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Question 1
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As a Foundation Year 3 doctor in a busy medical firm, you are required to attend the mortuary to view a body in order to complete a cremation form. The form requires you to state the time and date you viewed the deceased. The mortuary attendant informs you that the family is anxious for the paperwork to be completed in the next few hours so that funeral arrangements can be made.
While you are in the mortuary, you receive an urgent bleep from one of the Foundation Year 2 doctors requesting your assistance with a critically ill patient. The mortuary attendant asks you to sign the form before you leave, but you protest that you have not viewed the body. The attendant tells you that many of the other doctors do not even come down to the mortuary and complete the form based on their colleagues having certified patients as deceased. He advises you that this is hospital policy.
He says, Sign here, it'll take two seconds and will save you a trip back down to the mortuary and the family a lot of additional grief and delay. The mortuary is a 15-minute walk from your ward.
What is the most appropriate course of action?Your Answer: Advise the mortuary attendant that you will not complete the form until you have viewed the body and that you will return as soon as you are able. Ensure you report your concerns about doctors not viewing bodies but completing cremation forms to a senior member of staff.
Explanation:The Importance of Honesty in Medical Practice
From the available information, it is clear that returning to the ward immediately is necessary. While delaying the deceased’s funeral arrangements due to the decision not to sign the cremation form may cause harm, signing a form that falsely states that the body has been viewed is dishonest and cannot be justified. Dishonesty in medical practice can lead to a loss of trust in the profession and may even constitute a criminal act. The Bolan principle, which allows for compliance with common practice as a defense against claims of negligence, only applies when common practice is reasonable, which is not the case here.
Signing the form could have severe consequences for one’s career, including referral to the General Medical Council (GMC) and/or prosecution. If other doctors are also engaging in dishonest practices due to hospital policy, it is one’s duty to address these serious concerns about colleagues’ practices. Ignoring this ethical obligation would be difficult to justify.
In summary, honesty is of utmost importance in medical practice, and any deviation from this principle can have dire consequences. It is crucial to prioritize ethical obligations and address any concerns about colleagues’ practices to maintain the trust and integrity of the medical profession.
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This question is part of the following fields:
- Ethics And Law
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Question 2
Correct
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As a single-handed GP in a rural area, you come across a 35-year-old woman named Sarah who is expecting her fourth child. She expresses her dissatisfaction with the care she received at the local hospital during her previous pregnancies, but there were no reported adverse events. Sarah lives in a remote farmhouse and is adamant about having a home birth. However, the midwives are too far away to reach her in time for the delivery, and she has no plans to contact them until she is in active labor. Her residence is located near your home. What would be the most appropriate course of action in this situation?
Your Answer: Discuss her past experiences in detail and try and persuade her to involve the community midwifery or hospital-based obstetric team in her birth. If she does not agree then ensure the risks of home birth are discussed and that her and her family know what the early signs of perinatal problems are and what to do. Offer ongoing support throughout her pregnancy and during the perinatal period
Explanation:Balancing Autonomy and Risk in Home Birth Decision Making
This is a complex situation where the GP needs to consider the autonomy of the patient, Marie, and the potential risks of home birth to her and her unborn child. The GP also needs to balance their responsibilities to Marie with their obligations to other patients. While parous women and their newborns are not at significantly increased risk with well-trained midwives present, Marie’s social circumstances may increase the risk of adverse outcomes. However, involving the child protection team would be inappropriate at this stage.
As primary care services are not equipped to provide round-the-clock obstetric cover, guaranteeing 24-hour availability may not be feasible and could lead to inadequate care for other patients. Simply suggesting that Marie call 999 in case of problems would also not be sufficient. The best approach would be to discuss Marie’s past experiences and try to persuade her to involve the community midwifery or hospital-based obstetric team. If she refuses, the GP should ensure that the risks of home birth are discussed, and Marie and her family are aware of the early signs of perinatal problems and what to do. Ongoing support should be offered throughout the pregnancy and perinatal period. This approach balances Marie’s autonomy with the risks involved in a non-paternalistic manner, while providing adequate primary care.
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This question is part of the following fields:
- Ethics And Law
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Question 3
Correct
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A teenager arrives at the Emergency department after being involved in a fight at a party. During the altercation, one of the party-goers pulled out a broken bottle and stabbed him in the arm before fleeing the scene.
After a clinical assessment and an emergency CT scan, it is determined that the wound is not severe and he is discharged. The teenager insists that he does not want you to involve the police or any other authorities and claims to not know the attacker.
What is the appropriate course of action in this situation?Your Answer: Report the incident, including time and location, to the police but do not pass on the patient's name or address without his consent
Explanation:Balancing Confidentiality and Public Interest in Medical Practice
When faced with the decision to breach confidentiality in medical practice, it is important to weigh the potential harms, such as a loss of trust from patients and a reluctance to seek healthcare, against the benefits to the public good. Situations that may require breaching confidentiality include when a crime has been committed, when someone else is at risk due to the patient’s behavior, or when the patient has a communicable disease.
In cases such as knife and gun crimes, specific guidance from the General Medical Council (GMC) is available. The GMC advises that personal information about the patient should not be disclosed on the first occasion the police are contacted, but doctors should quickly inform the police if someone presents as a victim of such crimes so that the risk of harm to others can be assessed and addressed.
The GMC allows for doctors to breach patient confidentiality if there is a belief that not doing so could result in serious harm to the patient or someone else, or if disclosure could aid in the detection, prevention, or prosecution of a serious crime. However, it is important to be prepared to justify any decision to breach confidentiality to the GMC.
It is important to respect a patient’s wishes regarding confidentiality, even if it may be difficult to withhold their information in certain situations. Ultimately, the decision to breach confidentiality should be made with careful consideration of the potential consequences and benefits.
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This question is part of the following fields:
- Ethics And Law
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Question 4
Correct
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As an out-of-hours GP, you encounter a 44-year-old man with a head injury who needs to be admitted for observation. He discloses that he has hepatitis B and lives alone in a remote area, making it impossible for him to have someone monitor him for the next 24 hours. Although he reluctantly agrees to a brief hospital stay, he insists that you keep his hepatitis B status confidential from the medical team who will be caring for him. The most recent hepatitis serology results indicate that he has inactive disease, and his most recent liver function tests were not significantly abnormal. What is your course of action?
Your Answer: Advise him that you ought to inform the medical team involved in his care for their safety and that they will keep this medical information confidential. His rights and comfort will be maintained but should his clinical condition warrant blood tests or a blood transfusion, it would be better that the clinical team are aware from the outset. All patients are treated equally with universal precautions.
Explanation:Balancing Confidentiality and Patient Safety in Healthcare
When faced with a patient who refuses to disclose their hepatitis B status, healthcare professionals must weigh the potential harms and benefits of admission. The potential harms include the patient self-discharging, healthcare workers being exposed to contaminated equipment, and a breach of confidentiality. On the other hand, admission ensures that the patient does not come to harm as a result of their injury.
In this scenario, the likelihood of a healthcare worker contracting hepatitis B is low, but it is still important to persuade the patient to share their status with the clinical team responsible for their care. A conversation that emphasizes the importance of sharing this information for the patient’s care and the safety of healthcare personnel is likely to resolve the situation. It is crucial to prioritize clinical need and assure the patient that they will be looked after sincerely and honestly, with no judgement.
It is important to note that other options, such as breaching confidentiality or coercing the patient into disclosing their status, are not appropriate. Healthcare professionals must balance the need for patient confidentiality with the need to ensure patient safety. By having open and honest conversations with patients, healthcare professionals can navigate this delicate balance and provide the best possible care.
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This question is part of the following fields:
- Ethics And Law
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Question 5
Correct
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You are working on a pediatric ward. The mother of a young patient has recently had some blood tests performed in hospital. She says that her child was referred to a pediatrician by their general practitioner. She is anxious to find out the results.
Whilst you are sitting at the nurses' station doing some paperwork she asks if you would mind looking up the results for her on the hospital reporting system.
What should you do next?Your Answer: Apologise that you cannot look up the results as you are not involved in her care and do not have the information and knowledge needed to interpret the results
Explanation:Why Checking a Colleague’s Medical Test Results Could Do More Harm Than Good
Whilst it may seem helpful to check a colleague’s medical test results and reassure them that everything is normal, there are several potential risks involved. Firstly, without specialist knowledge and access to the patient’s medical history, it may be difficult to accurately interpret the results. Additionally, if the results are reported as normal, there may still be pending results that you are not aware of, which could falsely reassure the patient.
Furthermore, checking a colleague’s medical test results without a legitimate interest in their care could breach their confidentiality. This could result in inadvertently learning more about their medical history than they were willing to disclose.
Therefore, the best course of action would be to politely decline the request and encourage the colleague to liaise with their consultant about the results. It is important to prioritize patient confidentiality and avoid potentially causing more harm than good.
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This question is part of the following fields:
- Ethics And Law
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Question 6
Correct
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As a GP, you are approached by a 16-year-old girl named Lily who has a family history of breast cancer and is concerned about her own risk. Her mother carries the BRCA1 gene and has undergone a prophylactic mastectomy. Lily is requesting to be tested for the gene, but you have never encountered a case where a patient under 18 years has requested BRCA1 genetic testing before. You are unsure about the appropriateness of offering the test to someone so young, but Lily and her mother are insistent. What is the next best course of action?
Your Answer: Discuss the pros and cons of testing and implications for treatment with both Chloe and her mother. If you decide that she is competent to decide about testing then provide written information and additional materials to help them consider the matter further. Advise them that you would like further advice from the genetics and breast teams before you all make a final decision about whether to test.
Explanation:Balancing Autonomy and Medical Professionalism in Genetic Testing
In cases where a patient requests genetic testing, medical professionals must balance the patient’s autonomy with their own duty to act in the patient’s best interests. This is particularly important when dealing with minors, as they may not fully understand the implications of a positive test result. In such cases, it is important to consider the psychological impact of testing and whether it is appropriate to provide the test at this time.
As a medical professional, it is important to take the patient’s request seriously and not dismiss it or leave it to others to decide. However, it is also important to assess the patient’s capacity to make decisions and to consider whether testing is truly in their best interests. If necessary, seeking expert help in counseling the patient and their family can be beneficial.
Ultimately, medical professionals must balance the patient’s autonomy with their own duty to act in the patient’s best interests. This may mean declining to provide a test if it is not appropriate or if the patient lacks the capacity to fully understand the implications of a positive result. By carefully considering these factors, medical professionals can ensure that they are providing the best possible care to their patients.
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This question is part of the following fields:
- Ethics And Law
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Question 7
Correct
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As a GP registrar in general practice, you encounter a 63-year-old man who complains of back pain. There are no indications or symptoms that suggest a sinister cause of his pain. He is in good health, has no lower urinary tract symptoms, and does not take any regular medication. The pain began after he lifted some heavy furniture at home, and you diagnosed him with musculoskeletal back pain. You scheduled a follow-up appointment in six weeks if the pain did not improve.
While researching the case, you come across a local guideline that recommends performing a rectal examination and offering prostate-specific antigen (PSA) testing to all patients over 60 years of age who present with back pain to screen for prostate cancer. You notice that the patient had routine blood work done during his annual health check that morning. Unfortunately, you did not offer a rectal examination or PSA test during your consultation.
You are aware that approximately two-thirds of men who have a positive PSA test do not have prostate cancer. What is your next course of action?Your Answer: Telephone the patient and counsel him about having a PSA test, including recommending a rectal examination and the pros and cons of having the test done. See him again in surgery and/or request a PSA test as appropriate.
Explanation:Responding to a Potential Care Shortfall
In situations where it is possible that the care provided may not meet local best practice standards, it is important to take appropriate action. One such scenario is when a patient presents with back pain and is not offered a prostate-specific antigen (PSA) test or a further examination. While it may be tempting to do nothing, this could result in harm to the patient or a missed opportunity for optimal care. Therefore, it is advisable to contact the patient and offer them the option of a PSA test or further examination.
However, it is crucial to obtain the patient’s consent before requesting a PSA test. This is because a raised PSA level is common in older men and can lead to unnecessary investigations and treatments, which may have risks and side effects. Additionally, requesting a test without the patient’s permission could damage the trust between the patient and healthcare provider. Therefore, it is best to counsel the patient about the likelihood and implications of false negative and positive results and offer a rectal examination as part of any attempt to detect prostate cancer. This approach allows the patient to make an informed decision about whether to have the test done. Simply telling a patient that they might have cancer without a thorough discussion of the implications of testing is not an effective way to encourage them to undergo testing.
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This question is part of the following fields:
- Ethics And Law
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Question 8
Correct
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A 25-year-old patient who works as a graphic designer presents with symptoms and signs of appendicitis. She is adamant that she does not want surgery as she fears the potential complications and risks associated with it. Despite being informed of the potential consequences of not having surgery, she remains firm in her decision and provides a written declaration to this effect. She consents to hospital admission for intravenous antibiotics.
However, three hours after admission, her condition worsens and she begins to exhibit signs of peritonitis. She becomes delirious while still conscious. The high dependency unit is currently experiencing a high volume of patients, and the intensive care consultants are hesitant to accept a patient who has declined optimal treatment.
What is the appropriate course of action in this situation?Your Answer: Her wishes should be respected and she should receive the best possible non-surgical treatment, including admission to the high dependency unit for monitoring if appropriate.
Explanation:Advance Decision and Medical Best Interests
The Mental Capacity Act 2005 requires doctors to consider a patient’s previously known wishes when making decisions in their best interests. If a patient has made an advance decision to refuse surgery, doctors must respect this decision even if the patient loses the capacity to make decisions. In such cases, doctors cannot act solely in what they deem to be the patient’s ‘medical’ best interests.
A psychiatric assessment is not necessary if the patient’s lack of capacity has an organic cause and there were no previous indicators of mental illness. In situations where a patient’s autonomy and view that surgery will do long-term harm outweigh the medical view that not operating will be more harmful, it is important to seek legal advice to ensure compliance with the law.
Once a decision has been made that surgery is not possible due to the patient withholding consent, the patient should receive the best possible medical care. Decisions about admitting the patient to the high dependency unit should be based on clinical need rather than compliance with medical advice. It is crucial to prioritize the patient’s well-being and respect their autonomy in making decisions about their own medical care.
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This question is part of the following fields:
- Ethics And Law
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Question 9
Incorrect
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As a core medical trainee with full GMC registration, you are seeing a 95-year-old man with chest sepsis and acute kidney injury on a background of metastatic prostate cancer. Your consultant has expressed doubts about the success of cardiopulmonary resuscitation (CPR) in case of a cardiorespiratory arrest.
During the ward round, a nurse approaches you to complete a 'Do not attempt CPR' (DNACPR) form for the patient. However, the patient is currently suffering from acute delirium and lacks the mental capacity to make decisions about their care. You have not had any discussions about resuscitation with the patient or their family, and you do not have any information about their previous wishes and values. The patient's daughter has Power of Attorney with control over their financial affairs.
What is the appropriate course of action in this situation?Your Answer: Complete the DNACPR form when the patient is less unwell and has the mental capacity to consent to a DNACPR being completed
Correct Answer: Complete the DNACPR form only if you obtain consent from the patient's Power of Attorney
Explanation:Making Decisions for Patients without Capacity
When a patient lacks the capacity to make decisions about their care, healthcare professionals must act in their best interests. In the case of deciding when to complete a DNACPR form, the potential harm of CPR must be weighed against the distress that signing the form may cause the patient and their family. However, discussions about end-of-life care and CPR should ideally take place before a DNACPR order is signed.
It is important to note that even competent patients cannot demand medically inappropriate treatment, such as CPR. When a DNACPR order is justified on medical grounds, discussion with the patient, their power of attorney, and family is not necessary prior to signing the order. However, involving patients and their families in these discussions as early as possible is good practice.
Reference:
Resuscitation Council UK. Decisions relating to cardiopulmonary resuscitation. -
This question is part of the following fields:
- Ethics And Law
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Question 10
Correct
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As a Foundation Year 2 doctor on placement in general practice, you visit a 49-year-old man with schizophrenia at a local nursing home for individuals with severe mental illness. The patient is staying at the nursing home voluntarily and currently believes he is the Lord of the Manor, with all staff and residents serving him. He occasionally hears voices that reinforce this belief. The patient has been detained under the Mental Health Act five times and has attempted suicide twice during acute psychotic episodes. Your task is to conduct his annual medication review. However, you discover that the patient dislikes taking his antipsychotic medication, and your GP colleagues have authorized hiding these medications in his food. What should you do about his medication?
Your Answer: Reassess the patient's mental capacity. Check with your supervisor that local procedures for covert administration of medicines are being followed. If the patient does not have capacity and you consider it to be in the patient's best interests to receive antipsychotic medication and that local procedures are being following, reauthorise ongoing covert administration.
Explanation:Covert Administration of Psychiatric Medication for Patients with Mental Illness
Covert administration of psychiatric medication is sometimes necessary for patients with serious and enduring mental illness who lack the mental capacity to make decisions about their care. This practice is considered acceptable as long as it is in the patient’s best interests, taking into account their values and beliefs as well as their medical needs. It is important to note that this is only applicable to patients who are not detained under the Mental Health Act.
To ensure patient safety, healthcare providers must establish arrangements to share information about the patient’s medications in case of complications or emergencies. Mental capacity should also be regularly reassessed, as it may vary with the patient’s mental health and cognitive ability. This can be done during the patient’s regular medication review or as circumstances change.
Overall, covert administration of psychiatric medication should only be considered as a last resort and must be carefully evaluated on a case-by-case basis. The patient’s best interests and safety should always be the top priority.
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This question is part of the following fields:
- Ethics And Law
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