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Ethical issues & difficult decisions

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How would you handle a problem doctor - for example, if you suspected that your consultant had a drink problem? What would you do if you found a colleague taking illicit drugs?


How would you react if one of your junior colleagues turned up drunk on the ward first thing in the morning? What if it was your consultant? (NCAS advice below).


A patient mentions to you that on two occasions they have smelt alcohol on your consultant's breath during clinic in the past few weeks. What do you do?


A patient mentions that, during an examination, one of your colleagues examined her breasts. Although the patient is not aware that such behavior was inappropriate in that context, you are. How do you respond?


You observe your consultant making inappropriate sexual remarks to one of your patients. There are no other witnesses and the consultant is not aware that you were there. How do you react?


You have heard rumours that one of your colleagues is taking drugs. You also know that some drugs have disappeared from the cabinet. How do you react?


You have suspicions that one of your peers has been stealing an important amount of hospital property (including stationary and needles). What do you do?

These questions are essentially the same, dealing with significant concerns.

Dealing with a drunk colleague:

My first concern would be the safety of the patient. However I have a duty of care to my colleague and the hospital too.

Patient safety - I will talk to my colleague/consultant and send him home (if difficult, enlist the help of another consultant or clinical director). I will review all the patients seen by him and complete the ward round. I will also recall all the patients discharged by him. I will ensure that appropriate cover is arranged for him, if needed.

Duty of care to colleague - I will arrange a taxi for him to go home and check on him later, to ensure that he has reached home safely. I will have a discussion  with him (if a consultant, I will pass on the incident to the clinical director) and try to help. You could suggest occupational health referral. Insist that his behaviour was not appropriate.

Duty of care to the hospital - Keep accurate records and inform your consultant or clinical director.

Background

You must protect patients from risk of harm posed by another colleague's conduct, performance or health. The safety of patients must come first at all times. If you have concerns that a colleague may not be fit to practise, you must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary. You have a few options:

a. You can report your concerns to your clinical or medical director.

b. You can discuss your concerns with the National Clinical Assessment Service (NCAS). NCAS can provide advice on local procedures and may assess the practitioner to clarify any issues and then offer recommendations for resolving the concern.

c. Report your concerns to the GMC
If you think the action taken has been insufficient, contact the GMC. Acting on concerns about a colleague is never easy but all NHS staff have a professional duty to do so in order to protect patient safety and help the practitioner involved.

Where concerns about performance have arisen, it may be helpful, at any stage of the process, to consider why this has happened. THINK ABOUT:

The individual’s health and other factors:

  • Does the individual have a physical or mental illness?
  • Is the individual depressed or suffering other mental illness?
  • Might alcohol or substance misuse be involved?
  • Has there been a recent major life event?

Knowledge, skills and behaviour

Is there a difficulty with clinical knowledge and skills?

Might a deficiency in education, supervision or continuing professional education be contributing to the problem?

  • Was the practitioner’s induction appropriate or sufficient?
  • Does the individual have difficulty understanding the limits of their competence?
  • Is the problem predominantly one of the practitioner’s behaviour or attitude?
  • Is this new behaviour or is it an exacerbation of long-standing problems?

The job

  • Have work factors changed?
  • Is there a problem with technological advances or techniques?

The work environment

  • Are there team difficulties?
  • Have there been major organisational changes?
  •  Could issues relating to equality and diversity be a problem?
  • Could bullying or harassment be a problem?
  • Are there any systems issues that contributed to the performance difficulty?

 

What is meant by a significant concern?

Significant concerns about a practitioner may relate to any of the following areas:

  • Poor clinical performance
  • Ill-treating patients
  • Unacceptable behaviour, such as harassing or unlawfully discriminating against staff or patients
  • Breaching sexual or other boundaries with patients or staff
  • Poor teamwork that compromises patient care
  • Personal health problems leading to poor practice
  • Not complying with professional codes of conduct
  • Poor management or administration that compromises patient care
  • Suspected fraud or criminal offence

This list is not exhaustive and there may be other areas of concern that you should consider reporting.

How would you react if one of your female junior colleagues refused to treat a patient who is a known rapist?

GMC guidance -If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them that they have the right to see another doctor. You must be satisfied that the patient has sufficient information to enable them to exercise that right. If it is not practical for a patient to arrange to see another doctor, you must ensure that arrangements are made for another suitably qualified colleague to take over your role.

All patients are entitled to care and treatment to meet their clinical needs. You must not refuse to treat a patient because their medical condition may put you at risk. If a patient poses a risk to your health or safety, you should take all available steps to minimise the risk before providing treatment or making suitable alternative arrangements for treatment.


How would you react if a patient refused to be treated by one of your junior doctors because he is foreign?

First ensure that the patient is compos mentis. Most trusts will have a policy governing racist behaviour. Racist behaviour would be considered an assault on a member of staff under many trust policies. Most trusts have a zero tolerance policy towards abusive patients and care may be withdrawn for persistent offenders.

Most trust policies would recommend:

a. Explain to the patient that their behaviour is unacceptable and explain the expected standards of behaviour, which must be observed in the future.
b. If the behaviour continues, the responsible clinician will give an informal warning about the possible consequences of any further repetition.
c. Continued behaviour after a formal warning will lead to immediate exclusion from the Trust premises by the security staff/police. Such an exclusion from Trust premises would not mean that he would not receive care, as his clinician would make alternative arrangements for him to receive treatment.

Tell us about an ethical dilemma you have been involved in?

Remember, medical ethics rests upon four key principles:

  • The principle of autonomy – individuals have a right to be self-governing
  • The principle of non-maleficence – the patient should not be harmed
  • The principle of beneficence – the benefit of the patient should be promoted
  • The principle of justice – equals should be considered equally

Two representative examples of ethical dilemma:

Mary is clinically depressed and takes a lethal overdose. She leaves written instructions asking not to be resuscitated. If you arrived at Mary’s side in time to do so, would you resuscitate her?

Living wills (advance directives) are valid in English Law. However, an advance directive must be written by a person who has mental capacity. We do not know if Mary had psychotic depression. Nor do we know if she understood the consequences of her refusal of future treatment. The clinician should treat Mary until she is sufficiently competent to make her own decision about further treatment. The legal defence of 'necessity' would cover any treatment (including resuscitation) which was necessary to protect Mary's life, and which could not reasonably be delayed.

The idea of this question is to discuss an ethical dilemma. The most important bit of the answer is how you dealt with it. So, in the above question, you could have discussed it with the psychiatrist to get further guidance (so define the dilemma and then discuss how you resolved it).

Another example

Mike is in a persistent vegetative state. He is legally alive (spontaneous respiration and heart beat) but a decision to withdraw nutrients and antibiotics with the intention of ending his life would not necessarily be unlawful.
There is no legal duty to provide treatment that is no longer considered in the patient’s best interests. Although the withdrawal of life support is factually the cause of death, the legal characterisation of this ‘terminal regime’ as acting in the best interests of the patient means that the causative action has no legal consequences.

You see a patient verbally abuse a nurse. What is your response?

Firstly ensure that the patient’s behaviour is not due to his/her underlying medical condition. If it is willful, warn the patient that the behaviour is unacceptable. If the patient persists, he should be given a formal warning. If the behaviour is repetitive, he may be removed from the trust premises by the hospital security. However, his care should not be hampered and the responsible clinician should make adequate arrangements for transfer of his care. Most trusts have a policy regarding dealing with violent/abusive patients.


One of your peers arrives constantly late for work in the morning. What do you do?

For minor concerns (coming late) about performance, an informal approach may be all that is needed. Here, a discussion with the individual concerned, aimed at improving their performance or conduct, may be sufficient to resolve the issue. Dealing with the matter informally provides the opportunity for both parties to agree the way forward, without the use of formal disciplinary or other procedures. Even if an informal approach is taken, the outcome of the discussion and agreement reached should be communicated to the practitioner in writing and notes kept of all meetings held.

One of your junior colleagues is placing patients at risk. How do you react?

Essentially similar to Q1 and 2. The patient's safety is paramount. So notify immediately his supervising consultant.

In general, interventions to improve the practitioner’s performance may include the following:

  • An educational programme: clinical, personal or organisational skills
  • Referral to occupational health with onward referral and follow-up of any health problems
  • Mentoring by a trusted practitioner
  • Supervised practice
  • Behavioural coaching
  • Modification of duties

 

Your consultant does something that goes against protocol. How you do you tackle it? How would you approach the consultant?


Your consultant mentions something to a patient that you believe to be wrong. How do you react?

Don’t assume that your consultant is wrong. Discuss with him that you found his decision interesting and would like to learn the thinking behind it. If you are not satisfied and think that less than perfect care has been provided, you are duty bound to raise your concerns with your consultant. If you find it difficult, discuss it with your supervisor or the clinical director.

Your consultant does not provide adequate training and adopts a condescending attitude towards you because of your apparent lack of knowledge. How do you react?


Your SHO mentions that another SHO is complaining about the fact that their consultant does not provide adequate teaching. How do you respond?

There may be reasons for the consultant’s behaviour, e.g. for health or work-related reasons. Discuss it with him and see whether you could arrive at an acceptable training solution. The problem may be with the trainee too. If there are still concerns, discuss it with the college tutor or the clinical director.

 

One of your colleague seems to be suffering from stress. What do you do?

Discuss it with your colleague if you can, and suggest self-referral to occupational health. If they are not willing to cooperate and if you suspect it is compromising patient care, then discuss it further with your clinical director.


What is your opinion about accepting gifts?

All codes of practice for healthcare professionals have a similar rule. Note that accepting gifts is not prohibited, provided that the gift is not seen as an inducement.
In practice, this can be difficult to demonstrate, so it is probably unwise to accept any gift of significant value. ‘Significant’ is also a matter of judgement, of course, but it is unlikely that the code was intended to apply to the nurse who receives a box of chocolates from a grateful patient.


What do you think about euthanasia ?

An ethical justification for euthanasia is that it permits the ultimate expression of the patient’s right of autonomy. However, in the UK at the current time, ending a patient’s life may constitute murder.

However, it can be ethically acceptable to withdraw or withhold treatments, even if the patient dies as a result (a practice sometimes known as passive euthanasia). When treatment may indirectly hasten death (e.g. pain relief), the intent of treatment must be to relieve distress, not to shorten life.

The law forbids active euthanasia and assisted suicide for several reasons:

  • Medical knowledge is limited and it is presumptuous for a doctor to determine the moment a person dies. This loses some force, however, if it is the patient who chooses the time to die.
  • The pressure for active euthanasia can often be met adequately by suitable and sympathetic terminal care.
  • There is a danger in making the intent actively to hasten death part of medical ethos.

What do you think about choice in NHS?

The NHS was set up principally as a public service, aiming to meet common needs rather than consumerist demand.

There is no way logically for choice to be the dominating principle of healthcare provision unless there is an infinity of healthcare provision and one single consumer… you can choose a doctor you like but if the clinics are full, choice is limited.

What do you think about presumed consent for organ donation?

Although 90% of the UK population is in favour of organ donation, only 24% has signed the Organ Donation Register. Currently, when a person’s wishes are not known, relatives are asked to decide about donation, in the most difficult circumstances, when they are recently bereaved. Not surprisingly, a large number of families —around 40% — opt for the default position, which is not to donate.

The BMA has supported a system of presumed consent. The system of presumed consent may increase the organ availability but would still retain a role for relatives; opting out would be easy and accessible.

a. One of the major concerns people have with a presumed consent system is that individuals will lose control over what will happen to their body after death, and that the state will take over. This is not the case. Like the current system, under presumed consent people would retain the choice over whether or not to donate after death.

b. Mechanisms must be in place to ensure that all members of the public are informed of their choices and can register an objection quickly and easily — for example, through their general practitioner, post office or electoral registration forms. As an added safeguard, the system would retain a role for relatives. After death, relatives would be informed that the deceased person had not opted out of donation and, unless they object — either because they know of an unregistered objection by the person or because it would cause major distress to the close relatives — the donation would proceed.

c. The opt-out proposal will not mean that those who do not wish to donate their organs will have to do so, or that families will not have a choice. What it will mean is that everyone will be prompted to think about that choice, to make a decision and discuss it with their loved ones, rather than avoiding the issue and thinking, as is all too easy to do…

My opinion:

I believe presumed consent is not consent at all. The Human Tissue Act rightly puts consent at the heart of the act for the removal and use of human organs. To increase the organ supply, we should mandate all adults to make a choice regarding organ donation. A mandated choice will help quickly to resolve the issue.

AnaesthesiaUK would like to thank consultantmedicalinterview.com for allowing us to reproduce their material.

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