HCE - Ethics & Law

Ethics & Law • • • • • To use the concepts of ethical decision making of beneficence, non-maleficence, respect for autonomy and justice as applied to patients they are currently seeing. To discuss the concept of “futility” and problems and advantages of this concept. To identify how capacity to make an informed decision can be assessed. To identify the conflicts of interests that explain why proxy decision makers do not have the same ethical or legal rights in decision making, and hence how to use such proxies in clinical decision making. To introduce students to advance directives, their advantages, disadvantages and legal status 4 Principles of Ethics Autonomy Self determination, individual choice, consent Benifecence To do good Non-malifeicence To do no harm Justice / Equity Fairness between patients Autonomy = Self determination, individual choice, consent Capacity – under Mental Capacity Act 2005 (in effect from April 07) o For the purposes of a section 2, a person is unable to make a decision for himself if he is unable § To understand the information relevant to the decision § To retain that information § To use or weight that information as part of the decision making processs § To communicate his decision (in any manner) o The fact a person is able to retain the information relevant for a short period only DOESN’T prevent him from making the decision (check x3 if unsure) o The information relevant to a decision includes information about the reasonable foreseeable consequences of deciding one way or another and of failing to make that decision NB: capacity is task specific Involves o Comprehending & retaining treatment information (why needed, what, nature of it, risks, benefits, risk of not having) o Believing it (i.e. is free of delusions) o Weighing it in balance to arrive at this choice NB: can only force treatment on an adult under the mental health act, and only then mental health treatment. Overcoming incapacity Proxy decisions – do NOT count. No adult can consent / refuse treatment for another Advanced Directive (living will) – only count if refusing treatment. Must be specific (e.g. if X happens, I do not want Y). Only count if all options were available at the time it was written and person was capable at the time Enduring Power of attorney – only counts for financial matters Lasting power of attorney – in new act (MCA 2005). Can count for any decision (can have different people for different areas) Court of protection Getting courts to appoint somebody to manage to the financial affairs of a mentally ill patient Requires a certificate from a doctor Cost £5000 to do – so only done if significant assetts Testamentary Capacity About writing a will Should now extent of assets, natural beneficiaries and consequences of will Must be of sound mind (free of delusions that may affect choices) Best Interests Need to consider o Is the person likely to regain capacity? When? o Maximise participation in process o Past and present wishes / beliefs (religious, cultural etc) o Views of carers & other nominated / appointed persons The Courts If relatives & Drs disagree à Court of Appeal Guided by “Bolam Test” – asks a body of medical professionals Life supporting interventions Cardiopulmonary Resuscitation DNAR = do not attempt resuscitation NB: outside CCU 20% survive CPR, but only 14 % will leave hospital, only 4% over 75yrs Should be made by most senior doctor available After discussion with patient & the team Reviewed regularly Recorded in notes together with reason o Where CPR is not in accord with sustained wishes of patient o Where successful CPR would à quantity / quality or life unacceptable to patient o Where patient already has poor quality of life they do not wish prolonged o Where CPR would be likely to be unsuccessful (no patient dissussion required in this situation) o Advanced terminal cancer (death within weeks) o Sepsis o Pneumonia on admission o Renal failure o Hypotension o Severe disability o Deteriorating consequences (e.g. stroke) o Arrest due to GI haemorrhage Intensive Care Unit Similar issues to CPR for if to move to ITU bed Invasive methods of nutrition & hydration Bland Case = NG tube, PEG and IV fluids are medical treatment If unlikely to benefit the patient there is no obligation to provide it Where it is not benefiting the patient it can be withdrawn (although may require courts – e.g. persistent vegetative state) No feeding is risk free Oral – aspiration NG – reflux & aspiration PEG – skin infection and tube blockage Stroke and terminal cancer = biggest dilemma Stroke – should be given unless prognosis is hopeless & should be assumed that good recovery is possible and nutrition provided for those after 72 hrs still unable to take food Euthanasia “A good death” Voluntary euthanasia – a deliberate and intentional hastening of death at the request of a seriousl ill patient Non-voluntary euthanasia – ending a person’s life for their benefit when they cannot possess of express views whether they should live or die Physician assisted suicide – the patient takes a lethal cocktail of drugs which has been prescribed by the physician at the patients request ALL the above are illegal under UK law It is acceptable to increase sedative & analgesia that may incidentally shorten life if you intend to provide “double pain relief” Breaking Bad news § A trusted family doctor / nurse in the presence of a close family member (unless patient objects) § Ensure privacy, identify relatives, introduce self § Pre-plan the discussion, sit down to indicate you have plenty of time § Avoid jargon, don’t be afraid of eye contact, physical contact or silence § Try not to kill all hope, or give precise forecast of duration § Do not be afraid to speak of death and dying but avoid forcing the issue & only give as much information as you can cope with § Don’t strive for too much detachment – they often appreciate seeing we’re affected too § Record what was said, and to whom in the notes Death Certification At home – doctor should see the body, confirm & certify death In hospital – commonly confirmed by nursing staff & certificate signed by doctor, unless coroner needs to be informed Her Majesty’s Coroner The following deaths should be reported § Death of a person not attended by a doctor during their last illness § Death of a person not seen 14 day before / after death by doctor § When cause of death unknown § Deaths after accidents including falls, misadventure, starvation, severe deprivation (neglect) including hypothermia and poisoning § Drugs – whether therapeutic or of addiction or abuse – inc alcohol § Anaesthetics, surgical or medical mishap: also if patients express serious dissatisfaction or allege neglect § Deaths within 24 hours of emergency admission (unless GP is happy to sign) § Deaths within 24 hours of an operation § Industrial diseases – even if that is not cause of death § Those with disability pensions from service with the crown § Prisoners and anyone in the custody of the police Emergency symptomatic treatment of the incompetent patient o Parenteral sedation of the acutely confused, disturbed patient o whos behaviour is danger to self/others o It is permissible to hold down to administer injection as last resort o IF other physicians would regard it appropriate o AND if reasonable people would want the treatment themselves Mental Health Act (1983): National assistance act Section 2 – admission for assessment Applicant – nearest relative / approved social worker Signatories – 2 doctors, one must know the patient (pref GP), the other a specialist Duration – 28 days Section 3 – admission for treatment Signatories – as section 2 Duration – up to 6 months, unless consultant discharges sooner Section 4 – emergency admission Applicant – as section 2, must have seen patient in last 24 hours Signatory – ANY doctor Duration – 72 hours Section 5 – holding power Allows forcible detention of informal patients for up to 6hrs by a qualified mental illness nurse if doctor unavailable: consultant / deputy may enforce for up to 72 hrs Section 7 – guardianship More used in USA/Canada Applicant – as section 2 Signatory – 2 registered practitioners Guardian – local authority social services, or any other person Duration – 14 days Section 47 – removal to a place of safety More for physically infirm if in danger of self neglect or endangering others Can be removed to hospital / care home Authority of a magistrate required Duration 3 weeks Often initiated by social worker Driving o Everyone must surrender their licence at 70 o New licence is issued which is valid for 3 years o Can be renewed every 3 years on declaration of good health o Car insurance company can insist on reassessment o DVLA must be informed of any change in health The following render unfit to drive: o Episodic impairment of consciousness (epilepsy, hypotension, vertigo, poor DM control) o Paroxysmal cardiac arrhythmia & severe IHD (angina at the wheel) o Severe Parkinsons o Fluctuating or declining cognitive function o Uncorrectable visual defects (esp visual fields) o MI, pacemaker insertion, stroke with good recovery or TIA (for at least a month) Advice for elderly drivers o Avoid distractions – e.g. radio o Adequate breaks o Lots of advance preparation & lots of time for unfamiliar routes o Avoid peak traffic & night driving 2 Main ethics issues o Patient refuses to stop driving despite one of the above disorders o Patient has some degree of cognitive impairment which is not one of the above, but the Dr believes they are still unfit to drive Advise relatives or to seek driving assessment centre if wont listen to Dr