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Question 1
Correct
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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 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 2
Correct
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As a Foundation Year 1 doctor in your second week, you are working on a surgical ward and have a patient who is scheduled for a total colectomy with ileostomy formation on the day's theatre list. This patient, who is in her late 60s, has been waiting for the operation for several months to prevent further bouts of life-threatening illness caused by ulcerative colitis.
Two hours before the operation, the patient calls you to her bedside and asks, I won't be left with a colostomy bag, will I?
Although she has already signed a consent form indicating her awareness of the need for an ileostomy, her comments suggest that she may not fully understand the implications of the procedure. You know that patients are currently experiencing long wait times for surgery, and delaying her operation could result in another bout of colitis while she is placed back on the waiting list.
What is your next course of action?Your Answer: Put the patient at the end of the theatre list to give her more time to decide what she wants to do. Telephone the operating theatre and explain the situation to the surgeon. Ask them to come and discuss the matter with the patient urgently.
Explanation:Obtaining Informed Consent in Medical Practice
Obtaining informed consent is a crucial process in medical practice that involves providing patients with sufficient information to make decisions about their care. However, simply obtaining a signed consent form does not necessarily mean that informed consent has been obtained. In this case, the need for an ileostomy is a critical piece of information that must be shared with the patient to obtain their informed consent.
As a newly qualified Foundation Year 1 doctor, it is unlikely that you have the necessary knowledge and training to counsel the patient about the procedure and its risks. Therefore, it is best to notify the operating surgeon and allow them to assess the situation and determine whether the patient can effectively consent to the procedure. Doing nothing is not an option, as it would not be in line with your duties as a doctor and could potentially lead to a complaint or legal action against your colleagues.
In conclusion, obtaining informed consent is a vital aspect of medical practice that requires careful consideration and communication with patients. As healthcare professionals, it is our responsibility to ensure that patients fully understand their care options and the potential risks and benefits of any procedures.
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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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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 4
Incorrect
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Ms. Johnson is a 72-year-old patient who has been visiting your clinic with ankle swelling and breathlessness following a recent hospitalization due to acute respiratory distress. You have received the results of her tests, which indicate a significantly reduced ejection fraction on echocardiography and a high serum B-type natriuretic peptide, leading to a diagnosis of heart failure. She is currently taking an angiotensin-converting enzyme inhibitor, beta-blocker, and diuretic to manage her symptoms.
However, Ms. Johnson's family has requested that you do not discuss the specific diagnosis of heart failure with her, as they believe it will cause her undue stress. You recently read an article in a medical journal that suggests patients with similar echocardiography findings and symptoms have a poor prognosis, with an average life expectancy of less than a year.
Ms. Johnson is scheduled to meet with you to discuss her test results. How should you approach this consultation, taking into account her family's wishes and the potentially difficult prognosis?Your Answer: Respect the family's wishes in order to avoid distressing Mrs Rogers, especially as informing her of the diagnosis will not alter your management
Correct Answer: Find out how much Mrs Rogers wants to know about her condition and tailor your discussion appropriately, including a discussion about prognosis if she wishes
Explanation:Autonomy in Medical Decision Making
In medical decision making, the issue of autonomy arises when considering the patient’s right to information and the family’s right to make decisions on their behalf. In the case of a mentally competent adult like Mrs Rogers, it is important to consider both perspectives. While the family’s views should be taken into account, the patient’s information requirements must also be considered. Withholding information may damage the trust between doctor and patient and deprive the patient of the ability to plan for the future. However, informing the patient of their diagnosis and prognosis may also cause unnecessary distress.
It is important for doctors to take a patient-centred and non-paternalistic approach in such situations. The doctor should attempt to discover the patient’s information requirements and balance the need to avoid harm with the potential positive outcomes of informing the patient. By doing so, the patient may be more likely to comply with treatment and make the most of their remaining time. In summary, autonomy in medical decision making requires a delicate balance between respecting the patient’s wishes and ensuring their well-being.
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This question is part of the following fields:
- Ethics And Law
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SESSION STATS - PERFORMANCE PER SPECIALTY
