Ethics Flashcards
(183 cards)
1
Q
Summary: Discussing Do Not Resuscitate (DNR) Orders
When a patient reaches the end stages of life, and a Do Not Resuscitate (DNR)
order is put in place –
which is a decision made by the healthcare team, not by
the patient or the family-
, it is crucial to have open and compassionate
A
communication with the family. Healthcare professionals have an ethical
obligation to discuss and explain the reasoning behind the DNR order and provide
support to family members who may struggle to accept the decision.
Healthcare
professionals have a duty to ensure that families are informed and supported,
focusing on the patient’s comfort and dignity in their final stages of life.
Addressing their concerns helps ensure that everyone involved understands the
medical and ethical considerations that shape end-of-life care decisions, while
focusing on the best interests of the patient.
2
Q
An 81-year-old man with end-stage dementia is admitted to the hospital after a
severe stroke. Despite receiving appropriate medical care, his condition worsens,
and he is now nearing the final stages of life. A Do Not Resuscitate (DNR) order
has been put in place, agreed upon by the healthcare team after careful
consideration of his prognosis and the futility of resuscitation. His son, who is his
primary caregiver, is unaware of the DNR order and expresses his wish for
everything to be done to save his father’s life if his condition deteriorates. The
son is distressed and believes that resuscitation should be attempted. What is the
most appropriate next step in managing this situation?
Options:
A) Revoke the DNR order and proceed with resuscitation.
B) File the DNR order without discussing it with the family.
C) Discuss the DNR order with the son and explore his concerns.
D) Seek a second opinion from another consultant.
E) Ask the son to sign a consent form for resuscitation.
A
Answer → C) Discuss the DNR order with the son and explore his concerns.
In this case, the patient already has a DNR order in place, which was agreed upon
by the healthcare team after determining that resuscitation would not provide
any benefit due to the patient’s advanced dementia and terminal condition.
The
son’s distress and desire for resuscitation reflect the need for a compassionate
and open conversation.
It is crucial to explain the medical rationale behind the DNR order, address the
son’s concerns, and help him understand the reasoning for not pursuing
aggressive interventions at this stage.
Such discussions are essential to ensuring
that the family is aware of the patient’s condition and the medical decisions made
regarding end-of-life care.
Explanation of other options:
A) Revoke the DNR order and proceed with resuscitation.
Revoking the DNR order and resuscitating the patient would not be in line with
3
Q
A) Revoke the DNR order and proceed with resuscitation.
Revoking the DNR order and resuscitating the patient would not be in line with
A
the patient’s best interests, as the DNR was put in place due to the futility of
resuscitation in this terminal case.
B) File the DNR order without discussing it with the family.
Filing the DNR without discussing it would dismiss the son’s concerns and
undermine the importance of transparent communication in end-of-life care. This
would not be an ethical approach.
D) Seek a second opinion from another consultant.
Seeking another opinion is not necessary here as the DNR order was made after
careful consideration by the healthcare team, and there is no indication that
another opinion would change the situation.
E) Ask the son to sign a consent form for resuscitation.
The decision to resuscitate or not is a medical decision, and asking the son to sign
a consent form would be inappropriate, especially when a DNR order is already in
place.
4
Q
A 45-year-old doctor is conducting a routine visit to a nursing home to check on a
resident.
While passing by a patient’s room, they overhear a nurse speaking
harshly to an elderly man who has early-stage dementia.
The nurse is raising her
voice and repeatedly commanding the man to eat his meal. The elderly man
appears confused and begins to cry in distress. The doctor can clearly hear the
conversation from outside the room. What is the most appropriate action for the
doctor to take?
Options:
A) Speak to the nurse directly and address her behaviour.
B) Document the incident in the patient’s notes but take no further action.
C) Inform the General Medical Council (GMC) about the nurse’s behaviour.
D) Report the incident to the local authority safeguarding team.
E) Recommend to the nursing home manager that the nurse receive mediation
with the patient.
A
Answer → D) Report the incident to the local authority safeguarding team.
In this scenario, the behaviour of the nurse can be considered as emotional abuse
or neglect, especially because it involves a vulnerable elderly patient with
dementia.
Safeguarding procedures exist to protect individuals from harm, and a
referral to the local authority safeguarding team ensures that the situation is investigated formally. It allows for protective actions to be taken to ensure the
well-being of the patient and to prevent further distress.
5
Q
E) Recommend to the nursing home manager that the nurse receive mediation
with the patient.
Mediation may not be suitable in cases of potential abuse. The situation needs a
safeguarding referral, not just a recommendation for conflict resolution.
A
Neglect or Abuse to a Patient by a Caregiver → Involve the Safeguarding Team.
Explanation of other options:
A) Speak to the nurse directly and address her behaviour.
While addressing the nurse may seem like an immediate response, it does not
address the seriousness of the situation. Emotional abuse should be dealt with
formally through safeguarding channels to ensure proper investigation and
accountability.
B) Document the incident in the patient’s notes but take no further action.
Recording the incident without taking further action would not adequately
address the potential risk to the patient. Documentation is important, but
safeguarding procedures must also be initiated.
C) Inform the General Medical Council (GMC) about the nurse’s behaviour.
The GMC regulates doctors, not nurses. Reporting this incident to the GMC would
not be appropriate since they are not the regulatory body for nurses.
6
Q
Reporting Knife and Stab Wounds with Example Cases
Healthcare professionals in the UK are mandated by law to report any injuries
caused by sharp objects, such as stab or knife wounds, to the police, regardless of
the patient’s wishes.
This duty is in place to protect public safety and prevent
further harm. When reporting, only the fact that a knife injury has been treated
should be disclosed initially, with further patient details being shared only if:
• The patient consents to additional disclosure.
• There is a legal requirement, such as a court order.
• Public safety is at risk, and non-disclosure may lead to serious harm.
Confidentiality must be maintained unless a clear legal or public interest justifies
further disclosure.
Healthcare professionals are also encouraged to explain this
duty to the patient, so they understand the necessary steps and the limited
information being shared
A
7
Q
- A 28-year-old man arrives with a stab wound inflicted by his partner. They
have no children, and he strongly insists on not involving the police.
A
In this case, the police must be notified due to the legal duty surrounding knife
wounds.
The healthcare provider can discuss concerns about domestic violence
and offer resources, while respecting confidentiality for further details unless
legally required to disclose them.
8
Q
A 31-year-old woman with a stab wound has a young child at home. She does
not want the police involved.
A
In this scenario, the presence of a child may require involving social services or
safeguarding teams, as the child could be at risk in a violent household.
The
law mandates that the police and possibly social services or safeguarding
teams should be informed.
9
Q
- A 24-year-old man presents with a self-inflicted stab wound but does not
wish for police involvement.
A
In cases of self-inflicted injuries, there is typically no obligation to inform the
police unless there are concerns about public safety.
The focus should be on
assessing the patient for psychological/ psychiatric support.
10
Q
A 47-year-old woman is brought in with a stab wound from a random attack
in a public place.
A
Since this is a serious criminal act, it is mandatory to report the injury to the
police.
They will need to investigate the incident further, though personal
details should only be shared with the patient’s consent.
11
Q
- A junior clinician treats a 35-year-old man with a stab wound to the abdomen
from a domestic argument. The patient insists it was a one-time incident and
does not want the police involved.
A
The healthcare professional must still inform the police of the knife wound.
The extent of further disclosure, such as the patient’s personal information,
should be escalated to senior staff or legal teams for a final decision.
This summary illustrates how healthcare professionals must navigate their duty to
report knife injuries while balancing patient confidentiality and legal
requirements.
12
Q
A 27-year-old woman arrives at the Emergency Department with a cut on her
arm, which she explains occurred during a domestic altercation with her
partner
. She firmly states that this is the first time such an event has happened,
and she insists that it will not happen again. The patient is adamant that the
police should not be involved in the matter. Which of the following is the most
appropriate course of action?
Options:
A) Place the patient under temporary police protection.
B) Offer a referral for relationship counselling.
C) Inform the patient’s GP about the incident.
D) Respect the patient’s wishes and do not report the incident to the police.
E) Report the incident to the police
A
Answer:
Correct answer → E) Report the incident to the police.
• In cases where a patient presents with an injury inflicted by a sharp object,
such as a knife or any other weapon, it is mandatory for healthcare professionals
to inform the police, regardless of the patient’s wishes.
This is because the law
prioritises public safety and the possibility of future risk to the patient or others.
When reporting such incidents, healthcare professionals are expected to
disclose only the necessary information, specifically that a knife injury has
occurred.
More detailed personal information should remain confidential unless
further disclosure is legally required (eg, a court order), or in the public interest,
such as preventing serious harm to others.
13
Q
68-year-old woman with end-stage renal disease is admitted to the hospital
with severe sepsis. Despite aggressive antibiotic therapy and supportive care,
her condition is rapidly deteriorating.
She is now unconscious and unable to
make informed decisions about her care. Her son, who is her next of kin, lives in
another state and cannot be reached immediately.
The medical team believes
that resuscitation would not be in her best interests due to her poor prognosis
and the advanced stage of her illness. She does not have an advance directive in
place. What is the most appropriate course of action?
Options
A. Resuscitate her if her condition worsens
B. Wait for her next of kin to be contacted
C. Initiate palliative care without completing a DNR order
D. Complete a Do Not Resuscitate (DNR) order
E. Wait for her condition to improve so she can regain capacity
A
Detailed Answer
The correct answer is D. Complete a Do Not Resuscitate (DNR) order.
Reasoning:
- Resuscitate her if her condition worsens: Resuscitating a patient with a poor
prognosis and advanced stage illness, like this patient, might not be in their best
interest. This could prolong suffering and delay an inevitable outcome without
improving quality of life. - Wait for her next of kin to be contacted: While involving the family in decision-
making is important, the immediate medical needs of the patient must be
addressed. Waiting for the next of kin could delay appropriate care and cause
unnecessary suffering. - Initiate palliative care without completing a DNR order: Palliative care focuses
on providing relief from symptoms and improving the quality of life. However,
without a DNR order, there is a risk that resuscitation attempts might still be
made, which could counteract the palliative approach.
- Complete a Do Not Resuscitate (DNR) order: Given the patient’s poor prognosis
and advanced stage of illness, along with the medical team’s belief that
resuscitation would not be in her best interest, completing a DNR order is the
most appropriate action.
This respects the patient’s dignity and aligns with ethical
principles of beneficence and non-maleficence.
- Wait for her condition to improve so she can regain capacity: The likelihood of
the patient regaining capacity in such a critical condition is low.
Delaying the
decision could lead to unnecessary interventions that might not align with the
patient’s best interests or her likely wishes.
In summary, completing a DNR order ensures that the patient receives care that
aligns with her condition and respects her dignity, preventing unnecessary and
potentially harmful interventions.
Remember that: a DNR decision is a clinical one. Ie, if the patient went
unconscious and has no advance directive (a living well), the clinical team can
decide whether to assign a DNR or no. It is a clinical decision.
14
Q
A
15
Q
44-year-old man with a background of bipolar disorder is brough to the
surgery for elective hernia repair. On the day of operation, he was found that
he is in a manic state (elevated mood, with rapid speech and a lack of insight
into his condition). He had previously given consent for the operation during
the period of stability.
However, his current manic state could prevent him
from understanding the implications and the potential complications of the
surgery. What is the most appropriate action?
A
→ Postpone the surgery until the patient regains mental capacity so he can
understand the implications of the surgery.
√ Consent is not constant -one-time- event.
√ The patient must be capable of understanding the surgery implications on the
day of the surgery.
16
Q
You are a junior doctor (FY2). During your launch break in a nearby
restaurant, you saw your fellow FY2 doctor sitting with his friends and
discussing an argument that he had with his patient loudly.
He was disclosing
the patient’s medical background but not his identifiable details. What should
you do?
A
→ Inform him that he should not be discussing patients with his friends.
√ It may be considered a confidentiality breach to discuss patient’s details
outside of a professional setting (even without revealing patient identifiers).
√ If identifiable details were disclosed → Inform GMC.
17
Q
An 80-year-old woman with dementia and decreased cognitive function and
mental capacity is brought to her GP by her 32-year-old daughter.
The
daughter wants the GP to provide her with a medical report or statement
that mentions that her mother has declined cognitive function and capacity.
She wants to use this report to gain control over her mother’s financial
wealth so that she can buy personal expenses such as buying a car and a
house for herself. What is the most appropriate action?
A
→ Inform safeguarding authorities.
The daughter wants to be given the power so that she can financially abuse her
mother’s money.
√ Since there is a potential abuse to a vulnerable adult, the appropriate
authorities should be included.
√ It is important for the GP to safeguard vulnerable adult.
√ Suggesting the daughter to seek legal advice for establishing a Power of
Attorney does not solve the immediate issue here (which is a potential abuse).
18
Q
If a schizophrenic patient needs surgery, who is the responsible medical
personnel for assessing his mental capacity?
A
→ The surgeon.
Any healthcare professional can assess capacity. In this case, the primary
responsibility lies with the surgeon (as it is a case of surgery).
If there are concerns about the influence of the patient’s psychiatric condition
on their capacity, a psychiatrist expertise might be sought
19
Q
For a junior doctor who feels that he needs educational guidance, who should
he approach first?
A
→ His supervising consultant.
20
Q
A 78-year-old man is receiving a palliative care as he has end-stage lung
cancer. The patient is confused and desaturating and has a low systolic blood
pressure.
He is put on mechanical ventilation and being given the necessary
treatment. The medical team believe that he would not benefit from CPR
should he went into cardiac arrest, and CPR is not in his best interest. He has
no family and has no advance directive. What is the most appropriate action?
A) Fill a DNR (Do Not Resuscitate) form.
B) Wait for him to become less confused and discuss a (DNR) form.
C) Withdraw all treatment lines.
D) Seek advice from an independent advocate.
E) Seek court decision.
A
Answer → A.
• DNR “Do Not Resuscitate” is a decision of medical professionals not patients
or their families.
• However, the family members should know the meaning of a DNR and should
be told about the reasons of the DNR but their decision would not be
important.
• This might sound strange, but a decision of a DNR order can be made by the
doctors even if it is against the patient’s wish! The patient is not required to
consent on a DNR order!
21
Q
Dnr
A
Remember, having said that, if any patient was alert and conscious and want
NOT to be resuscitated, the doctors should respect his wishes).
What if the patient has no family?
→ Fill a (DNR) form.
In short, if the medical professionals believe that a DNR is not in the patient’s
best interest, they would fill a DNR form after discussing (revealing, clarifying)
this decision to the patient’s family.
The patient’s and the family’s opinion
would not overrule the doctors’ decision. If he has no family, they would fill a
DNR form.
22
Q
A 78-year-old man is receiving a palliative care as he has end-stage lung
cancer. The patient is confused and desaturating and has a low systolic blood
pressure. He is put on mechanical ventilation and being given the necessary
treatment.
The medical team believe that he would not benefit from CPR
should he went into cardiac arrest, and CPR is not in his best interest.
He has
no family and has no advance directive. What is the most appropriate action?
A) Fill a DNR (Do Not Resuscitate) form.
B) Wait for him to become less confused and discuss a (DNR) form.
C) Withdraw all treatment lines.
D) Seek advice from an independent advocate.
E) Seek court decision.
A
Answer → A.
• DNR “Do Not Resuscitate” is a decision of medical professionals not patients
or their families.
• However, the family members should know the meaning of a DNR and should
be told about the reasons of the DNR but their decision would not be
important.
• This might sound strange, but a decision of a DNR order can be made by the
doctors even if it is against the patient’s wish! The patient is not required to
consent on a DNR order!
Remember, having said that, if any patient was alert and conscious and want
NOT to be resuscitated, the doctors should respect his wishes).
What if the patient has no family?
→ Fill a (DNR) form.
In short, if the medical professionals believe that a DNR is not in the patient’s
best interest,
they would fill a DNR form after discussing (revealing, clarifying)
this decision to the patient’s family. The patient’s and the family’s opinion
would not overrule the doctors’ decision.
If he has no family, they would fill a
DNR form.
23
Q
Important Ethical Principles
◙ The doctrine of double effect:
From its name (double) → If there are 2 options; one good and one bad. If you
do one, the other would be outweighed.
Ie, applying one good thing has -unintentionally- led to a bad outcome.
Example:
If you give the maximum dose of morphine to this elderly suffering patient who
is with end-stage cancer, you would relieve his uncontrollable pain and
A
suffering. However, this act may lead to death indeliberately (without an
intention).
In this example, relieving pain and suffering was the primary aim.
This is called: the doctrine of double effect (imp √).
So, it is used to justify good and bad -unintended- effects.
This is different from euthanasia; which means killing the patient deliberately
(eg, by giving a lethal dose of potassium or morphine). Euthanasia is not-
allowed (ILLEGAL) in the UK. Careful!
24
Q
Beneficience
A
◙ Beneficence → Showing kindness and mercy.
Example: Holding a patient’s hand as he dies.
◙ Non-maleficence → (= Do No Harm)!
The rules include: do not kill, do not cause pain or suffering, do not
incapacitate, do not cause offence.
◙ Health maximization → Maximizing health with limited resources. In other
words, using the best treatment options that could result in the greatest
outcomes despite its economic values. (Health is first).
25
A 19-year-old Muslim girl had brain tumour and underwent surgery to
remove the tumour. Her last CT-brain showed brain herniation. She never
regained consciousness after the surgery.
The doctors told the family that
there is nothing to be done better than what they had already done. 3 days
later, she died in the hospital
. The family wants to bury her body as soon as
possible due to their religious principles. What is the most appropriate
action?
E) Keep the body in the hospital mortuary until the arrangement of the next of
kin to take it away is completed.
A) Refer to the coroner to further investigate and issue a death certificate.
B) Keep the body in the hospital mortuary until the completion of the death
certificate.
C) Release the body and allow the family to take it home.
D) Fill in a cremation form.
Answer → A.
Note: Muslim and Jewish families have religious beliefs indicate that the dead
should be buried as quickly as possible. So, if the (suspicious) death is for a
Muslim,
we also still refer to the coroner and inform him that the dead is a
Muslim so he can make the required investigations and procedures as quickly
as possible.
Doctors also need to explain to the family the necessity of including
the coroner in such cases and that the procedure would be quick.
◙ Who is coroner?
An official who investigates violent, sudden, or suspicious deaths.
26
◙ What can the coroner consider to be done?
• Allow the doctors to issue a cause of death certificate and takes no action.
• Open a post-mortem examination (could lead to open an investigation/quest).
• Open an investigation/quest without a post-mortem examination.
◙ When to inform the coroner?
- Deaths due to accidents, neglect, suicide, violence, industrial disease.
- Deaths in relation to surgical treatment or anaesthesia need to be referred
to the coroner even if the patient is already out of the theatre as long as
there is a possibility that the surgery may have resulted in death.
- Sudden and unexpected deaths (eg, within 24 hours of admission to a
hospital).
- Death of an individual who was not seen by a doctor in the last 14 days of
his/her life.
- Deaths of unknown cause.
- Deaths during surgery or before recovery from anaesthesia.
- Deaths shortly after police custody or prison.
Note: do not forget that patients with “mesothelioma” need to be reported to
the coroner as well. This is because it is an “industrial disease”.
27
A patient is about to have nephrectomy. The patient signed a consent for
performing (right) nephrectomy.
However, you as FY2 doctor noticed that the
consultant had written in the notes of the operation that the patient is due for
(left) nephrectomy.
What should be done?
The first thing to do
→ Inform the consultant about this note.
Then, the next legal thing that should happen is that the operation would get
cancelled or delayed for a different time as the consent of the patient must be
in line with the real operation!
28
The parents of a 16-year-old girl presented to the GP asking whether their 16-
year-old girl is pregnant or not. In her medical records, it is written that she is
pregnant in her 12th week gestation. What should the GP do?
→ Refuse giving them any information about their daughter.
Confidentiality is important and there is no reason in this stem to break it.
When to breach confidentiality?
• If the patient gives a consent to do so.
• If keeping confidentiality would likely to harm somebody. Breaching
confidentiality is in the public’s best interest.
• When requested by the Law (e.g. court order, requested by a judge).
• When breaching confidentiality is in the patient’s best interest “there is a
benefit for the patient who lacks capacity”.
29
Scenario (2)
A 3-month-old baby girl is seen in the A&E with her mother. The baby has
fever, and looks ill.
The baby had URTI last week that was treated. The mother
says that the baby rolled over and fall off the bed and hit her head on the floor.
There is a 3 cm bruise on the left occipital side of the head. There is a weight
loss of this baby on her weight chart.
What is the most appropriate initial
management?
→ Admit and investigate.
2 points mentioned here raise concerns about a possible child abuse which
needs safeguarding team to get involved for more investigations:
√ This baby is 3 months old. Babies mostly cannot roll from back to tummy
before the age of 5 months.
√ The noticeable weight loss.
However, since the baby in scenario 2 is now ill and has fever, the initial step
would be to admit and investigate (for treating the baby).
While he is
admitted, safeguarding team can be involved.
30
Scenario (1)
A 3-month-old baby girl is seen in the A&E with her mother. The mother says
that the baby rolled over and fall off the bed and hit her head on the floor.
There is a 3 cm bruise on the left occipital side of the head. There is a weight
loss of this baby on her weight chart.
What is the most appropriate initial
management?
→ Involve safeguarding team.
2 points mentioned here raise concerns about a possible child abuse which
needs safeguarding team to get involved for more investigations:
√ This baby is 3 months old. Babies mostly cannot roll from back to tummy
before the age of 5 months.
√ The noticeable weight loss.
31
32
DNACPR or DNR
• DNACPR stands for do not attempt cardiopulmonary resuscitation.
• It is the same as (DNR) = Do Not Resuscitate.
• NO one but DOCTORs (clinicians) can overrule a DNACPR.
• Remember: DNR is a decision of doctors.
• Anyway, the family, relatives, loved ones should be informed with detailed
explanations behind the decision. They should be told why a DNR is not in the
patient’s best interest. At the end, a DNR is a clinical decision.
Example 1:
A son of an 80 YO man with end-stage renal cancer wants to overrule a
DNACPR order. His father wad acceptable of this order. What to do?
→ Take the son’s views into consideration but advise that the final decision
rests with the clinicians.
33
A 75-year-old man is receiving an end-of-life care as he has end-stage renal
failure.
The medical team believe that he would not benefit from CPR shall he
went into cardiac arrest, and CPR is not in his best interest.
However, his
daughter believes that he should be resuscitated. What should be done?
→ Fill in a (DNR) form and inform the daughter.
34
A 78 YO female lives in a residential care home. She has Alzheimer’s disease
and short-term memory. She keeps attempting to go outside to buy ice cream
that she used to eat when she was young. However, one of the staff members
has locked her inside her bedroom to prevent her from going outside alone
since she should be accompanied
. The GP has been informed about this
event. What should be done?
→ Inform the local safeguarding team.
• Even if this action was made for her best interest, the safeguarding adult
team must be involved so they can investigate
and take steps to prevent any
possible harm to this lady.
• The GPs and the staff would then address her issue of going out alone. For
example, instead of locking the door, they may order her ice cream, or
accompany her, or try to talk to her about the matter.
• Locking the door on a patient should raise safeguarding concerns!
35
A 60-year-old man had a road traffic accident and was taken to the
emergency department by his friend as his son lives outside the UK. He is
slightly hypotensive (BP: 100/62 mmHg) and his hemoglobin is 10.2 mg/L.
The
patient is confused, drowsy and disoriented. His right thigh is swollen and
rotated. X-ray shows a mid-shaft fracture of his right femur
36
A 60-year-old man had a road traffic accident and was taken to the
emergency department by his friend as his son lives outside the UK.
He is
slightly hypotensive (BP: 100/62 mmHg) and his hemoglobin is 10.2 mg/L.
The
patient is confused, drowsy and disoriented. His right thigh is swollen and
rotated. X-ray shows a mid-shaft fracture of his right femur.
→ Proceed with surgery (femur fixation by intramedullary nail) without waiting
him to become fully conscious to sign a consent, without waiting for a court
decision, and without a consent from his abroad son.
• Note that he is not fully conscious (confused, drowsy and disoriented).
Therefore, taking a consent from him is not effective (not a correct option).
• It is important to know that femur fracture fixation is not an elective
surgery; it is an urgent surgery.
• This is because the resulting bleeding (blood loss) in closed femur fractures is
significant (1 – 1.5 Litres).
• This means that the surgeons should act fast in the best interest for patient
to save his life.
• His son should be informed; however, the decision of proceeding with the
surgery is done urgently by the surgeons for the patient’s best interest and
sake.
• After he becomes fully conscious, they would tell him about everything.
37
A 24-year-old man has been unconscious in the intensive care unit for 2
weeks after a road traffic accident. He is on mechanical ventilation and being
given IV fluids and medications.
The intensive care team believes that he is
not a good candidate for CPR if needed, and if resuscitating him would result
in a poor quality of life.
However, his family wants him to be resuscitated and
treatment continued. What is the most appropriate action?
A) Perform CPR if required.
B) Withdraw all treatment.
C) Seek legal advice.
D) Discuss the family’s wishes with the intensive care team.
E) Discuss the decision of the intensive care team with the family.
Answer → E
◘ Involve the patient’s family regarding the decision of the DNR (Do Not
Resuscitate) and discuss it with them. However, there is no need for their
consent as the DNR is a decision of the doctors only.
◘ Note that all treatment lines will still continue, we do not withdraw them.
However, if his heart stops and a decision of DNR (Do Not Resuscitate) has
been made and discussed with the patient and family, then we do not
resuscitate.
• This might sound strange, but a decision on a DNR order can be made by the
doctors even if it is against the patient’s wish! The patient is not required to
consent on a DNR order!
• However, the patient and his family need to be involved and to know about
the DNR decision.
• The patients have no right to ask for CPR if the doctors believe that CPR
would be unsuccessful or not in the patient’s best interest.
CPR (CardioPulmonary Resuscitation) is invasive, involving compressions and
possible rib fractures, electrical shocks, injected drugs,
may damage internal
organs, lead to brain damage leading to permanent physical disability and poor
quality of life if succeeded.
Thus, it is a decision of doctors.
38
What if this same patient has no family?
→ Fill a (DNR) form.
In short, if the medical professionals believe that a DNR is not in the patient’s
best interest, they would fill a DNR form after discussing (revealing, clarifying)
this decision to the patient’s family.
The family’s opinion would not overrule
the doctors’ decision. If he has no family, they would fill a DNR form.
39
14-year-old girl come to A&E with her boyfriend who is 24-year-old asking
for oral contraceptive pills.
Her parents do not know about her sexual
intercourse and she does not want anyone to know. What is the most
appropriate action?
→ Inform the local safeguarding authority
- Her sexual partner is much older than her, we fear of child abuse or
exploitation. (There is a big age gap and she is 13-15 YO).
- We inform safeguarding authority (who are already present in hospitals and
they would gather more information and involve the police if needed).
- If this was not in the options, pick (Inform Police)
40
You are a junior doctor. On a launch break, while in cafeteria, you heard one
of the FY2 doctors talking to his colleagues about an unnamed patient he was
treating in the emergency department.
The FY2 doctor was upset and telling
the events that happened with that patient as they had argument about the
diagnosis. He disclosed his medical background to his colleagues.
However,
the FY2 doctor did not mention any identifiable information about his patient
but was telling the conversations that happened between him and his
patient. What is the most appropriate action?
→ Do nothing.
• As long as he did not disclose his identifiable details, it is not confidentiality
breach. Also, there is no threat to anyone.
• If identity has been disclosed, the steps are:
Confront him (tell him it is not legal to do so) → Inform a senior → Inform GMC.
41
A 15-year-old Jehovah’s witness had a road traffic accident (RTA) and bled
massively. In the A&E, he was given IV fluids.
However, the doctors see that
an urgent blood transfusion is needed. The patient accepts to consent receive
blood to save his life.
However, his parents do not accept that their son
receive blood products based on their religious beliefs. What should be done?
→ Accept his consent and transfuse blood.
• Many Jehovah’s witnesses do not accept blood products based on their
religious beliefs.
• The law says that if they are competent or if they carry the blood refusal
card, we should respect their decision on not to receive blood products even if
this would lead to their death! IV fluid can be given instead.
• You can advise them to receive blood, but you are not allowed to pressure
them to accept it.
• However, the consent of this boy who is 15 YO is acceptable. It is in his best
interests. His parents cannot go against his wish especially if this would save his
life.
• If the boy in question refused to receive blood based on his religious beliefs,
we also should respect this and give IV fluids instead even if this is dangerous.
42
You are a junior doctor.
On a launch break, while in cafeteria, you heard one
of the FY2 doctors talking to his colleagues about an unnamed patient he was
treating in the emergency department.
The FY2 doctor was upset and telling
the events that happened with that patient as they had argument about the
diagnosis.
He disclosed his medical background to his colleagues.
However,
the FY2 doctor did not mention any identifiable information about his patient
but was telling the conversations that happened between him and his
patient. What is the most appropriate action?
→ Do nothing.
• As long as he did not disclose his identifiable details, it is not confidentiality
breach.
Also, there is no threat to anyone.
• If identity has been disclosed, the steps are:
Confront him (tell him it is not legal to do so) → Inform a senior → Inform GMC.
43
44
In a suspected case obstructive sleep apnea (not confirmed yet):
Firstly → do not drive advise to pt
After OSA has been confirmed → Advise patient to inform DVLA himself.
45
Clinical Audit Cycle has 5 Stages:
Define → Measure → Compare → Implement → Re-audit
1) Define the standard:
e.g., 100 patients with CAD should be given advice to stop smoking.
2) Measure current practice:
i.e., collect data from patients record over a certain period.
3) Compare results of current practice to the defined standard.
4) Implement “apply” sustainable changes for improvement.
5) Re-audit to determine if the changes made are effective or more
improvement is needed.
46
Q) An FY2 doctor was tasked to make clinical audit.
He defined his group
of patients (children with asthma less than 5 YO in his hospital), he
collected their data over 3 months,
he compared results and came out
with some plans “changes” to make. What is the Next step?
ep?
→ Apply sustainable changes and Re-audit in 6 months.
47
In 4 cases:
√ Unable to communicate their decisions
√ Unable to understand the information given to them.
√ Unable to retain the information long enough to make decisions.
√ Unable to weigh up information to make decisions.
Communicate/ Understand/ Retain/ Weigh up
Q) A patent who is non-verbal (cannot speak) and with severe learning
disabilities and recent trauma is unable to communicate his decision to
his carer or to his doctor. In this scenario, why do we consider him as
“lacking mental capacity”?
Because he is → • Not because of his disabilities or recent trauma. Careful
• Also, even those who cannot speak (non-verbal) can still communicate their
decisions by a different way (eg, writing).
48
Using any picture of a patient that includes his personal data for any purpose
(eg, medical lectures) requires →
patient’s consent.
49
Before telling a patient about his Diagnosis and Prognosis (ie, before breaking
bad news
) → Ask him if he wants to know his diagnosis and prognosis or no.
50
A man with Obstructive Sleep Apnea (OSA), what shall he do regarding driving
issue?
- If OSA is not yet confirmed →
- After the Dx of OSA is confirmed
→ - If he refused to inform DVLA after confirming OSA
1→ Advise him not to drive until assessment.
2Encourage him to inform DVLA.
3Inform DVLA on his behalf.
51
Important Summary Points on Informing DVLA (Driver and
Vehicle Licensing Agency) In Different Scenarios:
Quick Summary:
❤️√ Confirmed cases of Epilepsy, Seizures,
Alzheimer’s,
Dementia, OSA
(Obstructive sleep apnea)
always need to be reported to DVLA. (First by the
patient, if he refused, you as a doctor should inform DVLA).
💕Those who has not yet been confirmed should be advised to stop driving until the
diagnosis is confirmed.
After that DVLA should be informed.
❤️√ Cases of TIAs (Transient ischemic attacks) should stop driving for a specific
period (depending on whether he is a car: 1 month or a lorry driver: 1 year) but
not always need to be reported to DVLA – See Below.
❤️√ Cases of DVT and Pulmonary embolism can continue driving without an issue
as long as they haven’t experienced loss of consciousness and can move their
legs. They do not need to be reported to DVLA.
52
❤️A lorry driver has seizure. What should be done?
→ Advise him to inform DVLA.
If he refuses → You as a doctor should inform DVLA.
❤️Alzheimer’s • A mother with so. However, she insists to drive.
continues to drive. Her son advised her not to do
→ Report to DVLA.
53
Transient Ischemic Attack (TIA) and Driving, DVLA Issues:
Any patient with TIA should stop driving (car for 1 months, and lorry or bus for 1
year).
But informing DVLA is not necessary if only single TIA if he is a car driver.
However, if he is a lorry or a bus driver, DVLA should be informed even if he has
only had a single TIA
.
❤️◙ A man has a single “Transient Ischemic Attack”, and he is now fit for
discharge. What should you advise him about car driving?
→ Stop car driving for at least TIA + (no need to inform DVLA as it is a single
1 month TIA, and he is a car driver not a lorry or a bus driver).
❤️◙ A man has a single TIA “Transient Ischemic Attack”, and he is now fit for
discharge. What should you advise him about Lorry/ bus driving?
→ Stop lorry or Bus driving for 1 year + (Inform DVLA).
54
When to inform DVLA (in case of TIAs)?
- If group A driver (Car driver) and has MULTIPLE TIAs within a short period.
- If group B driver (Lorry or Bus driver) and has even a SINGLE TIA.
- You must tell DVLA if you’ve had any epileptic attacks, seizures, fits or
blackouts.
When to inform DVLA (in case of TIAs)?
- If group A driver (Car driver) and has MULTIPLE TIAs within a short period.
- If group B driver (Lorry or Bus driver) and has even a SINGLE TIA.
- You must tell DVLA if you’ve had any epileptic attacks, seizures, fits or
blackouts.
55
You are a FY 2 doctor. You have suspicions that your colleague (Peter) is using
cannabis. Upon confronting him, he admits that he is using cannabis. He
rejected your advice to stop cannabis.
A)
B) Ask him to inform his superior.
Report to GMC.
The right option here is (A).
We cannot trust him that he would inform his
seniors.
In the previous example, the option was (YOU) report him to his senior
and this is correct. But if this option is not available, then (A) is correct.
Something has to be done as he is putting the patient’s well at risk.
56
You are a FY 2 doctor. You have suspicions that your colleague (Peter) is using
cannabis. Upon confronting him, he admits that he is using cannabis. He
rejected your advice to stop cannabis.
A) Report to GMC.
B) Inform his superior.
The correct option here is (B). Please, see the next question with the mild
difference in the options.
57
Cannabis use colleague
Remember:
1st → confront him.
2nd → inform a senior.
3rd → inform GMC.
58
An 85 YO woman who lives in sheltered accommodation has fell while
climbing the stairs. X-rays show femur neck fracture.
The surgical team has
discussed the case and they believe that she needs an operation as this would
improve her general outcome.
However, she lacks capacity to decide. Also,
she has no relatives, no appointed attorney or advance directive. What shoud
be done?
→ Perform the surgery in her best interest. Even without her consent.
In cases like this where no one can decide on the patient’s behalf.
And the
team agree on the operation. The surgical team would proceed with what’s in
the best interest for the patient.
59
GP wants to prescribe antidepressants to a very old man who has severe
depression for 12 months after the death of his wife.
The patient lacks mental
capacity and cannot understand the benefits of the medication. The GP
believes that antidepressant would help alleviate his depression. However,
the patient’s daughter (the next of kin) refuses. What should be done?
→ Seek legal advice (Seek advice from the medical defence organisation).
• The next of kin “the closest relative” legally cannot take decisions.
• The patient lacks mental capacity to decide.
• If this was an emergency case, the doctor should do what’s in the patient’s
best interest.
• However, this is not an emergency → we have time to involve the legal team
60
61
GP had mistakenly prescribed a medication to be taken 3 times a day
instead of twice a day.
The patient had been taking this medication for 3
months until another doctor discovered the mistake. What should be done?
→ Report incident via local reporting managing system.
62
daughter is claiming that her mother lacks mental capacity and wants to be
her power of attorney for her mother’s finances.
→ Involve safeguarding.
If there is suspect of financial abuse → safeguarding should be involved.
63
64
man presents to the ER with superficial cut wound on his left arm. He was
treated by a FY2 doctor “junior”.
The patient informed the FY2 doctor that
this cut is caused by a knife by his wife during an argument,
and the patient
wishes that the accident would not be disclosed to the police. What should
this FY doctor do?
→ Seek advice from the senior “consultant”.
When there is risk of harm to others, all gunshots and knife injuries should be
reported to the police.
In this case, it is a bit complicated as the harm is for the patient only.
As a junior doctor, refer to a senior and he should decide whether to inform
the police or to respect the patient’s wish.
65
83 YO patient with advanced dementia was admitted to the hospital
because of lower respiratory tract infection.
She has not recovered yet and
she wants to leave the hospital. She tried to escape several times.
→ Obtain legal paperwork to keep her admitted.
She has not recovered yet.
Mental capacity is doubtful and needs to be assessed.
Sedation with benzodiazepines might be used after the legal paperwork is done
or if she tends to harm herself or others.
66
67
An 83 YO patient with advanced dementia was admitted to the hospital
because of lower respiratory tract infection.
She has not recovered yet and
she wants to leave the hospital. She tried to escape several times.
→ Obtain legal paperwork to keep her admitted.
She has not recovered yet.
Mental capacity is doubtful and needs to be assessed.
Sedation with benzodiazepines might be used after the legal paperwork is done
or if she tends to harm herself or others.
68
69
man with hepatitis B came to your clinic. He is sexually active with his wife.
What should be done?
First Step “initial step” → inform him to tell his wife about his hepatitis B.
If he refuses → Inform his wife through the “Partner Notification Programme”
√ So, firstly, the clinician should encourage him to inform his partner about his
communicable disease.
√ If he insists not to tell his partner, it is then the duty of the clinician to inform
the partner.
70
71
An 88 YO woman with a long history of dementia and seizures has been
admitted to ICU for severe pneumonia. IV fluids and antibiotics have been
commenced.
The anaesthetic team believe that it would be futile (pointless)
to resuscitate her or to intubate if she develops cardiac arrest.
However, her
family insist on resuscitating her in that case. There is no advance notice or
living will in her notes that point towards her decision for resuscitation. What
is the most appropriate action?
A) Fill in a DNR order.
B) Respect her family’s wishes and resuscitate her if needed.
C) Withdraw all treatment.
D) Seek a court order.
E) Discuss the concerns of the anaesthetic team with her family.
√ Remember:
• DNR “Do Not Resuscitate” is a decision of medical professionals not patients
or their families.
• However, the family members should know the meaning of a DNR and should
be told about the reasons of the DNR but their decision would not be
important.
So, in this question, a DNR order would be filled in after it has been revealed
to and discussed with her family FIRST to explain the reasons for them.
What if this same patient has no family?
→ Fill a (DNR) form.
In short, if the medical professionals believe that a DNR is not in the patient’s
best interest, they would fill a DNR form after discussing (revealing, clarifying)
this decision to the patient’s family.
The family’s opinion would not overrule
the doctors’ decision. If he has no family, they would fill a DNR form
72
A 55 YO man with severe peripheral arterial disease needs to have
amputation of his right leg. He has a Hx of schizophrenia that is well
controlled for the past 5 years. The surgery team need his consent for the
amputation. What is the most appropriate initial action?
→ Take consent from the patient.
• Having schizophrenia does not necessarily mean he lacks capacity.
• In addition, his schizophrenia is well controlled.
• Doctor should assume that all adults have capacity unless it is clear they lack
it e.g., if they are not able to understand, weigh up information or
communicate their decisions.
73
The family members of an old man with terminal cancer ask the doctors to
hide the diagnosis and the prognosis from the patient as he will get so
depressed. What should be done?
→ The doctors need to ask the patient to what extent he would like to know
about his diagnosis and prognosis
74
y
97
A patient has signed to go for an elective herniorrhaphy. He has been given
pre-anaesthetic medication. Shortly after, he changed his mind and wanted
to cancel the procedure. What should be done
?
The patient has the right to change his mind at anytime before the surgery.
However, the decision should be discussed and made by senior doctor. Thus,
→ Inform the consultant in charge.
75
Key
98
The family members of an old man with terminal cancer ask the doctors to
hide the diagnosis and the prognosis from the patient as he will get so
depressed. What should be done?
→ The doctors need to ask the patient to what extent he would like to know
about his diagnosis and prognosis.
76
A patient has signed to undergo surgery. However, on theatre, the surgeon
found out the types of the procedure that the patient has signed on is
different than the type of the approach they are planning to follow during the
surgery. What should be done?
→ Cancel the operation and wait the patient to wake up and re-sign on the
appropriate surgery.
Never take consent forms lightly. They are legal documents.
77
A 13-year old boy is brought to you by his mother. She wants a cosmetic
surgery for her son’s ears (pinnaplasty) as they are sticking out and his school
friends bullies him for it.
The boy also asks for the operation as he is a subject
of extreme bullying, and he understands all aspects. What should be done
?
Refer to a NHS plastic surgeon
78
A 13-year old boy is brought to you by his mother. She wants a cosmetic
surgery for her son’s ears (pinnaplasty) as they are sticking out and his school
friends bullies him for it.
However, the boy refuses the operation and he
understands all aspects. What should be done?
Refuse to refer
79
12-year old boy is brought to you by his mother. She wants a cosmetic
surgery for her son’s ears as they are sticking out and his school friends
bullies him for it.
However, the boy refuses the operation. What should be
done?
Involve social services and explore their concerns
- Cosmetic procedures are not usually carried by the NHS. However, this case
is not entirely cosmetic as it is a reconstruction of a congenital deformity.
- We cannot neglect the boy’s decision as this is a surgery which may affect his
life. So, we may involve social services and explore their concerns, one of
which is to assess the boy’s capacity.
- At the same time, we cannot rely entirely on his decision as he is below 16
(The legal age to make decision in the UK).
- If it was a life-saving procedure, we would proceed with the intervention
despite his refusal as he is below 13 and his mother’s decision can override
the 12-year old decision. (Always lean towards what is in the patient’s best
interest).
80
81
A young male with epilepsy has been prescribed an antiepileptic medication
(lamotrigine). However,
he is not compliance and does not take the
medication and therefore he still develops seizure. The patient lacks capacity.
What should be done?
→ Arrange the meeting to discuss the patient’s best interest.
In the case of a patient lacking capacity and not compliance with his
medications, follow the following steps in order:
1) Arrange a meeting between the medical professional and the family member
to discuss it.
2) If still no agreement → an independent advocate should be involved.
3) Is still no agreement → a court should be involved for independent ruling.
82
83
84
85
patient with a knife injury on his thigh comes to A&E. later, the police
comes and tell you that there is a murder they are investigating on. What
should be done?
Provide only necessary information after getting a consent from the patient
- It is not allowed to let the police access the patient if this will delay or affect
his treatment or recovery.
- Before disclosing personal information of a patient, ask the patient for his
permission and consent UNLESS if hiding this information would likely put
others at risk of harm.
HOWEVER, if the gun, knife injury is caused by the patient himself
e.g. a female cuts her wrist by herself
→ refuse to give the police any information about the patient.
86
87
88
A 50 YO woman had a Hx of stroke 2 years ago and she has been on
clopidogrel since then.
She went to elective appendectomy and was advised
to stop clopidogrel 7 days before the elective surgery by the surgical team
because it may lead to perioperative hemorrhage.
However, after stopping
clopidogrel and going for the surgery, she developed another stroke.
Her
husband comes upset and asking about the cause of this second stroke. What
should be done?
→ Explain to him that stopping clopidogrel might be the cause of the second
stroke but do not apologise for stopping clopidogrel.
On weighting the risks and benefits, clopidogrel should be ceased 7 days before
surgery to prevent possible bleeding during the operation.
Thus, no need to
apologise for following the guidelines that are made based on the patient’s
best interest.
89
92
If a GP has prescribed contraceptive medication to a girl who seems to have
competence and understanding of the whole situation, if her mother
discovered and becomes upset about it
→ Explain the patient confidentiality to the mother.
90
An old female with chronic myeloid leukemia singed an advance directive
that she does not want to be transferred to a hospital if she becomes unwell.
She also has a “DNR: do not resuscitate” form singed by her GP. However, her
daughter wants her mother to be transferred to the hospital and to be
resuscitated. What should be done?
→ Inform the daughter that her mother wishes not to be transferred to the
hospital and explain to her what a DNR means.
• Advance directive should be followed.
• DNR is signed by her GP, DNR is a decision of medical professionals not
patients or their families.
However, the family members should know the meaning of a DNR and should
be involved about the reasons of the DNR but their decision would not be
important.
91
1) An elderly woman with Dementia has had a car accident. She does
not remember the accident. What should you do?
Advise her to stop driving and to inform DVLA.
If she refuses →
Inform DVLA yourself
92
2) An elderly woman with Alzheimer’s disease continues to drive and
refuses to inform any authority. What should you do?
Inform DVLA “Driver and Vehicle Licensing Agency”
- It is the responsibility of the patient to inform DVLA.
- However, if they refuse to do so, it is now your responsibility as a doctor to
inform DVLA.
93
What forms do abuse and neglect take?
❤️Neglect and Acts of Omission – failure to act or ignoring medical, emotional or
physical care needs.
❤️Self-neglect – neglecting to care for your own health, hygiene or surroundings.
This can include hoarding.
❤️Physical abuse – including hitting, slapping, pushing, unnecessary restraint or
misusing medications.
❤️Domestic violence – including all types of abuse between family members or
partners; so called ‘honour’ based violence.
❤️Sexual abuse – including inappropriate touching, indecent exposure, rape,
harassment or any sexual acts the adult has not consented to.
❤️Psychological abuse – including emotional abuse, threats of harm, attempts to
control, coercion, verbal abuse and bullying.
•
‘❤️Cuckooin‘’ is a te’m used where criminals exploit vulnerable people by
taking over their homes to deal drugs and commit other crimes
❤️Financial or material abuse – including theft, fraud, coercion with regard
to financial affairs
❤️Modern slavery – including forced labour and human trafficking.
• Modern Slavery is a serious and brutal crime in which people are treated as
commodities and exploited for criminal gain. The true extent of modern
slavery in the UK, and indeed globally, is unknown – Home Of–ice
❤️Discriminatory abuse – harassment or slurs due to someone’s race, ’ender, age,
disability, sexual orientation, religion or gender identity.
❤️Organisational abuse – including neglect and poor care practice within a care
setting or in relation to care provided in one’s own home.
93
The six principles for safeguarding adults are:
Empowerment – presumption of person led decisions and informed consent
Prevention – it is better to take action before harm occurs
Proportionality – proportionate and least intrusive response appropriate to the
risk presented
Protection – support and representation for those in greatest need
Partnerships – local solutions through services working with their communities
Accountability – accountability and transparency in delivering
94
❤️What do we mean by abuse?
Abuse is described as a violation of an individual’s human and civil rights by any
other person or persons which results in significant harm. Abuse may consist of a
single act or repeated acts. Abuse can occur in any relationship and may result in
significant harm to, or exploitation of, the person subjected to it
❤️Adult safeguarding/ Social Services
What does safeguarding adults mean?
Safeguarding means protecting the health, wellbeing and human rights of adults
at risk, enabling them to live safely, free from abuse and neglect. Safeguarding is
everyone’s respon’ibility.
It is about people and organisations working together to prevent and reduce both
the risks and experience of abuse or neglect.
It also means making sure that the
adult’s wellbe’ng is supported and their views, wishes, feelings and beliefs are
respected when agreeing on any action.
❤️Who is an ‘adult at‘risk’?
An ‘ad’lt at‘risk’ is some’ne who may be in need of help because they have care
and support needs. They may be unable to stop someone else from harming or
exploiting them.
Abuse happens when someone hurts you or treats you badly. It can be accidental
or deliberate. Abuse can take many forms. There doesn’t need t’ be an injury for
abuse to have taken place. Neglect is when someone who is meant to look after
you does not look after you properly.
95
96
Key
87
An elderly man with Alzheimer’s disease living in the nursing home have been
deteriorating lately. He had signed his advance directive “living will” 2 years
ago that states that he does not want to be admitted to a hospital if he
deteriorated. He selected his son to be his lasting power of attorney 3 years
ago.
The son now insists that his father should be admitted to a hospital. His
daughter is the next of kin insists to admit her father as well.
The patient is
assessed by the nurses and found to lack mental capacity. What should be
done?
A) B) Follow the son “The lasting power of attorney for health”.
C) Follow the daughter “The next of kin”
Let’s firstly exclude the next of kin “the closest relative” as they legally cannot
take decisions.
√ Now let’s see the advance directive VS Lasting power of attorney:
• The most recent one is the one to be followed.
• Since the advance directive was signed 2 years ago while the lasting power of
attorney was appointed 3 years ago, the advance directive is to be followed as
it is more recent.
If the advance directive was signed 3 years ago, and the lasting power of
attorney was nominated 2 years ago, the wish of the lasting power of
attorney is to be followed as it is more recent.
97
An elderly lady with Alzheimer’s disease presents to her GP asking him to
change her will as she believes that her family is looking for her money. What
should this GP do next?
→ Assess her mental capacity.
√ Remember that the mere fact this lady has Alzheimer’s does not mean she
lacks capacity. We need to assess first!
√ Remember that having dementia does not necessarily indicate impaired
mental capacity.
√ GMC says “mental capacity is decision and time specific”.
Some may choose the option that says “refer for a psychiatrist to assess
her mental capacity”.
This is incorrect.
In the UK, any doctor can assess the mental capacity and thus no need to refer
to a specialist.
98
An old patient with terminal stage lung cancer presents to his GP and states
that he does not want to be resuscitated shall he undergo a cardiac arrest.
The GP believes that CPR would not help in his case and even if it goes
successfully,
it would lead to a poor quality of life. The patient is also
following up with an oncologist and a palliative care team. What should this
GP do?
→ Fill in and sign DNR form.
DNR = Do Not Resuscitate.
√ NHS states that: everyone has the right to refuse CPR “cardiopulmonary
resuscitation” if they wish.
√ As this is the patient’s wish, it is enough for his GP to fill in a DNR form.
√ The GP is legible to fill in and sign a DNR form. In fact, most DNR forms are
signed by GPs given that they know their patients the best.
√ In the case of a junior doctor, the DNR form should be countersigned by a
more senior doctor.
√ Note that a DNR decision is a clinical one. Ie, if the patient went unconscious
and has no advance directive (a living well), the clinical team can decide
whether to assign a DNR or no. It is a clinical decision.
99
A 15-year-old girl presents to her GP for Contraception. She is having sex with
a boy who is in her class.
She doesn’t want her parents to know because they
would be upset.
Which of the following should the GP inform?
No one
A. B. Her Parents
C. Police
D. school Nurse
E. Social service
- If her partner is the same age as her or slightly older, you should advise her
to tell her parents first.
If she refuses, then advice about safe sex and
prescribe the contraceptive pills as long
as she understands the aspects of
the treatment and it is in her best interest physically and mentally.
- As the boy she is having sex with nearly has the same age as her, you should
not tell anyone if this is what she wants.
100
FY2 doctor had reviewed a chest X-ray of a patient who has chronic cough.
The FY2 doctor considered the X-ray to be normal and thus sent the patient
home on proton pump inhibitor thinking that his chronic cough is due to
GERD.
However, the following day, the X-ray was reported by a consultant
radiologist which states that there are patchy opacities in the perihilar lungs.
The A&E consultants then contacted the patient, started him on antibiotics,
and wrote his finding on his clinical notes. What should the FY2 doctor do?
a) Add an addendum to the initial notes, stating new findings with today’s date
and sign
b) no changes to record
c) Delete your previous documentationsand write a new one
d) Write a letter to the patient apologizing and put a copy in the patient’s
record
Since the A&E consultants have already informed the patient’and documented
his actions, the FY2 doctor does not need to do any action.
101
A 50 YO woman who is admitted in the surgical ward starts to have shortness
of breath. The surgical team suspects pulmonary embolism. The junior
radiologist has reported her CT scan as Normal.
Later on, the consultant
radiologist has reviewed the CT scans and found that there is a mass in the
left breast. What should the consultant radiologist do?
a) Add an addendum to the initial notes, stating new findings with today’s
date and sign
b) no changes needed to record
c) Delete your 4revious’ documentation and write a new one
d) Write a letter to the pa4reviousssspologizing and put a copy in the patient’s
record
Always document the events in the patient’s record.
No del’tion or amendments on the previously added notes should be made.
Just add a new addendum regarding the recent/ new events.
102
You suspect a college junior doctor to be under the effect of recreational
drugs. What should you do?
1st ➔ If he does not respond:
2nd ➔ Confront him directly.
Inform a senior consultant.
103
104
A delivering lady had abnormal CTG and thus an emergency Caesarean Section
decision is made.
However, the patient refuses to sign the consent. She has a
mental capacity and she understands the risk for her baby. What should you
do?
Accept her wish and proceed with Vaginal delivery
In the UK, an unborn child has no rights.
The husband is unable to consent. It is up to the mother.
105
You stick yourself with a needle that was used to obtain a blood sample from
an unconscious patient.
You are afraid to get blood-borne disease. What
should you do
?
You need to wait for the patient to become conscious in order to obtain a
consent and send a blood sample to investigate for blood-borne infections
You cannot investigate for infections unless he accepts and consents EXCEPT if
it is for his best interest. In the given scenario, this sample of blood and analysis
are in your own best interest, not the patient’s.
106
A 15-year-old girl asks you for OCP. Her partner is 35-year-old. She refuses to
tell her parents. What should you do?
Breach the confidentiality and inform authorities
- This is because her partner is much older than her. In this case, we fear child
abuse or exploitation.
- If her partner is the same age as her or slightly older, you should advise her
to tell her parents first.
If she refuses, then advice about safe sex and
prescribe the contraceptive pills as long as she understands the aspects of
the treatment and
it is in her best interest physically and mentally.
- The legal age is 16.
107
patient was involved in a fight and brought to the A&E uncooperative and
with open wound and laceration on the head.
Soon, he becomes unconscious.
What should you do?
Proceed to investigation and treatment without his consent
- This is in his best interest and the case is acute and urgent.
- An early detection of abnormalities is vital. We cannot wait for him to
become conscious nor can we wait to seek legal advice.
108
You suspect that your colleague doctor is under illicit drugs. So, you
confronted him but he denied the allegation.
You still suspect he is taking
drugs. What is the next best step to take?
Inform the consultant
Remember, you cannot investigate and gather evidence as this is
unprofessional.
You only firstly confront him with advice and secondly inform
the consultant.
If still not satisfied and still has concerns → raise it to the GMC
109
pregnant young woman is brought to the A&E by her mother and husband
.
She has lower abdominal pain and she has active heavy vaginal bleeding. IV
fluid and tranexamic acid are given but the patient is still hypotensive.
An
urgent evacuation of retained products of conception is needed.
However,
she cannot sign the consent to be taken to the theatre as she is semi-
conscious. What should be done?
Take her to the theatre to save her life without a need for her consent
- This is an urgent and life-saving action. It is in the patient’s best interest. So,
no need for consent.
- However, you need to document that she is unable to sign as she is semi-
conscious in her records.
- The family members and the husband are not allowed by the legislation to
sign on her behalf (Imagine they refuse the operation)!
110
You suspect that one of your colleague doctors is under alcohol effect. What
should you do?
1st → Confront him
2nd → inform a senior doctor.
3rd → inform GMC.
If unsure what to do → Seek advice from medical defence organisation.
111
A case of paracetamol poisoning is brought to the A&E. She is unconscious.
The serum paracetamol level is found to be above the treatment line. What
should be done?
Treat the patient without his consent and collect collateral information
- This is in the patient’s best interest.
- Paracetamol overdose could be fatal.
- N.B. N-Acetylcysteine is the antidote for paracetamol overdose.
112
burglar is injured during a gunfire fight with the police. He comes to the
A&E and asks you not to tell the police. What should you do?
Inform the police but do not reveal any personal information of the patient
- GMC says that any victims of gunshots who come to the Emergency
Department need to be reported to the police.
This is in the public and the hospital staff’s best interest as a protection and
precaution.
- Revealing their personal details should not usually be done in the first
contact with the police.
113
Your patient who is a surgeon is diagnosed with hepatitis B. He asks you not
to inform the NHS trust about his diagnosis. What should you do?
Inform the relevant health authorities
- He is a surgeon with a blood-borne communicable disease and there is a risk
that his hepatitis transmits to his patients.
Therefore, you need to inform the
relevant health authorities as this is in the patients’ best interest.
114
A 16-year old boy with acute appendicitis that requires surgery. The patient
agrees on the operation and is willing to consent. However, his parents refuse
the surgery. What should be done?
Get a consent from the patient and go for the surgery
- At 16-year-old, the individual is presumed to have the capacity to consent.
Parents cannot override his consent.
- Under 16, we need to look for the signs of maturity in the individual and his
understanding of the situation so we can decide accordingly whether he is
capable to consent or not.
- Under 13, the individual is considered by low as unable to consent.
In short:
• < 13 ➔ Unable to give consent.
• (13-15) ➔ Can give consent if they are mature enough to do so. However, if
• ≥ 16 it is not an emergency case and the patient is refusing a life-saving
procedure ➔ Seek Legal Advice. (There is time to do so).
➔ Can give consent.
115
116
woman wants to do Laparoscopic Sterilisation and she understands the
risks of this procedure. However, her husband refuses as he wants an
additional child. What should be done?
Take a written consent from the patient (the woman) and proceed to the
surgery
- It is her body. The husband has no legal rights to object.
- This is a surgical intervention; thus, a Written consent is required.
117
15-year old child is brought to A&E by his parents. He has lower abdominal
pain. After examinations, the doctors suspect appendicitis and decide to
admit the patient.
Nonetheless, the boy seems to be unable to well
understand the complications of the untreated appendicitis.
He refuses the
admission as he wants to go to a party with friends tonight.
On the other
hand, his parents want him admitted and willing to sign the consent. What
should be done?
Obtain parental consent and admit the patient
- It is clear that the boy lacks maturity + he is under 16 ➔ we can rely on
parental consent.
- Remember that:
• < 13 ➔ Unable to give consent.
• (13-15) ➔ Can give consent if they are mature enough to do so. However, if
it is not an emergency case and the patient is refusing a life-saving
procedure ➔ Seek Legal Advice.
Greater than 16➔ Can give consent.
118
119
120
17 to 84
121
An FY2 doctor who is a friend of yours working at the same department has
been having suppurative tonsillitis. He asks you to write him antibiotics
prescription. What should you do?
→ Ask him to see his GP.
√ In the UK, it is a good practice not to prescribe for family, friends or
colleagues.
√ Also, his GP is the best option as he knows his medical history and drug
history.
122
A 44 YO woman comes to the GP requesting sleeping pills because she cannot
sleep at night due to the loud music being played at nigh by her neighbours.
She asked them several times to keep it down but they did not response. She
cannot focus at work because of the lack of sleep. What is the most
appropriate action?
→ Advise the patient to inform the local authorities.
What if the local authorities have already been informed?
Then → Advise the patient to inform the police.
No point of advising on sleeping hygiene because the reason is physical (loud
music at night by the neighbours).
• Also, prescribing sleeping pills is incorrect as long as the cause is external and
can be stopped.
123
FY2 doctor who is a friend of yours working at the same department has
been having suppurative tonsillitis. He asks you to write him antibiotics
prescription. What should you do?
→ Ask him to see his GP.
√ In the UK, it is a good practice not to prescribe for family, friends or
colleagues.
√ Also, his GP is the best option as he knows his medical history and drug
history.
124
divorced mother who has 3 children under her care presents complaining of
depression. During history taking, she admits that she had used cocaine last
year for only a week to cope with her low moods.
However, she has not used
it since then. She asks you not to write these notes about taking cocaine in
her medical records. What would you do?
→ Inform her that any clinically relevant notes have to be documented but
will stay confidential.
125
One of your colleague doctors has recently posted an Instagram photo of him
and a 21-year-old girl on a drunken date. You have realised that this girl was a
patient under this doctor’s care recently.
You confronted him, but he said
that she has made the first move, and he finds her attractive. He does not see
his act as improper because she is not his patient anymore. What should be
done?
Since you have already confronted him “which is the initial step” and he
persists, the next most appropriate step would be:
→ Report to the lead consultant.
It is inappropriate to start a relationship with your current or former patient,
especially if the professional relationship has ended recently like in this case.
126
You are a FY2 doctor and one of your colleague doctors has started to have a
relationship with one of the patients.
He told you that he thinks that she is
cute and he would like to go out with her on date.
They are already friends on
Facebook. What should you “initially” do?
◙ Initially → Speak to him and tell him that making relationships with
patients is unprofessional and against good medical practice.
“he might be unaware of this and might stop after being informed”
◙ If he continues to pursue this relationship after you have approached him:
→ Inform his clinical supervisor/ consultant/ medical director.
◙ If he continues to cross professional boundaries:
→ Inform GMC.
127
An elderly woman has been living with dementia for 3 years. Her neighbour
comes to the GP clinic and says that the daughter of that elderly lady is
treating her sick mother weird.
She locks her mother in house when she goes
out. What should be done?
→ Inform the local safeguarding team.
√ The local safeguarding team would investigate this issue and try to offer
solutions that will not endanger that elderly lady with dementia.
√ There is a risk that this elderly woman would be exposed to neglect, or may
be her daughter is trying to protect her by locking her in house for long periods.
However, the safeguarding team and the social services would speak to the
daughter and know her intentions and work together to provide appropriate
solutions.
√ The police might be involved if the safeguarding team feels that the elderly
mother is being abused and neglected by her daughter.
128
man with HIV refuses to tell his wife about his diagnosis. He promised to
used condoms but he does not want his wife to know about his diagnosis.
What should be done?
• First Step “initial’’ most appropriate step is to:
→ Encourage him to tell his wife and to bring her for a check-up
• If he refuses
→ Notify his wife through the “Partner Notification Programme”
This would be done by the sexual health doctor.
√ Condoms are good barriers to reduce the risk of HIV transmission but they
are not 100% effective. Also, we cannot rely entirely on his promises.
- This programme is to notify about the sexually transmitted infections (STIs)
and/or HIV as they are communicable disease.
- The wife has to know in order to get investigations and proper treatment if
required.
Firstly, the affected patient is asked to inform their spouse within a time
frame. If he does not, then the “[partner notification programmes” should
inform the spouse.
129
45 YO male presents with a lump on his left testicle. The male doctor offers
a chaperone.
However, the patient declines and says that he does not want a
chaperone. The patient’s wife and friend are in the waiting room. What
should be done?
→ Carry on without a chaperone and document that the patient refused a
chaperone.
√ The chaperone MUST be offered.
√ However, if the patient refuses, the doctors can carry on without a
chaperone but they need to document this in the patient’s records.
√ Family, relatives, and friends are not considered chaperones. However,
they may attend beside the chaperone if the patient is willing.
√ If the doctor feels that he cannot proceed without a chaperone, he can
refer the patient to another doctor provided that any delay will not cause
harm to the patient.
130
A FY2 doctor sustained a needle stick injury while taking a sample from an
unconscious patient with a history of Intravenous drug use.
The department
of public health recommends that a sample to be taken from the patient for
further investigation. What is the appropriate next step?
A. No need to take the sample
B. Ask for consent from the family of the patient
C. Take the sample.
D. Wait until the patient is conscious and take consent
E. obtain a court order for sampling
You need to wait for the patient to become conscious in order to obtain a
consent and send a blood sample to investigate for blood-borne infections.
You cannot investigate for infections unless he accepts and consents EXCEPT if
it is for his best interest. In the given scenario, this sample of blood and analysis
are in the doctor’s best interest, not the patient’s
131
female patient requiring breast examination. She came to clinic with family
and friends. You as a male doctor offered a female chaperone but the patient
refuses the presence of the chaperone. What should be done?
B) Allow friend to chaperone
C) Accept her refusal to chaperone, go ahead and examine her, and document
what happened.
D) Refuse to carry out the examination without a chaperone
E) a chaperone must be made available whether the patient consents or not
Chaperone should be offered. However, if the patient refuses the presence of
chaperone, the doctor may proceed without him/her. Nonetheless, he should
document the event in the patient’s record
132
A man who had chest infection, seen by FY2 doctor who requested CXR.
Radiologist reports normal findings and man is treated. Afterwards, abnormal
findings are discovered and patient is notified and treated. What should the
doctor do?
a) Add an addendum to the initial notes, stating new findings with today’s
date a’d sign
b) no changes needed to record
c) Delete your previous documentation and write a new one
d) Write a letter to the patient apologizing and put a copy in the patient’s
record’
√ Always document the events in the patient’s record.
√ No deletion or amendments on the previously added notes should be made.
√ Just add a new addendum regarding the recent/ new events.
133
15-year-old girl presents to her GP for Contraception. She is having sex with
a boy who is in her class. She doesn’t want her parents to know because they
would be upset. Which of the following should the GP inform?
No one
A. B. Her Parents
C. Police
D. School Nurse
E. Social service
- If her partner is the same age as her or slightly older, you should advise her
to tell her parents first. If she refuses, then advice about safe sex and
prescribe the contraceptive pills as long as she understands the aspects of
the treatment and it is in her best interest physically and mentally.
134
An elderly lady with breast cancer has learning difficulty was offered to
be on a new medication trial but her daughter disagreed? What to do
next?
→ Refer the patient to psychiatrist to assess her capacity to refuse.
135
A man with HIV refuses to use condoms and refuses to tell his wife about
his diagnosis. What should be done?
First Step “initial step” → Encourage him to tell his wife.
Second step if he insists not to inform his wife
→ Notify his wife through the “Partner Notification Programme”
- This programme is to notify about the sexually transmitted infections (STIs)
and/or HIV as they are communicable disease.
- The wife has to know in order to get investigations and proper treatment if
required.
- Firstly, the affected patient is asked to inform their spouse within a time
frame. If he does not, then the “[partner notification programmes” should
inform the spouse.
136
obese man slept while driving a lorry. He is afraid to lose the job. What is
the likely Dx and what should be done?
Obstructive sleep apnea
→ Advise him to inform DVLA
If refuses → Inform DVLA
137
patient with Multiple Sclerosis (MS) has taken 40 paracetamol pills to end
his life.
His wife wants him to be treated from paracetamol overdose;
however, he insists not to be treated. What should be done
?
→ Assess his mental capacity
Prior to make him consent not to receive treatment, we need to make sure that
he is mentally capable to take such a decision. Remember also that he has MS.
138
You suspect that one of your colleague doctors is taking cannabis. What
should you do?
1st line → Confront him
2nd → inform a senior doctor.
3rd → inform GMC.
If unsure what to do → seek advice from medical defence organisation.
139
An 85-year-old woman with advanced dementia was admitted for
pneumonia. A few days later, she becomes better but without a full recovery.
She insists to leave the hospital. However, her daughter says that leaving the
hospital might be unsafe as she lives alone. What should be done
?
Assess her mental capacity
- Remember that having dementia does not necessarily indicate impaired
mental capacity.
- GMC says “mental capacity is decision and time specific”.
Some may choose to sedate the patient with benzodiazepine. This is wrong
unless she clearly lacks mental capacity and her leaving might cause harm to
herself or to others.
140
When to inform DVLA (in case of TIAs)?
- If group A driver (Car) and has MULTIPLE TIAs within a short period.
- If group B driver (Lorry or Bus) and has a SINGLE TIA.
- You must tell DVLA if you’ve had any epileptic attacks, seizures, fits or
blackouts.
◙ A man with Obstructive Sleep Apnea (OSA), what shall he do regarding
driving issue?
→ Encourage him to inform DVLA
lorry driver has seizure but continues to drive. What should be done?
→ Inform DVLA.
A mother with Alzheimer’s continues to drive. Her son advised her not to do
so. However, she insists to drive.
→ Report to DVLA.
◙ A man has a single TIA “Transient Ischemic Attack” and he is now fit for
discharge. What should you advise him about car driving?
→ Stop car driving for at least 1 month +
→ Stop lorry or Bus driving for 1 year
141
patient wants to thank you so he offers you a valuable hand watch. What
should you do?
Refuse it and explain to him that doctors are not allowed to receive valuable
gifts from patients
- Valuable gifts include money and gifts that are of £100 or more. You cannot
accept these.
- You can accept small tokens, symbolic gifts.
If the patient insists ➔ Recommend donating it to a charity or to the
department fund
142
Patient was diagnosed with HIV in a Genitourinary clinic. He asks not to
tell his GP about his diagnosis. What to do?
• Accept the patient’s decision and do not tell his GP
- This is because the patient can take his anti-viral treatment at the GU Clinic.
- Also, AIDS is a blood-borne disease and its disclosure has no public interest
(It won’t make any differences to the risk of transmission if you break the
news to the GP).
- The case might have been different if the disease is an air-borne disease.
143
schizophrenic young man attends a psychiatry clinic for follow-up. He says
that he hears sounds telling him to hurt his ex-girlfriend.
He admits that he
knows that these sounds are not real but he sometimes has a tendency to
follow them. Suddenly, he leaves the clinic before the consultation is ended.
What should be done?
Breach the confidentiality and inform the police AND his ex-girlfriend
The risk of harming the ex-girlfriend outweighs the patient’s privacy.
Always consider breaching confidentiality if there is a public interest or if
keeping the confidentiality would likely to harm somebody.
144
When to breach confidentiality?
When to breach confidentiality?
• If the patient gives a consent to do so.
• If keeping confidentiality would likely to harm somebody. Breaching
confidentiality is in the public’s best interest.
• When requested by the Law (e.g. court order, requested by a judge).
• When breaching confidentiality is in the patient’s best interest “there is a
benefit for the patient who lacks capacity”
145
While on a restaurant, you found a paper with patients details on a nearby
table which is unattended. What should you do?
Look through the paper to find the GP contact and then inform the GP
practice
What if no contact details are there?
→ take the paper to the hospital named on it.
146
Jehovah’s witness has severe postpartum hemorrhage. Her vital signs are
deteriorating.
She has an advance directive form states that she is not to be
given blood products even if to save her life. Her husband wants blood
transfusion. What should be done?
Give IV fluid
- We must respect her wishes of not to receive blood products “as stated in
her blood refusal card”.
- Pay special attention to the options as sometimes there will be an option
“Give IV fluid”. This would be the correct answer.
- If this was not in the options, pick (Respect her wishes and do not transfuse
blood).
147
148
An 85-year old woman with advanced dementia was admitted for
pneumonia. A few days later, she becomes better but without a full recovery.
She insists to leave the hospital. However, her daughter says that leaving the
hospital might be unsafe as she lives alone. What should be done?
Assess her mental capacity
- Remember that having dementia does not necessarily indicate impaired
mental capacity.
- GMC says “mental capacity is decision and time specific”.
- Some may choose to sedate the patient with benzodiazepine. This is wrong
unless she clearly lacks mental capacity and her leaving might cause harm to
herself or to others.
149
13-year old girl presents to the GP with her 13-year old boyfriend and asks
for OCP. What should be done?
Give contraception
They are the same age. No fear for child abuse or exploitation.
However, a GP
would advise them to inform their parents first, and then advise on safe sex
and provide the OCP.
150
lady insists on undergoing sterilisation as her last child has cerebral palsy.
She has tried many forms of contraception and finally decided to go for
sterilisation.
Nevertheless, her husband refuses the procedure. What should
be done?
Respect her wishes and proceed to sterilisation
- There is no indication in the question towards lacking the mental capacity.
- The husband has no right to override her decision.
151
12-year old boy is brought to you by his mother. She wants a cosmetic
surgery for her son’s ears as they are sticking out and his school friends
bullies him for it.
However, the boy refuses the operation. What should be
done?
Involve social services and explore their concerns
- Cosmetic procedures are not usually carried by the NHS. However, this case
is not entirely cosmetic as it is a reconstruction of a congenital deformity.
- We cannot neglect the boy’s decision as this is a surgery which may affect his
life. So, we may involve social services and explore their concerns, one of
which is to assess the boy’s capacity.
- At the same time, we cannot rely entirely on his decision as he is below 16
(The legal age to make decision in the UK).
- If it was a life-saving procedure, we would proceed with the intervention
despite his refusal as he is below 13 and his mother’s decision can override
the 12-year old decision. (Always lean towards what is in the patient’s best
interest).
152
Seek Legal Advice
Although this patient seems to be competent to consent, the case is a life-
threatening one and it is not an emergency case.
Therefore, we have time to
seek legal advice (+) the surgery is in her best interest.
In a competent patient who refuses the treatment of a life-threatening
condition ➔ Seek Legal Advice.
General Note: Who can give consent?
1) The Patient (Unless if lacks mental capacity).
2) The Doctor (when the patient is unconscious to decide).
3) The Relative (when authorised by the power of attorney).
However, if the ne
153
pregnant woman in early labour with Umbilical Cord Prolapse. The senior
obstetrician decides to take her to the theatre for Urgent Caesarean Section.
She is unable to consent as she is illiterate. What should be done?
Take Verbal Consent and Proceed to the Caesarean Section
This is an emergency case. A Verbal Consent is sometimes appropriate instead
of a written consent such as in the case of illiterate patient or the urgency of
the operation.
Remember to document her verbal consent and the reason for not obtaining a
written consent in the patient’s medical records.
Notes:
- The husband cannot sign on her behalf unless she lacks capacity
Seeking legal advice is not appropriate in an emergency case.
154
Key
19
A 14-year old girl asks for oral contraceptive pills. Her partner is 15-year-old.
What should be done?
Prescribe OCP and advise her to tell her parents
- If her partner is much older than her, we fear child abuse or exploitation. So,
we would tell the police.
- If her partner is the same age as her or slightly older, you should advise her
to tell her parents first. If she refuses, then advice about safe sex and
prescribe the contraceptive pills as long as she understands the aspects of
the treatment and it is in her best interest physically and mentally.
- The legal age is 16.
155
During a surgery, the patient developed cardiac arrest and died while on the
operating table. What should be done?
→ Inform Coroner.
◙ Who is coroner?
An official who investigates violent, sudden, or suspicious deaths.
156
◙ When to inform the coroner?
- Deaths due to accidents, neglect, suicide, violence, industrial disease.
- Deaths in relation to surgical treatment or anaesthesia need to be referred
to the coroner even if the patient is already out of the theatre as long as
there is a possibility that the surgery may have resulted in death.
- Sudden and unexpected deaths (eg, within 24 hours of admission to a
hospital).
- Death of an individual who was not seen by a doctor in the last 14 days of
his/her life.
- Deaths of unknown cause.
- Deaths during surgery or before recovery from anaesthesia.
- Deaths shortly after police custody or prison.
157
◙ What can the coroner consider to be done?
• Allow the doctors to issue a cause of death certificate and takes no action.
• Open a post-mortem examination (could lead to open an investigation/quest).
• Open an investigation/quest without a post-mortem examination.
Note: do not forget that patients with “mesothelioma” need to be reported to
the coroner as well. This is because it is an “industrial disease”.
Note: Muslim and Jewish families have religious beliefs indicate that the dead
should be buried as quickly as possible.
So, if the (suspicious) death is for a
Muslim, we also refer to a coroner and inform him that the dead is a Muslim so
he can make the required investigations as quickly as possible.
Doctors also
need to explain to the family the necessity of including the coroner and that
the procedure would be quick
158
pregnant woman in the second stage of labour. The CTG is abnormal and
indicates foetal distress.
The doctors decide for CS but the woman refuses the
surgery and wants vaginal delivery despite knowing the risk on the fetus.
Her
mental capacity assessment concludes that she has capacity. What should be
done?
Respect her wishes and go for a vaginal delivery
- She has capacity.
- In the UK, an unborn baby has no rights until he is born.
- Her husband cannot consent on her behalf unless he has power of attorney.
- If a patient makes an unwise decision, this does not make him incompetent!
159
A 90-year old woman with terminal stage breast cancer with multiple bone
metastasis.
She is on morphine but still in severe pain. Her doctors suspect
she has a few months to live.
The patient discusses ending her life with her
family and they agree. She asks you to give her a lethal medication to end he
life. She is compos mentis (Able to think clearly and to make decisions). What
should be done?
Refuse the lethal drug and tell her that there are other more powerful
analgesics to alleviate her pain
- Euthanasia is illegal in the UK.
- A few hours to days before her death (Expectedly), doctors can give
palliative sedation.
160
A 15-year old girl come to A&E with her boyfriend who is 24-year old. She
complains of lower abdominal pain.
After examinations, she is fit to
discharge. What should be done before discharging her?
Inform Safeguarding authority
- Her sexual partner is much older than her, we fear of child abuse or
exploitation.
- We inform safeguarding authority (who are already present in hospitals and
they would gather more information and involve the police if needed).
- If this was not in the options, pick (Inform Police).
161
An elderly woman with dementia presents with pneumonia which soon
deteriorates.
The doctors decide that resuscitation is not in the patient’s best
interest as it will lead to a poor quality of life. However, her daughter wants
them to resuscitate her.
The nurse checked the patient’s file and did not find
any “Advanced Notice” or “Living Will” related to DNR. What should be done
regarding the DNR “Do Not Resuscitate” Order?
Involve the patient and her daughter regarding the decision of the DNR but
there is no need for their consent as the DNR is a decision of the doctors only
- This might be strange, but a decision on a DNR order can be made by the
doctors even if it is against the patient’s wish! The patient is not required
to consent on a DNR order!
- However, the patient and his family need to be involved and to know
about the DNR decision.
- The patients have no right to ask for CPR if the doctors believe that CPR
would be unsuccessful or not in the patient’s best interest.
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When are doctors allowed not to resuscitate?
(When is DNR allowed)?
• If a patient “with capacity” refuses the resuscitation, respect his wish!
• If there is advanced notice or living will that says the patient does not want
to be resuscitated.
• If the doctors see that the resuscitation is unlikely to succeed.
• If the doctors see that the resuscitation is not in the patient’s best interest
(e.g. it would lead to a poor quality of life).
- Remember, CPR is traumatic and can lead to ruptured spleen and fractured
ribs…etc.
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164
A Jehovah’s witness man had a road traffic accident (RTA) and bled massively.
In the A&E, he was given IV fluids.
However, the doctors see that an urgent
blood transfusion is needed. The patient refuses this according to his religious
beliefs. What should be done?
Accept his wish and do not transfuse blood
- Many Jehovah’s witnesses do not accept blood products based on their
religious beliefs.
- The law says that if they are competent or if they carry the blood refusal
card, we should respect their decision on not to receive blood products even
if this would lead to their death! IV fluid can be given instead.
- You can advise them to receive blood, but you are not allowed to pressure
them to accept it.
165
A man with dementia has large ulcer on his face and he wants it removed as
he thinks that this would improve his memory.
His wife says that he lacks
capacity to consent. What should be done?
Refer him to a psychiatrist to assess his mental capacity
Even if the patient is clearly lacking capacity, a documented lack of capacity
needs to be obtained (Through a psychiatrist).
166
A 14-year old girl comes to your clinic and asks for contraception. Her partner
is her teacher at school.
She does not want anyone to know about her
relationship with the teacher and she refuses to involve her parents. What
should be done?
Inform the safeguarding authority
- This is likely to be a case of exploitation.
- The teacher has a position of trust and this position must not be abused.
- Inform the safeguarding. If not available in the options, Pick: inform the
police.
- (We initially inform the safeguarding authority as long as there is no
immediate risk to the girl).
- The safeguarding team would obtain all necessary information before they
inform the police.
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17-year old boy is brought to A&E after RTA. He is unconscious. What
should be done regarding the initiation of treatment?
Begin treatment and resuscitation as needed without his consent
- This is an emergency case and beginning the treatment without his consent
(as he is unconscious) is in his best interest and is a life-saving act.
- When he becomes conscious, we can ask for his consent on the upcoming
treatment plans.
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15-year old mentally competent girl asks you for contraceptive device.
What should be done?
As the patient is mentally competent,
First → Advise her to inform her parents.
If she refuses → provide the contraceptive device
HOWEVER, before doing so,
Ask her about her sexual relationship and the age of her partner!
• Any of these would be the right answer if given in the options.
• The cervical smear is not required in the UK until the age of 25 years even if
she is sexually active
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An unconscious pregnant woman is brought to the A&E after RTA. She is
bleeding massively, and blood transfusion is urgently required.
She carries a
witnessed written directive refusing blood and all blood products. What
should be done?
Respect her wish and do not transfuse blood but give IV fluids
- Many Jehovah’s witnesses do ant accept blood products based on their
religious beliefs.
- The law says that if they are competent or if they carry the blood refusal
card (Witnessed written directive), we should respect their decision on not
to receive blood products even if this would lead to their death!
- You can advise them to receive blood, but you are not allowed to pressure
them to accept it.
- An unborn fetus has no rights in the UK until born.
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mother of a 14-year old girl comes to the GP clinic and asks him to prescribe
a medication to alleviate the dysmenorrhea of her 14-year old daughter. The
daughter could not come as she is busy at school. What should be done?
No prescription by Proxy ☺)
Arrange an appointment to meet both the mother and the girl together
The doctor needs to assess the daughter’s mental capacity and to take consent
from her that allows her mother to take responsibility of her own health care.
171
A patient with Multiple Sclerosis (MS) has taken 40 paracetamol pills to end
his life.
His wife wants him to be treated from paracetamol overdose;
however, he insists not to be treated. What should be done?
Assess his mental capacity
Prior to make him consent not to receive treatment, we need to make sure that
he is mentally capable to take such a decision. Remember also that he has MS.
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A patient is brought to the A&E after RTA. He is conscious, alert and oriented.
His wife has just arrived to the hospital and asked you about her husband’s
condition. What should you do?
Ask the patient’s permission before disclosing any information
No information should be disclosed to a third party without a permission
from the patient even to his spouse and relatives!
What if the patient is unconscious?
You may inform the relatives about the patient’s condition unless you
STRONGLY believe that the patient would not allow
174
15-year old girl comes to your clinic with her boyfriend who is also 15-year
old.
She asks you for Oral Contraceptive Pills (OCP) as they are sexually
active. They could not be convinced to tell their parents. What should you
do?
Advise them about safe sex and prescribe the OCP
They are the same age → no fear of child abuse or exploitation.
- They refuse to tell their parents.
175
You suspect that your colleague FY2 doctor is under illicit drugs as some
nurses have told you he is hallucinating sometimes and does not complete his
duties.
You confront him and he admits that he is taking cannabis. What
should you do next?
Inform his clinical supervisor.
1st → confront him.
2nd → inform a senior.
3rd → inform GMC.
In some situations, we cannot just give advice and leave it at this level. This
might endanger patients’ safety.
It is clear that this FY2 doctor is likely to have a
psychological illness which may endanger the patients.
Therefore, raise your
concerns to his clinical supervisor
176
A 15-year old girl present with mild vaginal bleeding. Pregnancy test is
Positive.
She refuses to tell her parents and she refuses to give any
information about her partner. What should be done?
Assess her competency to make decisions
177
A patient with a knife injury on his thigh comes to A&E.
later, the police
comes and tell you that there is a murder they are investigating on. What
should be done?
Provide only necessary information after getting a consent from the patient
- It is not allowed to let the police access the patient if this will delay or affect
his treatment or recovery.
- Before disclosing personal information of a patient, ask the patient for his
permission and consent UNLESS if hiding this information would likely put
others at risk of harm.
178
young lady comes to A&E with her husband complaining of abdominal pain.
She does not speak English and her husband translates to both of you. While
examining her abdomen, you found many bruises.
The husband tells you that
she has fallen the stairs a week ago. What should be done?
Admit the patient and request an independent translator
- As doctors, we need to take suspected domestic abuse seriously.
- Admitting the patient would prevent her contact with her husband who
might continue hurting her.
- It would also give us a chance to arrange an independent translator via “NHS
Language Line” so we can understand the real story as she will most likely
speak freely away from her husband.
- We should not contact the police or the safeguarding before knowing the
whole story.
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man has a single TIA “Transient Ischemic Attack” and he is now fit for
discharge. What should you advise him about car driving?
Stop car driving for at least 1 month
Stop lorry or Bus driving for 1 year + Inform DVLA even if single TIA
When to inform DVLA?
- If group A driver (Car) and has MULTIPLE TIAs within a short period.
- If group B driver (Lorry or Bus) and has a SINGLE TIA.
Important:
√ Cases of DVT and Pulmonary embolism can continue driving without an issue
and as long as they don’t lose consciousness and can move their legs freely. They
do not need to be reported to DVLA.
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