1. Innovation and excellence in health and care Addenbrooke’s Hospital I Rosie Hospital Medico-Legal Issues Trauma Care Rebekah Ley, LLB (Hons), MSc

2. Introduction Challenges of trauma care and trauma units. The Law – but which ones? Scenarios. Ethics. Shields not swords. Innovation and excellence in health and care

3. Challenges What makes trauma care (the emergency department) different? What do you know about your patient? How many patients need to be seen? How quickly must you make a decision? Quality indicators. Legal and ethical interface. Innovation and excellence in health and care

4. The Law – but which ones? Privacy and confidentiality. –Viewed as a basic human right. –If you don’t keep things secret patients won’t share important information to enable diagnosis and treatment. However: sometimes disclosure is compulsory and permissible –Data Protection Act. –Public Health. –Professional codes of conduct. Innovation and excellence in health and care

5. The Law – but which ones? Capacity: –Mental Capacity Act. –Can’t simply explain the risks and then ask a patient to agree. Quick screen, ask the patient: –What is wrong with you? –Do you know what your options are? –What’s likely to happen if you accept the treatment or refuse it? –What is your choice? –Why have you made this choice? Innovation and excellence in health and care

6. The Law – but which ones? Advance Directives: –Basis is the concept of autonomy. –Mental Capacity Act. –Prior the Mental Capacity Act. The directive may: –Be a statement a competent individual has made about desired future care. –Be more formal and rarely appoint a person to make decisions for them. –Consider intention not just the specifics; consult. Innovation and excellence in health and care

7. The Law – but which ones? Criminal behaviour –Investigation and prevention of crime. –Road traffic offences. –Judicial or other statutory proceedings. –Safeguarding. Innovation and excellence in health and care

8. Scenarios – Privacy and Confidentiality 15 year old girl admitted following RTA; her boyfriend was driving the car. She admits to being pregnant. She tells you that she does not want her parents to know. What should you do? Innovation and excellence in health and care

9. Scenarios – Privacy and Confidentiality Consider: Normally only share with express consent. Competence. GMC Guidance. Safeguarding issues?

10. Scenarios - Capacity 27 year old male brought to the Trauma Centre by friends after consuming an unspecified amount of cocaine. He is unkempt and shivering. His observations are: pulse 172 bpm; BP 196/30 mm Hg; RR 36 breaths/min; temp 37.8˚C; Sp02 100% on room air. He is connected to a cardiac monitor, given oxygen and an intravenous catheter inserted. Innovation and excellence in health and care

11. Scenarios - Capacity The doctor asks for the patient to be given 10mg of diazepam. The patient says he doesn’t want it. He says that he has been through this before and recovered. His friends say that “he doesn’t’ know what he’s saying” and ask the doctors to treat him. What should you do? to treat him. What should you do?

12. Scenarios - Capacity The consequences of refusing emergency care may be serious and permanent. Sudden cardiac arrest? Intoxicants, hypoxia, brain injury, mental illness and dementia are common problems that can impair decision making but just because they are present doesn’t mean the patient lacks capacity. Be sure to assess carefully you can use the quick screen. Can you defer the decision while the patient improves? Document the decision Innovation and excellence in health and care

13. Scenarios – Advance Directives A 75 year old male has been airlifted to hospital after falling 10ft from a roof. He was initially unconscious but when paramedics arrived he was awake but confused. His GCS was 14. He was immobilised with a C-collar and backboard. During transfer to the trauma centre his GCS dropped from 14 to 10. On assessment significant head injury was suspected and arrangements being made to transfer the patient to CT when the patient’s wife and son arrive. Innovation and excellence in health and care

14. Scenarios – Advance Directives The patient suddenly deteriorates dropping his GCS to 8. Clinicians prepare to intubate but the wife becomes very upset saying that her husband has a living will that says if he is critically ill he does not want any interventions including intubation.

15. Scenarios – Advance Directives Advance Directives/living wills can have limited application. Context. Would the patient have wanted the directive to apply to this particular circumstance e.g., did he write it contemplating something irreversible or this situation? What will you do? Innovation and excellence in health and care

16. Ethics Understanding and acknowledging your own views. Dissecting common problems and common themes. Remember: Ethics and the law are not the same: following the law does not necessarily result in ethical behaviour and ethical behaviour might not be covered by the law. Difficult to disentangle these concepts in trauma care. While legal and ethical conclusions may be similar, ethical and legal analysis are often very different. Innovation and excellence in health and care

17. Shields not swords Having worked in the NHS for twenty years I have seen most things. The best advice I can give anybody here today is simple (you should be doing it anyway) but just in case… I call it 3Cs - C asenotes C ommunication C ompetence Innovation and excellence in health and care