risk of multiples
9
Q
What are the restrictions to reduce the number of multiple pregnancies with ART?
A
<40 - 2 embryos
> 40 - 3 embryos
10
Q
What do we mean by ‘interests of future children’
A
If, as a result of being concieved, a child is likely to suffer serious physical or mental harm, then it would be hard to justify ART in child’s best interests
11
Q
What Act includes ‘welfare cirterion’
A
Human fertilisation and embryology act
12
Q
What is a welfare criterion:
A
A woman shall not be provided with ART unless account of future childs welfare has been taken
13
Q
Criticisms of welfare criterion:
A
- Fertile couples don’t have to meet this
- Research shows father isn’t needed - ammended
14
Q
Fertile couples don’t have to meet the welfare criterion, what is the counter argument to this?
A
- Maybe they should
- Difference to between positive and negative rights. Don’t have the +ve right to conceive without state if state is helping.
15
Q
What argument is used against selection of embryos with disabilities?
A
Right to an open future
16
Q
Right to an open future =
A
Choices should be make to ensure child will have maximally open future.
17
Q
3rd party interests in ART =
A
- ART is expensive
- Child may place high burden on state
18
Q
What does NICE recommended for women between 23-39:
A
Up to 3 IVF cycles funded on NHS
19
Q
PGD =
A
Pre-implantation genetic diagnosis
20
Q
Less contentious use of PGD:
A
Screen for genetic abnormalities like CF
21
Q
More controversial use of PGD:
A
Sex-selection
Desirable traits
Survivor sibilings
22
Q
MRT =
A
Mitochondrial replacement techniques
23
Q
Positives of MRT
A
Health benefits to child
Benefits to parents
24
Q
What act allows termination of pregnancy?
A
The abortion act (1967) - 1990
25
Abortion is legal if:
- 2 docotrs
- <24 weeks
- Risk to mothers life
- Risk to mother physical or psychological wellbeing
- Risk of child suffering from serious physical or psychological handicap
26
GMC on conscious objection:
Respected, provisions need to be made. Refer, don't obstruct. Must in an emergency situation
27
York IV criteria:
- 28-42
- 2 yr stable relationship
- 2 yr unprotected sex
- BMI 19-29
- No smoking for 6 months prior
- No other children
28
Why are young people particular vulnerable?
- Vulnerable to harm
- Rely on others for care
- Communication issues
- difficulty accessing services
29
What does the GMC say about young people
They are individuals with rights that should be respected. Should listen and take into account what they have to say. Respect their decisions and confidentiality.
30
Making treatment decisions: children <16
- If child is Gillick competent, can consent
- If child isn't competent, someone with parental authority can consent
- If parent won't consent to childs best interests, court or treat in an emergency
31
Those with parental responsibility have a legal obligation to:
Act in child's best interest
32
Gillick competence refers to what age
Children under 16
33
Gillick competence:
The parental right yield to the child’s right to make his own decisions when he reaches a sufficient understanding and intelligence to be capable of making up his own mind on the matter requiring decision
34
Fraser guidelines refer to
Contraception/STIs/Sexual health
35
What are the Fraser guidelines:
- Understand all aspects of advice and implications
- Cannot be persuaded to tell parents
- There is risk of physical or mental harm without
- In patients best interest to recieve advice without parental knowlege
- Likely child will have sex with/without advice
36
Young people aged 16-17 consent:
- Assumed competent to consent to treatment
37
If someone under the age of 18 refuses treatment =
Allows treatment is consent from parents or court
38
Why are parents generally allowed to make treatment decisions for children?
Parental autonomy
39
Parental autonomy =
Assumption that parents know children the best (best interests) and will be motivated to act in best interests
40
Can parental autonomy be overruled?
Yes - e.g. Charlie Guard
41
Arguments for compulsory immunisation:
- Harm principle
| - Bring about public good
42
Arguments against compulsory immunisation:
- Parental autonomy
| - Risk harm (side effects)
43
Who described the harm principle?
Mill
44
The harm principle (Mill) =
The harm principle holds that the actions of individuals should only be limited to prevent harm to other individuals.
45
How does the harm principle relate to childhood immunisations?
- Prevents harm to others
| - Prevents more harm than it will cause
46
What does, as present, the BMA recommend in regards to compulsory immunisation?
Inform and educate patients
47
Confidentiality and children =
Doctors owe children obligation of confidentiality. This isn't absolute
48
When should you share info in regards to child's sexual health?
- Young person too young/immature to understand
- Disparity in age/power
- Position of trust - teacher, healthcare worker
- Threat, force, pressure
- Drugs or alcohol
- Partner known to police/child protection
49
Medicalisation =
Process by which human conditions and problems come to be defined and treated as medical condition
50
Childbirth is becoming increasingly
Medicalised
51
Tokophobia =
Psychological condition characterised by extreme fear of childbirth or pregnancy
52
Are all vaginal deliveries natural?
No
53
'Normal' labour occurs with
- Spontaneous onset and vaginal delivery
- Low obstetric risk
- Sequential nature
- Progressive cervical dilation and effacement
- Progressive urterine contractions which are regular
54
'Normal' labour occurs without
Induction
Instrumental assistance
Surgical assistance
Epidural/spinal/general anaesthesia
55
Social model of birth =
Aim for increased choice and greater control of own labout.
56
Birth rate/trends
Declining
Older mothers
More single parents
More mothers in work
57
C-section rate
25% of births
58
Name a mode for the active management of labour:
O'Driscoll's model
59
O'Driscolls model for active management of labour:
- Diagnosis at 2cm
- ARM (artificial rupture of membranes)
- 2 hrly vaginal exam
- Syntocinon if slower than 1cm/hr
- Personal nurse
60
What did O'discolls model do?
Increased rate of spontaneous vaginal births
61
What was the most important factor in O'Driscolls model?
Personal nurse
62
What influences a woman's 'choice' in birth?
- Media
- Stories from family/friends
- Fear of unknown
- Fear for safety of body or baby
- Perception of the birth process
63
Examples of high risk pregnancies =
```
Psychiatric disorders
Multiple pregnancies
Prev PPH
Borderline DMI
HIV/AIDS
Groups B Strep
Blood disorders: sickle cell, thalassemia
High Bp
Lupus
Maternal age >35, teenage
Thyroid disease
Diabetes (type 1, 2 and gestational)
Alcohol/smoking/substance abuse
```
64
Fergurson reflex =
Fetal ejection reflex. Neuroendocrine reflex comprising the self-sustaining cycle of uterine contractions
65
Fergurson reflex is initiated by
Pressure at the cervix or vaginal wall
66
3 things highlighted in Maternity matters (2007) -
- Continuity of care
- More choice
- Improve access to care
67
How many infants, children and adolescents die every year in England and Wales?
>5000
68
What group of children have the highest mortality?
Infants, before the 1st year
69
What group of children have the 2nd highest mortality?
Adolescents (15-19)
70
What kind of conditions dominate in infancy?
Perinatal conditions
| Congenital
71
>50% of deaths in adolscents occur because of
External causes
72
External causes of adolescent deaths =
Trauma
Accidents
Suicide
73
Deaths in infancy most likely related to
Preterm births
74
Injury in boys is what % more likely than females?
>70%
75
What % of external deaths in adolescents does road traffic accidents account for?
50%
76
Non-intentional causes of child death:
Drowning
Falls
Fire related
Suffocation, strangulation
77
Examples of 'intentional' causes of child deaths:
Homicide
Physical assaults (shaking)
Abuse, neglect
78
Patterns of suicide and deliberate self harm in children =
Rare in <10s
Higher in older boys
Ligature, jumping, poisioning
79
How many deaths a year does suicide count for in older adolescent boys?
>60
80
Examples of injuries in childhood:
```
Falls
Head injuries
Road traffic collisions (pedestrians, unrestrained children)
Drowning
Swallowed foreign body
```
81
50% of poisioning occurs in
<5s
82
Almost all posionings occur
In child home
83
Types of posioning =
Non-medicinal: cosmetics, cleaning
| Medicinal = analgestics, cough medicine, antibiotics, vitamins
84
Common illnesses in children =
```
Congenital: chromosomal, cardio
Infection
Respiratory
Trauma
Malignancy
Neurological
```
85
Which malignancies account for 2/3rds of all childhood cancers?
Leukemia
Brain
Lymphoma
86
CNS disease in childhood =
- Result of perinatal asphyxia
- Epilepst
- Cerebral palsey
- Neurodevelomental disorders
87
Examples of chronic illness in children:
```
CF
Diabetes
Epilepsy
Psychiatic
Neurodisability
IBD
Obestiry
Asthma
```
88
Most common chronic illness in children
Asthma
89
Implications of childhood chronic illness:
- Childs physical, mental and social health
- Development
- Missed school
- Siblings
- Parents
- Finances
- Lifelong
90
In the UK, how many babies died before 1
>3,000
91
In the UK, how many children died >1
>2,000
92
After infancy, what is the most frequent cause of child death
Accidents
93
Prevalence of childhood asthma in UK
1 in 11
94
Most common type of meningitis
Viral
95
Most common cause of bacterial meningitis
Strep.pneumoniae
96
Common causes of childhood death in low income countries
```
Infection
Diarrhoae
Pneumonia
Malaria
HIV/AIDS
```
97
Common causes of childhood death in high income contries =
```
Congential
Preterm birth
Accidents
Posioning
CNS disorders, cancer
```
98
Talking to vs talking with children =
Talking to = implies as exclusive approach, child feels left out. Less likely to comply, conveys message child doesn't own their body and makes them less likely to own their problems in later life.
With = inclusive approach which implies discussion. Encourages responsibility, compliance and ownership of problem in later life. Values child
99
When talking with children you should talk at a level appropriate for their
Stage of development
100
What can be used to assess very young children?
Behaviour and play
101
Things that may affect communication with children
Hearing problems
Sight issues
Speech
Comprehension
102
Why might a child be anxious?
```
New school
Domestic situation
New home
Recent illness
Bereavement
Being told off etc.
```
103
Good listening and clear talking can be summed up with:
1. Is language appropriate?
2. What is body language conveying
3. Eye contact, turn-taking, listening, validating child, talking TO child
104
What questions should be used when talking with children?
Open
105
What kind of questions should be avoided with children?
Why questions
106
WHO definition of adolescence =
10-19
107
Children's Act (1989)
States that children must be kept informed about what happens to them and participate in decisions about their future
108
Adverse event/patient safety event =
Unintended event resulting from clinical care than causes patient harm
109
Near-miss =
Situation in which events or omissions arise during clinical care and don't go any further, resulting in no harm to patients
110
% of hospital admissions which experience a AE
10%
111
Examples of AEs
```
Wrong site surgery
Med error
Side effects
Failure to treat
Wrong diagnosis
Falls
Pressure sores
Nosocomial infections
```
112
Most common adverse event in hospital =
Falls
113
Most common NEs in hospitals =
Wrong site surgery, retained foreign objects
114
Serious incidents =
Events where potential for learning so great, or consequences so significant that resources should be spent to investigate and act
115
Never events =
Subset of serious incidents that should never occur if the proper guidance and safety recommendations are put into place
116
How many adverse events occur each year in NHS hospitals?
850,000
117
How many patients lodged a new clinical negligence claim last year?
11,000
118
NHS England paid out how much in clinical negligence?
£1.6 billion
119
How do people assess 'safety of hospital'
Mortality data
Safety event data: AEs, SIs
Monitoring and inspections
120
Who inspects hospitals?
CQC
| NHS improvement
121
Why can't we just compare 2 hospitals?
Different age
Different complexity of cases
Different location etc.
122
SMR stands for
Standardised mortality ratio
123
Standardised mortality ratio -
Ratio between observed number of deaths in a study population and number of deaths that would be expected based on age/sex-specific rates in standard population and population size. High SMR = high number of excess deaths.
124
Why are HSMRs not fit for purpose =
- People die in hospital
- Not a measure of avoidable deaths
- Doesn't relate to quality of care
- Depends on hospice/when hospital discharges patients etc.
125
What % of hospital deaths are avoidable?
3%
126
Name a model for why there is harm
Swiss cheese model
127
What is the swiss cheese model?
Need a lot of things to go wrong for things to actually go wrong! Lots of layers where things have helped to make adverse event occur
128
Active failure =
Unsafe acts committed by people in direct contact with patient.
129
2 types of active failure and their subsets
- Error: knowledge, rules, skills
| - Violations: routine, situational, reasoned, malicious
130
What is very important for causing error (more important than active failures?)
Latent conditions
131
Latent errors develop
Over time and combine with active failures
132
2 types of bad culture for patient safety
- Blame culture
| - Normalisation of deviance
133
Elements of a safety culture:
```
Leadership
Teamwork
EBDM
Communication
Learning
Patient centered
```
134
What was long recognised in the aviation industry but is now only being acknowledge in health care?
Human factors/the inevitability of human error
135
What should we do with human error?
Design it out
136
Situations associated with increased risk of error =
* Unfamiliarity with the task
* Inexperience
* Shortage of time
* Inadequate checking
* Poor procedures
* Poor human equipment interface
137
Duty of candour
Need to tell patient about wrror
138
NHS resolution is a
National safety and learning service
139
What should be avoided to reduce human error?
Reliance on memory
| Reliance on vigilence
140
What should be done to reduce human error?
Make things visible
Streamline, standardise, simplify
Checklists
141
Ex of designing error out
Surgical checklists
142
What to do if adverse event occurs =
```
Report
Assess seriousness
Root cause analysis
Apologise and explain to patient
Learn from event
```
143
Examples of 'dangerous healthcare'
- Mid-staffordshire
- Bristol royal infirmity
- Individual doctors: Rodney Ledward, Richard Neale
144
Mid-Stafforshire =
Between 400-1,200 patients died as a result of poor care between 2005-2009 at Stafford Hospital
145
What report came our of the Mid-Staffordshire case?
Francis report
146
Bristol royal infirmity =
High death rates in paediatric cardiac surgery due to:
- Old boys culutre
- Lack of leadership
- Lax approach to safety
- Secrecy amongst doctors
147
What % of hospital deaths are avoidable
3%
148
When is a patient's death judged to be 'avoidable'
Problem with care which contributed to death
149
Avoidable deaths can be due to acts of
Omission
Commission
Complications
150
Omission =
Failure to treat according to the evidence
151
Commission =
Incorrect treatment or management
152
Complication =
Unintended harm due to care
153
What % of hospital admissions are avoidable death?
<0.1%
154
Examples of scheme to improve patient safety:
TArgeted efforts to reduce MRSA and C.diff infection: reporting, fines.
Introduction of never events
155
Why might increased number or errors be good?
Means there is increased reporting - can learn
156
PROMs =
Patient-reported outcome measures: QoL before and after procedure
157
What is a patient's responsibility in healthcare?
Informed, make a decision.
158
Medical practice has 3 deficiencies internationally which effect quality of care:
1. Medical practice has a weak evidence base
2. Large variations in training and practice
3. Difficult to measure outcomes
159
The basis of healthcare reform what be at what level?
Organisational/structural
160
SHMI =
Summary hospital-level mortality indicatior
161
Summary hospital-level mortality indicatior
Actual mortality rates within 30 days of discharge compared to expected mortality given hospitals characteristics
162
SHMI in york?
100 deaths per month (small)
163
HES =
Hospital episode statistics
164
What are hospital episode statistics, what do they include?
Detailed dataset including diagnoses, consultant responsible, referring GP, procedures given, duration of stay and discharge/death
165
CQC =
Care quality commission
166
What does the CQC do?
Regulated all health and social care providers.
Licences
Unannounced visits
167
Name some agencies involved in consumer protections:
```
CQC
NHS improvement
Public health england
GMC
Royal collages
NICE
Department of health and NHS England
```
