Category Archives: Generic

Parenting and permanence orders

Child protection, Ethics

Permanence order is mechanism for local authority to apply for parental rights and responsibilites to be removed from parents.

Not specifically detailed in law (2007) but “threshold test” must be satisfied:

  1. living with parent poses threat of serious detriment to welfare of child
  2. the need to safeguard and promote welfare of child is paramount consideration
  3. that it is better for the child that the order be made, than that the order not be made

Supreme Court decision In the matter of EV (A Child) (No 2) (Scotland) 2017 –

Not duty of parents to prove parenting ability, but for social work to prove lack of ability with full assessment (or adequate records and sworn evidence of non-engagement).

Also, although allegations of harm may be sufficient reason to place child in care, not sufficient for seeking “permanence order”.  Given that this may mean waiting on criminal proceedings to be completed, children may be stuck in hearing system for longer than before.

[https://andersonstrathern.co.uk/news-insight/supreme-court-permanence-order-decision-lessons-learned/]

 

Family centred ward rounds

Communication, Generic, Patients

A study highlighted that the attending physicians talk outside the room as much as or more than they do inside the room.

“It is frustrating to hear the team speaking about you in the hallway before they come in and wondering what they are saying. Then, after they leave the room, they continue to have discussions in the hallway, where we can hear pieces and parts but not all of the discussion.

“We would prefer that all discussion happen in the room with the nurses and the family present.”

The nurses are the ones who have spent the most time with the family, and they have a lot of information to offer. However, the study highlighted that the nurse does not have much of an opportunity to speak during the rounds.

Sometimes, the entire rounds process is effectively over by the time the medical team comes into the room, and rounds are more of a procedural event than a discussion.

Other comments from one family:

  • It would be nice if all physicians involved in the care could participate in the family-centered rounds experience, even if some need to be on the phone. Many times, the rounding process happens but then we are left with a statement that they will wait until the other doctors come by to make a decision. This not only prolongs the decisions but also splinters the care that the concept of family-centered rounds is trying to improve.
  • We appreciate when the medical teams sit down in the room with us. It makes us feel as if we are having a discussion where everyone is invited to participate instead of a group of people standing over us. This style of communication seems to engage the patient and family in honest, open conversation, and it seems to cause the team to slow down enough to listen to our story.
  • It would be nice to have some idea of when they are coming to the room because it seems that no matter what we do, the team comes in when one of us has run to the cafeteria to get breakfast or to take a phone call in the lobby.
[Sarah Pickel, Mark W. Shen, Collin Hovinga.  Hospital Pediatrics  Jul 2016,  6  (7)  387-393;  DOI: 10.1542/hpeds.2015-0136]

Patient centred care

Communication, Generic

As seen in previous studies of medical students, junior doctor patient-centred attitudes declined during their first year of residency.

There is a clear gender gap.  Female residents were generally more inclined to a patient-centred attitude. The difference by gender was more evident for the caring component than the sharing component.

Male residents became less patient-centred in terms of caring attitude after 1 year, while female residents showed little decline.

A previous meta-analysis indicated that female physicians are more likely to address psychosocial issues, use emotional talk and positive talk, and more actively incorporate patient input.  All of this could be considered patient centred.

Role models tend to be same gender, which perhaps explains why male doctors tend to learn patriarchal styles.

Interestingly, physicians’ confidence in communicating with patients increases more in those who showed a smaller decline in patient-centred attitude.

[BMC Med Educ. 2018; 18: 20.         doi:  10.1186/s12909-018-1129-y]

See also Family centred ward rounds.

 

Bawa Garba case

Clinical governance, Ethics, Generic

High Court ruling regarding Dr Hadiza Bawa-Garba following the tragic death of a 6-year-old boy in 2011. Subsequently convicted of manslaughter. Removed from the GMC register, although Medical Practitioners Tribunal Service (MPTS) decision was to suspend for a year.  GMC appealed, saying it had not taken into account the manslaughter conviction.

High Court then overturned erasure, saying that tribunal did not commit any errors in its procedures, and therefore its conclusions were valid.

The trust acknowledged systemic failures, so why the vindictiveness? Its report into the death (“no single error responsible for death”) was not brought before jury, as being beyond scope of the trial! Not lazy or under influence, rather, took on extra duties in overstretched hospital with very little supervision.

And since when was gross negligence manslaughter law the right way to deal with errors made by doctors in training?

Why not corporate manslaughter case against trust?

Concern about reflective notes being used in court – despite being confidential? Used in support of Dr Bawa-Garba to show remediation efforts.

Twitter response from consultants was to emphasise “WE are responsible – so long as you tell us what’s going on”.

Subsequently 2 reviews –

  • Marx review by GMC
  • Williams review by government into medical gross negligence.
    • Suggested that GMC lose right to appeal Tribunal decisions.  Most of these appeals have been regarding sexual misconduct cases.  Professional standards Authority would still be able to appeal.
    • Suggested that GMC not be allowed to access reflective notes eg portfolio.  Could still be used as evidence in prosecution, however, not clear whether would help defence or prosecution more
    • Touched on high rate of cases involving black or minority ethnic doctors, but did nothing other than suggest BAME representation in investigations
    • Recommends explanatory note for gross negligence law, to improve consistency.  Law remains the same, however

Insurance and genetic testing

Ethics, Generic

You have to answer truthfully any question you are asked when applying for insurance.  You do not need to volunteer information not asked for!

The Government and the ABI have a policy framework (‘Concordat’) for cooperation that includes a voluntary Moratorium on insurers’ use of predictive genetic test results (NOT diagnostic tests) until 1 November 2019, (to be reviewed in 2016).  So for most tests, companies cannot force test before providing cover, customers do not need to disclose result while insurance in place, and do not need to disclose results of blood relatives.

Only one exception currently, for cover above £500 000 and Huntingdons.  Certainly no need for time limited policies eg travel, private medical care; really just for life insurance, critical illness and income protection. Recognition that increased risks of a small minority can be mitigated by larger population of policies [2014]  Evidence from US is that significant proportion conceal their diagnosis.

Asymmetry of information—when the customer knows more than the insurer—is the industry’s nightmare.  Testing positive for ApoE4, a mutation of a gene related to increased risk of Alzheimer’s, would be a good reason to get life insurance before symptoms develop.

See also ethics.

Death certificates (Scotland)

Ethics, Generic,

New system from 2015.  Medical Certificate of Cause of Death (MCCD) provides a permanent legal record of the fact of death and enables the family to register the death, make arrangements for the disposal of the body, and settle the deceased’s estate. In addition, a MCCD provides a record of causes of death for public health reasons.

Electronic system available but paper copy remains legal, and family  needs it to register death.

Ideally consultant responsible for patient completes or is at least involved in completion.  This should be recorded in notes.

New system of reviews:

  • In the shorter level 1 review cause of death checked, reviewer will speak to the certifying doctor about anything unusual. If the certifying doctor is unavailable or incapacitated, the Medical Reviewer will discuss the MCCD with the consultant in charge of the case or another member of the team who knew the deceased and / or has access to the clinical records.
  • A level 2 review is similar to a level 1 in that the Medical Reviewer will check the MCCD and speak to the certifying doctor. However, in addition, the Medical Reviewer will also consider relevant documents associated with the death, including health records and results of investigations. They may also wish to view the body.

These review types will be conducted through a random selection process, will be available on request in certain circumstances from interested persons, or may be targeted by Medical Reviewers in response to any emerging pattern that requires further checks.

The last type of review is the “Interested Person” review – provides further reassurance. Includes relatives, any person present at death, healthcare professional involved with deceased etc.  Must be within 3yrs of death, and can only take place if not already reviewed randomly.  Request to medical review service.

Tips for Certifying Doctors

Contact the Death Certification Review Service (DCRS) by phone or email for help, open Monday to Friday 08:30-17:30. There is an on-call medical reviewer available out of hours.

Consider whether there is any reason to report to or discuss the case with the Procurator Fiscal (guidance here) e.g. trauma has been identified as a cause or contributor to death, there is a complaint about the care provided prior to death etc.

If you have discussed a case and agreed with the Procurator Fiscal that the case does not need to be formally reported, then do not tick the “PF” box.

Your writing should be in CAPITALS using BLACK ink throughout when completed by hand.

The time of death is the time that to the best of your knowledge and belief you think the patient died and NOT the time that death was verified.

Use business telephone numbers; do not include personal mobile numbers.

You must not include any abbreviations except HIV or Aids which are both permissible.

The causes must make sense both medically and chronologically. If you use more than one line in section 1 then what is entered in 1a MUST be caused by what is in 1b which MUST be caused by what is in 1c etc. Durations likewise should be sequential.

Sites and organisms in infections, including resistance and routes of infection are important and should be entered if known.

If you wish to enter a cause of death that you believe is the case but you have no confirmatory evidence, you can qualify it with “Probable” or “Presumed”.

If obesity has significantly contributed to the death it should be included.

None of the form is optional and all parts and questions on both sides should be considered and answered as appropriate.

It is the statutory duty of the doctor, who has “attended” the deceased during the last illness, to issue the MCCD. There is no clear legal definition of “attended”, but it is generally accepted to mean a doctor who has cared for the patient during the illness or condition that led to death and so is familiar with the patient’s medical history, investigations and treatment. It is not unlawful to complete a certificate if you have not personally attended the patient but you have to be in a position to certify to the best of your knowledge and belief and willing to be personally accountable having had access to the appropriate records.

If you cannot issue an MCCD you should contact a colleague who can, or discuss/report to the Procurator Fiscal.

[HIS tips – Support around Death (SAD) website]

 

Webcam clinics

Patients,

Webcam clinics for diabetes (Newham, all ages) – mean duration only 9 minutes for both consultants and nurses, cf 25/30 minutes for face to face!  DNA rate 13% cf 28% for face to face.

Patients felt HCPs more focussed on them, other studies have confirmed that eye contact is better! But feels more impersonal, so prior relationship is important.

Hospitality

Ethics, Generic

It is acceptable for staff to receive small tokens of gratitude from a relative or carer in appreciation of care and treatment received. These are typically cards, chocolates or biscuits. Where staff are offered gifts of greater value these must be politely refused. [bottles of wine?  Whisky?]  If this is difficult they must refer the matter to their line manager.

Hospitality

It is acceptable for staff to receive small promotional items, e.g. pens, calendars, diaries. However,

  • staff must not accept any offer of a gift or hospitality from any individual or organisation which stands to gain or benefit from a decision NHS Lanarkshire maybe involved in determining, or who is seeking to do business with NHS Lanarkshire.
  • staff must not accept any offer, by way of gift or hospitality, which could give rise to a reasonable suspicion of influence on their part to show favour, or disadvantage, to any individual, organisation or company.
  • staff should consider whether there may be a reasonable perception that any gift received by their spouse or partner or by any company in which they have an interest, or by a partnership of which they are a partner, can or would influence their judgement.

Note – the term ‘gift’ includes benefits such as provision of services at a cost below that generally charged to members of the public.

Modest hospitality may be acceptable provided it is normal and reasonable in the circumstances e.g. lunches in the course of a working visit. Any hospitality accepted should be similar in scale to that which the NHS as an employer would be likely to offer.

All other offers of hospitality should be declined.

Staff should register with their line manager all such modest hospitality which they wish to accept, using the hospitality register declaration form (Appendix 3). In cases of doubt, staff should seek advice from their line manager.

If the nature of the event dictates a level of hospitality which exceeds this, then the individual should ensure that their line manager is fully aware of the circumstances and approves their attendance. An example of such an event might be an awards ceremony involving a formal dinner. If the line manager grants approval to attend, the individual should declare their attendance in the register of hospitality held by their line manager. The approving manager must ensure that this will not result in any future conflict of interest.

If the individual is invited to an event in a private capacity (e.g. as result of their qualification or membership of a professional body), they are at liberty to accept or decline the invitation without referring to their line manager. The following matters should however be considered before an invitation to an individual acting in a private capacity is accepted.
a) The individual should not do or say anything at the event that could be construed as representing the views and/or policies of NHS Lanarkshire.
b) If the body issuing the invitation has (or is likely to have, or is seeking to have) commercial or other financial dealings with NHS Lanarkshire, then it could be difficult for an individual to demonstrate that their attendance was in a private and not an official capacity. Attendance could create a perception that the individual’s independence had been compromised, especially where the scale of hospitality is lavish. Individuals should therefore exercise caution before accepting invitations from such bodies and
must inform their line manager.
c) Where suppliers of clinical products provide hospitality it should only be accepted in association with scientific meetings, clinical educational meetings or equivalent, which must be modest, normal and reasonable in the circumstances and in line with what the NHS would normally provide. Any such hospitality should be held in appropriate venues conducive to the main purpose of the event. 

Sponsorship [should be] clearly disclosed in any papers relating to the meeting; products discussed should be described in relation to the Scottish Medicines Consortium, Formulary and the active promotion of clinical products is restricted to those in the Board’s Formulary and equivalent clinical product catalogues.

Any educational meetings hosted by suppliers must be approved by the line manager.

Before accepting an offer of hospitality the individual concerned should fill in a Registering Hospitality Declaration Form (attached as appendix 3) and have it approved by their line manager. A copy of the request form will be held as part of a Hospitality Register which will be available for scrutiny by the
NHS Board, Corporate Management Team, members of the public or press should they request such information.

Competency

Ethics, Generic

Gillick ruling (1985) was primarily about sharing of information with parents (use of oral contraceptive), not about going against their decision!

You should involve children and young people as much as possible in decisions about their care, even when they are not able to make decisions on their own (GMC).

Competence is not binary, it varies according to context and over time.  You need to assess ability to:

  • understand, retain, use and weigh Information about consequences of treatment/non-treatment
  • Communicate

And you need to assess context:

  • Complexity, level or risk, seriousness of consequences
  • Physical/emotional development
  • Changes in health/treatment

Even then, you should encourage involvement of parents.  In difficult situations, consider involving multidiscip team, independent advocate, child protection teams. ”You should not make unjustified assumptions about a child or young person’s best interests based on irrelevant or discriminatory factors, such as their behaviour, appearance or disability”.

At 16yrs, a young person can be presumed to have the capacity to consent.  In Scotland, parents cannot authorize treatment a competent young person (even under 16yr) has refused.  In E&W/NI, High Court can override up to 18yrs – “children and young people have a right to consent, but not to refuse treatment if this would put their health in serious jeopardy” (BMA consent toolkit).  Court rulings have gone both ways.

 

 

Consent

Ethics, Generic

Neuberger criteria: competence, information, understanding, voluntariness. All dubious!

GMC guidance on consent (2008) – places it in context of process of discussion and decision-making. There is no “once size fits all” method. Starts with information being provided, in different formats. References advocacy services. Does not set threshold values for discussing risks: sensible, given how complex the communication of risk can be!

Acknowledges that some patients do not wish to go into detail about their condition. While doctors must respect their patients’ wishes, there is a minimum level of information that a patient is likely to need in order to give valid consent.

Adults with Incapacity Act (Scotland 2000) and Mental Capacity Act (England 2005) establish mechanisms for incapacitated adults. Provides practical advice on assessing capacity.

In Scotland, legal age of consent is clearly defined as 16yrs (Age of Legal Capacity (Scotland) Act 1991).  In England, Family Law Reform Act 1969 defines “child” as under 18yrs!  This leads to some issues when it comes to competency.

Written consent – the law only requires written consent for a very few things, eg IVF, organ donation! But you must record the fact that you have gained consent in medical records. And it may just make everything easier to get it written anyway.

For research

Proxy consent by parents can create conflict of interest eg handicapped child. Authorization a better concept (presumes right of child to take part in research)? Non-therapeutic research is not strictly legal, but usually accepted if minimal risk ie not significantly increased risk compared with standard care. Right of research enshrined in possibility of benefit outweighing possible risks. Alternative is therapeutic orphans, treated without good evidence of benefit. Failure to conduct research led to prophylactic sulphonamide disaster in 1950s (increased kernicterus). Research without consent not strictly legal but possibly acceptable for emergency situations, but retrospective consent should be sought (not really consent at all, of course) else assent (simplified consent) with later ratification, in stages if necessary.

Reasons for refusal in EURICON study: perceived risks/distress; distrust of research/researchers; dislike of the tone of approach of the doctor; shock and inability to decide; inconvenience of follow up. Hence communication skills essential. Information sheet should be given but should not be relied upon. As a minimum, parents must know that the treatment is being given as part of a trial, that their child may be receiving an experimental or unproven treatment, that they are free to say no and to opt for standard treatment. Check list should be provided. Involvement of independent committee should be highlighted. Feedback to parents should be encouraged.

Inability to give consent eg children, unconscious, learning difficulties does not mean research should not be done – indeed that would deprive patients and others of potential benefit. But should only be done if unable to do same study with patients who can give consent; risks should be minimal (for non-therapeutic research that means equivalent to everyday life or minimally invasive therapeutic interventions; assent should be sought from appropriate advocates eg relatives, who should be provided with the same information which would have been given to a competent patient; research should be explained after its completion to participants who have regained their competence subsequently (NOT retrospective consent, mind you).

Use of medical records without consent is a moral wrong – should be balanced against potential benefit. Patients should be informed of this potential use of their records and reassured about confidentiality. Only do if consent not praticable; research is of sufficient merit and has potential benefit; identifiers should be removed where possible; contact with patients is not anticipated; permission should be gained from responsible clinician.

How to get consent

  • Parents should feel they are being cared for, as well as their child. They should feel that they are being involved in the discussion of care. They should feel that they are being asked for their permission to enter the baby into a trial, not to defend the best interests of the baby.
  • Parents hate the idea of their baby being a guinea pig, so emphasize background to study: importance, plausibility, etc.
  • Acknowledge the pressure being put on parents to absorb and understand all the information. Invite questions and interruptions, reiterate key points.
  • Accept that research has negative connotations. Randomization is difficult to understand (and if they do, computer allocation is seen as more appropriate than tossing a coin or drawing from a hat!)!
  • Don’t say what you would do.
  • Beware strange comments/questions – suggest misunderstanding.
  • Reinforce that whatever the decision, the best proven care will be given.
  • Don’t rush.