Ethical dilemmas

Question 1

What are the 3 C’s of medical ethics?

Answer 1

• Consent
• Confidentiality
• Capacity

Question 2

What is consent?

Answer 2

when a patient gives permission before receiving any form of medical treatment, examination or test.

Question 3

When is consent valid?

Answer 3

• if it is voluntary
• it is informed
• they have capacity

Question 4

What does voluntary medical consent mean?

Answer 4

The decision to consent or to deny treatment is only influenced by that patients beliefs.

As a medical professional you must not influence a patients decision, You must not put pressure on a patient to accept
your advice, as well as recognise if the patient is being influenced by friends and family.
->As both of these means that consent that is given isn’t voluntary.

Question 5

Why does consent have to be voluntary?

Answer 5

If they are influenced by others then this is not autonomy. The patients decision isn’t their own and that is important when they are deciding on their own medical treatment.

Question 6

What does informed medical consent mean?

Answer 6

The patient must be provided with information about what the treatment is, its pros and cons, its side effects and risks, alternative treatments as well as what would happen if they didn’t have the treatment

Question 7

Why does medical consent have to be informed?

Answer 7

it allows the patient to make decisions and participate in their own medical care. It respects the autonomy of the patient

They have the opportunity to weigh up the pros and cons and make a decision that is right to them.
-> examples would be activities important to their quality of like, their values and priorities and their preferences

Question 8

What kind of information do you give to a patient when discussing treatment?

Answer 8

• diagnosis and prognosis, uncertainties about the diagnosis or prognosis, including options for further investigation
  -options for treating or managing the condition and the option to take no action
  -the nature of each option
  -benefits, risks of harm,
  uncertainties about and likelihood of success
  for each option

Question 9

What should you d when discussing treatment plans?

Answer 9

• The information you give patients
• Finding out what matters to a patient
• Answering questions and dealing with uncertainty
• Supporting patients’ decision making

Question 10

What should you disagree with a patient’s choice?

Answer 10

• You must respect your patient’s right to decide
• If their choice seems out of character or inconsistent with their beliefs, its reasonable to check their understanding
• you must not assume a patient lacks capacity because you disagree

Question 11

What does having capacity when consenting to medical treatment mean?

Answer 11

the person must be capable of giving consent, which means they understand the information given to them and can use it to make an informed decision

• all adults are assumed to have capacity

Question 12

The four steps to know if someone has capacity

Answer 12

• Understand: are they able to understand the treatment or diagnosis
• Retain: can they remember this information in sufficient detail
• Weigh-up: Are they able to come to a decision and weigh up pros and cons according to their values beliefs and priorities
• Communicate a decision: can they express their choice to DR that sounds reasonable and just decision

Question 13

Consent in 16-17

Answer 13

can do all the things an adult needs to do to consent, then their consent is valid as if they were 18. However they cant refuse the treatment if their parent says yes

Question 14

What is Gillick competence

Answer 14

Gillick competence outlines whether a child (under 16) can consent to their own medical treatment without their parents having to know or give permission. If the child has enough intelligence, competence and understanding to truly be informed about their treatment, they would be considered Gillick competent.

Question 15

What are questions to see if a child is Gillick competent

Answer 15

How old are they? How mature are they?
What’s their mental capacity?
Does the child understand what the treatment entails, including the pros, cons and long-term impact?
Does the child understand the risks, implications and consequences that could result from their decision?
Has the child understood the advice and information they’ve been given?
Is the child aware of alternative options, if available?
Does the child possess the ability to explain the rationale behind their decision making?

Question 16

What Are The Fraser Guidelines?

Answer 16

outline the scenario in which advice can be given to an under 16 about contraception and sexual health without parental consent.

Question 17

The five points of Fraser Guidelines?

Answer 17

Is the child mature and intelligent enough to understand the nature and implications of the treatment proposed?
Is it impossible to persuade the child to tell their parents, or let the Doctor tell them?
Are they likely to begin or continue having sexual intercourse with or without contraception?
Are their physical or mental health likely to suffer unless they get the advice or treatment?
Is the advice or treatment in their best interest?

Question 18

How do you break bad news?

Answer 18

Setting up
Perception
Invitation
Knowledge
Emotion with Empathy
Strategy or Summary

Question 19

What is setting up when breaking bad news?

Answer 19

Establishing an appropriate setting
- preparing what to say prior to the conversation, the appropriate vocabulary to use and the information shared is reviewed
-provide a separate, quiet space during communication between the clinician, the patient, and the family.
- Reducing or eliminating body signals that illustrate nervousness is very important in establishing rapport with the patient

Question 20

What is Perception when breaking bad news?

Answer 20

Before discussing the medical findings, the clinician uses open-ended questions to create a reasonably accurate picture of how the patient perceives the medical situation

For example, “What have you been told about your medical situation so far?” or “What is your understanding of the reasons we did the MRI?

Question 21

What can you find out when using Perception when breaking bad news?

Answer 21

• you can correct misinformation and tailor the bad news to what the patient understands
• determining if the patient is engaging in any variation of illness denial: wishful thinking, omission of essential but unfavorable medical details of the illness, or unrealistic expectations of treatment

Question 22

What is Invitation when breaking bad news?

Answer 22

• ask for permission to share the current news
• to give a patient control over the amount of information they hear and the pace of the conversation

Question 23

What is Knowledge when breaking bad news?

Answer 23

-to “Fire a Warning Shot” and warn the patient and family that the incoming news is not good
- “Unfortunately I have some bad news to tell you,” or “I am sorry to tell you,” or “Things are not going in the direction we had hoped,” allows the patient to emotionally brace themselves for the information .
- The actual sharing of the bad news should be done slowly so that the patient and family understand. Choosing words carefully is particularly important if the news indicates a very poor prognosis.

Question 24

What is Empathy when breaking bad news?

Answer 24

use empathic responses to acknowledge their own sadness or other emotions (“I also wish the news were better”). It can be a show of support to follow the empathic response with a validating statement, lets the patient know that their feelings are legitimate
= Giving them time and space to express their feelings and worries will help them come to terms with the information

Question 25

What is Strategy and summary when breaking bad news?

Answer 25

s to confirm what has been said to support the patient’s understanding and processing of the information.
-ask patients if they are ready at that time for such a discussion.

Question 26

What is euthanasia?

Answer 26

-the act of deliberately ending a persona life to relieve suffering

Question 27

What are the types of euthanasia?

Answer 27

Active - When someone deliberately intervenes to end someone’s life. An example would be a doctor prescribing an overdose of a drug that cause that patient to die(definitely illegal)
Passive - When the patent dies as a result of withholding medical treatment, with the intent to end their life that was otherwise keeping them alive.

Question 28

When is euthanasia illegal?

Answer 28

all euthanasia is illegal as the intent is to end their life, which is murder and illegal

Question 29

What is physician assisted suicide?

Answer 29

when the doctor provides the drug that will end the patients life however the act of taking it/ administering it is done by the patient (illegal)

Question 30

When can treatment be withdrawn?

Answer 30

• but withdrawing or withholding treatment that results in someone dying, for the patients best interest is good clinical practice.
  
  • When withdrawing treatment, the intent is that clinically the treatment is no longer in the best interest
  • you aren’t saying that living is no longer in the patients best interest, the motivation is that the treatment is not in their best interest
  • example would be someone who is in hospital and requires lots of machines. you could say that the suffering caused by being treated by these machines is no longer in the best interest (not that their life isn’t worth living as they need those machines) THE INTENT IS TO RELIEVE THEIR SUFFERING AS THE TREATMENT IS NOT IN THEIR BEST INTREST

Question 31

Arguments for euthanasia?

Answer 31

→ sometimes illnesses can cause large amounts of suffering no matter how much care is provided. It could be considered compassionate to help those in ending their life that would otherwise be unbearable

→ Autonomy - people do have autonomy (they have the ultimate decision in their treatment). They are allowed to decide if and when to end their lives only if they have competency and capacity. Are they able to make the informed decision, and do they understand what it means?

→ people often resort to travelling to other countries to end their lives, this is important as euthanasia being illegal in the uk means that people who wold have still considered it whilst being surrounded by family

→ ultimately people are allowed to decide about their health and lifestyles (within the limits of competency). Arguably it doesn’t cause direct harm to others.

→ with it not being available, people may often resort to other methods that aren’t proper and effective. Maybe it hadn’t killed them and left them with further permeant medical illnesses or the way that they had died was very ineffective (it could have been long, painful and distressful). with it being legal and there being clear guidelines on treatment people have authority over their own life and know that it will be a non-traumatic experience

→ if legal then less people being charged for assisted suicide

Question 32

Arguments against euthanasia

Answer 32

→ non-maleficence is a main duty of a doctor, making euthanasia legal could mean that doctors are acting in a harmful way.

→ People argue that a discussion or a change in the law on euthanasia could lead to more extreme discussion (euthanasia for children is legal in Belgium).

→ Another concern is that the legislation could be used to justify assisted dying in vulnerable groups, such as those with disabilities and mental illnesses. The legislation sends out a message that, where a life falls short of certain conditions, it is not worth preserving

→ The legislation debated does not deal with the issue of those with terminal illnesses who are unable to take their own lives. It would not help those with illnesses such as locked-in syndrome or motor neurone disease

→ * The legislation also assumes that Doctors are at all times benevolent. If the patient asks for help to die and helping the patient would be the easier route for the Doctor, theoretically, this could lead to an increase in deaths that otherwise would not have occurred. These decisions are irreversible.

→Another significant concern is that vulnerable people may feel pressure to spare their carers the burden of looking after them or, worse, might be bullied into choosing death. There could never be sufficient safeguards to ensure that a patient is not being softly pressurised – either by their own families or by societal expectations

Question 33

Argument against “ non-maleficence is a main duty of a doctor, making euthanasia legal could mean that doctors are acting in a harmful way.”

Answer 33

It is worth acknowledging that not having euthanasia means that people with terminal illnesses will/could experience prolonged suffering. Living a painful life that they don’t want

Question 34

Arguments against “People argue that a discussion or a change in the law on euthanasia could lead to more extreme discussion (euthanasia for children is legal in Belgium)”

Answer 34

Although it is debatable if a law like this is just (is a child able to consent to death? capacity and competency? ) it shouldn’t be a reason to prevent discussions and law changes of an issue and a topic that perhaps lots agree with. The reason why not to worry about the limits of euthanasia is because it has already been a long debated topic that if it were to be implemented would have regulations and guidelines that doctors would follow.

Question 35

When can confidentiality be broken?

Answer 35

• required by law (TB, Enterovirus 71)
• under court order
• protects a third party
• emergency

Question 36

What information is disclosed when you break confidentiality?

Answer 36

• ## only the information that is necessary

Question 37

What is the difference between Fraser guidelines and Gillick competence?

Answer 37

Gillick - used to asses a child’s ability to make and understand decisions
Fraser- specifically to advice and treatment around a young persons sexual health and contraception

Question 38

What do you consider under fraser guidelines?

Answer 38

• is the child mature an intelligent to understand the treatment
• likelihood of undergoing sexual intercourse with/out contraception
• is it in their best interest
• can the child tell their parents
• mental and physical health

Question 39

According to the GMC what should you consider for Fraser guidlines?

Answer 39

• views of child or young person
• views of parents and other close to them
• cultural, religious or other beliefs and values of the child and parents
• views of healthcare professionals involved, and other professionals

Question 40

What should you do when you have a young person who wants contraception?

Answer 40

• make its clear you can see the child by themselves if they want
  – involve child in discussion
• open and honest with parents whilst respecting confidentiality
• give opportunity to ask questions
• communication
• give them same respect as adult

Question 41

When can you keep information from a child?

Answer 41

• if it would cause them serious harm
• they ask you not to tell them

Question 42

What should yo do if a child without capacity disclose infor and doesn’t want you to tell the parents?

Answer 42

• try to persuade the child to involve a parent
• if they refuse and its in their best interest for the info to be shared (so the parent can make a decision) you can disclose to parents of local authorities

Question 43

When can you provide contraception, abortion and sti treatment without parental knowledge or consent?

Answer 43

• they understand all aspects of the advice and its implication
• you cannot persuade child to tell their parent
  young person is likely to have sex without the treatment
• physical and mental health may suffer
• best interest of child

Question 44

Can 16-17 refuse treatments

Answer 44

no and con be overridden by court or parents

Question 45

What is ICE?

Answer 45

Ideas
Concerns
Expectations

Question 46

Phrases to explore a patients Idea (ICE)

Answer 46

• tell me about what is causing the problems
• do you have any ideas what might be going on
  what do you think might be happening
• do you have any ideas as to what is going on at the moment

Question 47

Phrases to explore a patients Concern (ICE)

Answer 47

• what’s you worry at the moment
• are you worried about anything in particular
• Want is you concern about ___

Question 48

Phrases to explore a patients Expectations (ICE)

Answer 48

• What were you hoping id be able to do for you today
• What do you think might be the best plan of action
• it seems you have thought about this a lot, Do you have any thought on the best way we could to tackle the issue?

Question 49

3 parts of clinical communication

Answer 49

Introduction
- Check you have correct patient and ask if its ok to call them ___
- Explain why you are meeting
- apologies if they arent seeing their usual doctor
- gain consent to talk about the topic
Active listening
-appropriate eye contact
- open relaxed professional bod language
Establish a rapport
Ask how they are, offer water
-empathies with emotion they display and acknowledge the difficulty of the situation
-listen and respond