What THREE things are required for valid consent? Valid consent CapacityInformation Voluntariness (free from coercion)
What FOUR things are required to demonstrate capacity? Understand info Retain infoWeigh-up Communicate decision Capacity
What FOUR pieces of information are required? Information Broad info Risks, benefits, alternatives Defence against BATTERY Defence against NEGLIGENCE
A 52 year old women needs her gallbladder removed, what would be the first thing to consider?
Assess capacity Facilitate a capacitous decision if possible Does patient have a valid advance refusal? Treat in patient’s “Best Interests” (another topic in itself!) Does patient have someone with lasting Power of Attorney? 1. 2. 3. 4. 5. Communication aids Time of day Remove sedation Understand Retain Weigh-up information Communicate decision Over 18 years of age Relevant circumstances Patient not done anything inconsistent with directive For refusal of life-sustaining treatment Written Signed witnessed Can only give or refuse life-sustaining treatment if this was specifically stated
If an adult lacks capacity to consent, who can consent of their behalf? Welfare Lasting Power of Attorney which covers healthcare decisions Appointed by court
Who can give consent for treatment of minors? 16-17 year old with capacity Gillick competent under 16s Adults with parental responsibility (only need 1 parent) Court May treat without consent in an emergency Note: children and young people have the right to participate in decisions about their healthcare regardless of their capacity
What are the requirements for Gillick competence? Understands the problem and implications Understands the risks and benefits of treatment Understands the consequences if not treated Understands the alternative options Understands the implications on the family Is able to retain (remember) the information Is able to weigh the pros and cons Is able to make and communicate a reasoned decision about what their wishes are.
What is battery? Any form of procedure (even touching) without consent
When can you break confidentiality of an adult patient without their consent? Lacks capacity and acting in best interests Public interest to disclose information Legally required
When is it legally required to break confidentially? Notifiable diseases Suspected cases of abuse Gunshot wound DVLA You must disclose information if ordered to do so by a judge or presiding officer of a court.
What is an ethical justification for breaching confidentiality? Consequentialist: best overall consequence – overall benefits outweigh harm (greater good) Moral duty: non-disclosure would result in serious harm to another individual greater then that of the person whose confidentiality you breached
32-year old man, presents with severe fever, chills, productive cough and muscle aches. Recent travel history to Philadelphia. You suspect Legionnaire’s Disease A notifiable disease. However at this stage it is only a suspicion. So, no.
20-year old student, known to be sexually active, measures positive for HIV on a routine check. Follow-up investigations confirm the diagnosis of HIV No. HIV is not a notifiable disease.
During a follow-up appointment: Whilst giving the patient information about safe sex, he admits he doesn’t use a condom, and he hasn’t told his girlfriend he is HIV+ Once the patient is aware of his diagnosis, he is criminally liable for transmission. In this case, the GMC states you can disclose to the partner without consent The patient’s girlfriend is at risk of serious infection
After becoming a Doctor (congrats.) you’re working on the stroke ward, you discharge one of your patients and advise her she shouldn’t drive for a little while. However, she disagrees with you, and when you see her a week later she informs you she has been driving Strokes do not require formal notification to the DVLA. What should you do instead? Ask them to get a second opinion What if they keep ignoring you? Then you should notify the DVLA, after telling the patient what you’re going to do Strokes/TIA, ACS don’t require formal notification to the DVLA (just advice about a period off driving) Things that do require notification: epilepsy/seizures, diabetes mellitus, acute psychosis, alcohol/drug abuse
One of your patients, a 14-year old girl, is diagnosed with cancer. You first break this news to the parents, who inform you that they do not want her to know. What do you do? You should explain to them that you should assess the capacity of the child and deliver information in a way they can understand. (Children and young people usually want to know about their illnesses. You shouldn’t withold information unless the patient refuses knowledge of that information Give me some exceptions: The information would cause “serious harm” The child specifically requests that someone else makes the decisions for them
In GP-land: a 15-year-old girl visits you asking for contraception. Do you tell her parents? In this case, realistically –no. Its all about the patients competency. Think Gillick-Fraser guidelines These are all about trying to identify abuse btw.
In GP-land: a 15-year-old girl visits you asking for contraception. However, she is visiting with her 35-year-old partner Do you tell her social services? In this case, realistically –yes. The GMC says you should consider sharing information are where: a big difference in age is ringing alarm bells
In GP-land: a 17-year-old girl visits you asking for contraception. However, she is visiting with her 21-year-old partner, her art teacher Do you tell social services? In this case, realistically –yes. The GMC says you should consider sharing information when: The partner is in a position of trust The full list where the GMC says you should consider sharing information: The young person is too immature to understand The child is under 13 A big difference in age is ringing alarm bells The partner is in a position of trust There is a force/threat suggesting emotional,psychological or physical pressure Drugs/Alcohol are involved