#ethics

A 30-year-old male is unconscious on admission following a road traffic accident.

He was the driver of the car and there is the suspicion that he was responsible for the accident in
which a passenger of another car died.

In attendance with the patient is his wife who was uninjured in the accident.

The police are keen to obtain a blood sample for alcohol measurement but the patient is incapable
of giving consent for this procedure and there is no forensic physician who can do so. You are
working in the A&E unit but are not directly involved in the clinical care of this patient. The police
have asked you to obtain a sample of blood for analysis. The clinical team who are looking after the
patient are aware of the request made to you by the police.

What is the most appropriate action in these circumstances?

(Please select 1 option)

Draw a blood sample for later analysis when the patient is competent to consent

Draw a blood sample which can be analysed immediately

Inform the police that you may only take blood samples on medical grounds

Obtain consent from his wife, as next of kin, to draw the blood sample

Refuse to obtain a blood sample until the patient is competent to provide consent

Answer is A : U need to take consent from patient so you the blood sample and keep before the
alcohol in the blooD disappears.

#ethics

A 76-year-old man is admitted to hospital with sudden-onset paralysis and paraesthesia affecting his
left side. He has a background of vascular dementia, coronary artery disease and chronic obstructive
pulmonary disease (COPD). The speech and language therapy (SALT) team have deemed that he has
an unsafe swallow, and have recommended insertion of a nasogastric (NG) tube. His wife refuses the
procedure, stating that he gets great enjoyment from his food and feeding him through a tube
would make him miserable. She is his lasting power of attorney (LPA). What is the most appropriate
initial course of action?

Insert a percutaneous endoscopic gastrostomy (PEG) tube

Continue oral feeding

Consult another family member

Insert an NG tube

Assess the patient's capacity

Answer is E : You need to assess mental capacity of patient despite having history of dementia

Also LPA ( lasting power of attorney) applies only when person is incapable and not having capacity
to make decisions by themselves. So first assess capacity of patient.

#Ethics

A 36-year-old woman is one of your formal patients on an inpatient psychiatric ward. One of the
patient's work colleagues rings the ward asking after the patient. What is the most appropriate initial
course of action?

Give the colleague a full summary of the patient's progress so far

Only give limited information about the patient e.g. 'she's doing well'

Inform the colleague that the patient is on the ward and that she can come and see her (but do not
give details out over the phone)

Tell the colleague to call back later

Do not confirm the presence of the patient

Answer : E , Do not confirm the presence of the patient. This is the same for any patient admitted in
the hospital, not just for psych patients.

#Ethics

You are the FY2 in a small hospice and you are asked to speak to a patient about her do not attempt
cardiopulmonary resuscitation order (DNACPR). The patient is ninety eight years old with advanced
heart failure and metastatic lung cancer. She previously agreed to a DNACPR, a decision that was
supported by an number of healthcare professionals, but has now changed her mind and is asking
for the order to be rescinded. She doesn't want to die and would like CPR if her heart stops. How
should you proceed?
Revoke the DNACPR as the patient has the right to refuse and they can be revoked

Explain to the patient the DNACPR has been lifted but in the event of her arrest perform only
perfunctory resuscitation efforts

Ask your registrar to speak to the patient and explain the DNACPR order will stay in place as
resuscitation would be unsuccessful. If the patient is still unhappy offer to refer for a second opinion

Explain that she has no right to demand intervention and that the order should stay in place as
resuscitation would be unsuccessful

Ask the patient to appoint a lasting power of attorney (LPA) and when she does persuade the LPA to
consent to the DNACPR

Answer: C

This case focuses on some of the nuances on DNACPR orders.

Forcing the patient to change his mind in order to perform the operation is coercion and may
invalidate his consent. Lying to the patient is patently unethical and may open you up to
prosecution. A capacity assessment is likely to find the patient has capacity as he has reasonable
reasons to want a DNACPR and so an assessment will not move this situation forward.

Referring to a number of anaesthetists until one is found that will perform the procedure is not good
practice and finding someone who agrees with you is not evidence of ethically correct decision
making.

DNACPRs are situation specific and can be suspended for specific procedures such as operations.
There is guidance to support this and is possible because of situations such as this where the
outcome of a CPR attempt is so likely to be successful. Look over these extensive DNACPR guidelines
for more information - https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr/

#Ethics

A twenty four-year-old woman is approaching the second stage of labour when cardiotocography
(CTG) shows late decelerations likely suggesting foetal distress. The situation is explained to her and
the need for an emergency caesarean-section made clear, she considers this and consents. However,
when you approach to insert the cannula required for induction she begins to panic. The patient
reveals she is needle phobic and refuses to allow the caesarian to go ahead. Which course of action
is it best to pursue?
As she has already given consent, simply continue with the procedure

Involve her partner in the decision making process and, if she still will not consent, allow him to
consent on her behalf

Perform a mental capacity assessment and act in the patient's best interest if she is found to lack
capacity by performing the procedure

Continue without consent as to do otherwise would violate the foetus' human rights

Respect her wishes and attempt to deliver vaginally

Answer is C

If she is found to have capacity and refuses then you can’t do anything about it, you have to just
respect her wishes.

#Ethics

A seventeen-year-old patient with advanced lymphoma presents to the London Royal Free Hospital
following ingestion of seventy 500mg tablets of paracetamol. The patient was likely in the last few
months of life and did not wish to die slowly. When the patient is bought in you note that an
advanced care directive is stapled to his shirt. The statement reads that in the event of accidental or
deliberate overdose the patient would not like to receive any intervention that may reverse such
overdose. It goes on to acknowledge that such decision may shorten his life expectancy and it is
signed and dated by the patient and a witness. Is the advanced care directive applicable in this
instance?

Yes - it is signed by both the patient and a witness, it also acknowledges the risk of lessened life
expectancy and is therefore it is valid

No - it is not written on headed paper

Yes - it is specific to the situation

No - it may have been signed but was not notarised by a person of sufficient authority

No - people under the age of 18 cannot sign advanced care directives

Answer : E , people under 18 can’t sign advanced care directives

#Ethics
An eighty-year-old man is recovering on a surgical ward following a major abdominal surgery. He has
developed delirium which you diagnosed using the confusion assessment method (CAM) a few days
ago. You feel this is likely due to his large opioid load but have been unable to wean him due to
persistent post operative pain. The patient has been receiving one to one nursing for his own
protection as he tends to wander. The ward matron approaches you and asks that the patient be
sedated this evening as she is short staffed and cannot afford to use a nurse for one to one cover.
How should you proceed?

Give 0.5mg of haloperidol to sedate the patient overnight

Give 2mg of oral lorazepam overnight

Use raised cot sides to prevent the patient leaving his bed overnight

Use a waist strap to secure the patient to the bed

Refuse to change the patients care plan and suggest the matron obtains an agency nurse or HCA to
cover the patient overnight

Answer is E. Doctors don’t work according to nurses convenience.

A man is very depressed and miserable after his wife’s death. He sees no point in

living now that his wife is not around and apologises for his existence. He refuses any

help offered. His son has brought him to the ED. The son can’t deal with the father

any more. What is the most appropriate next step?

a. Voluntary admission to psychiatry ward

b. Compulsory admission under MHA

c. Refer to social services

d. Alternate housing

e. ECT

Answer is B. The accurate answer will be B.

Here we have a suicidal patient with mental health issues(depression) who is not giving consent for
treatment. In such case, ideally we should

1. Refer to psychiatry team for capacity to refuse treatment assessment.

So if that is not in the answer option, the attending Doctor can detain the patient under Mental
Health Act.(Section 4 under emergency). It can be used in Emergency Department or anywhere in
the hospital.

(Ref: Mental Health Act UK)

#Ethics

A two-year-old boy with recurrent croup requires a general anaesthetic for a laryngoscopy to
ascertain if there is an underlying anatomical disorder causing his presentations. During induction he
becomes agitated and refuses to breath into the mask as required for induction. His father is present
with him but refuses to hold the child still to force it to breath in the gas as he too has become
distressed. How should you proceed?

Abandon the operation as the patient is not giving assent to proceed

Reschedule the operation for tomorrow but give pre-operative midazolam to the patient so as to
avoid a repeat incident

With the fathers consent allow the operating department assistant to restrain the child while he is
induced

Perform a capacity assessment, if the patient is found not to have capacity, continue with the
procedure

Switch to propofol induction as the gas mask is not tolerated

Answer is C

#Ethics

You are working on a medical ward when you are asked to see a patient who has suffered a probable
stroke. The patient is a seventy eight-year-old man who was admitted for treatment of a urinary
tract infection - he has a dense hemiplegia and dysphasia. After referral to the stroke team his
diagnosis is confirmed but thrombolysis cannot be performed as he has a large space occupying
lesion. His wife is present and produces an advanced care directive - the directive is signed, dated
and countersigned. Within it, the directive expresses that in the event of life limiting illness
treatment should be given regardless of contra-indications. His wife explains this was written
specifically after he developed his brain tumour in case he had a stroke. How should you proceed?

Perform the thrombolysis as the patient was aware of the risks and the directive is valid
 Refuse to perform the thrombolysis as the directive is not written on headed paper and is therefore
invalid under law

Refuse to perform the thrombolysis as advanced directives cannot be used to demand treatment

Explain to the wife that the directive should have been given to the hospital on admission and as it
was not it is therefore invalid

Perform the thrombolysis as the patient has no DNACPR in place and his quality of life may be much
improved by intervention

Answer is C

ETHICS

Q.1 A 14-year-old girl has been sexually active for 6 months and seeks sexual health advice. She has
a regular partner and has no symptoms. She is very anxious that her mother does not find out that
she is sexually active, and wants reassurance that her confidentiality will be maintained. In which
single situation might breaching her confidentiality be justified?

A She is found to have a sexually transmitted infection

B She is in a sexually abusive relationship

C She requests a prescription for the oral contraceptive pill

D She requests a termination of pregnancy

E None of the above, as she has an absolute right to confidentiality

Answer is B, she has rights of confidentiality except if something is going to bring harm to patient.

ETHICS:

1. A 14-year-old girl requests emergency contraception. She had unprotected intercourse with her
14-year-old boyfriend 2 days ago. She appears to understand the nature of emergency
contraception. Which is the single most appropriate management?

A . Advise her that she cannot have emergency contraception, as it is too long since intercourse took
place

B. Advise her that she is too young to be legally prescribed emergency contraception

C. Prescribe emergency hormonal contraception and advise her about future contraception

D. Prescribe emergency hormonal contraception only after informing her parents

E. Prescribe emergency hormonal contraception only after informing social services

Answer is C. You can give contraceptive/STD/Abortion advice or treatment to Children less than
16yrs of age who are mature enough to understand what is involved in the management as long as
they have capacity to consent to their treatment. These grp are refered to as gilick competent.

The girl appears to be Gillick competent, as she understands the nature of the treatment. Therefore
she should be prescribed emergency contraception like any other patient. Emergency contraception
can be given up to 72 hours after unprotected sex. Thought must be given to ongoing contraception
to avoid further incidents.

#ethics

A 19-year-old female presents to the GP with her mother, she is reporting a growing breast lump
that is causing her distress. You offer to examine her and ask if she would like a chaperone. She says
that she doesn't want a stranger there so would rather have her mum as the chaperone, what do
you do?

Explain that family members cannot be used for chaperones and reoffer the patient someone at the
practice to chaperone

Accept the mother as a chaperone but ensure you have documented this in the notes

Explain that family members cannot be chaperones and ask her to re-book for 2 weeks time

Explain that family members cannot be chaperones and document this in her notes, continue with
the examination on your own

Explain that is isn't her choice who the chaperone is, continue with the examination on your own

Answer is A

#ethics

A 15-year-old female presents to the GP requesting the contraceptive pill, on questioning, she
demonstrated Gillick competency, however she discloses that her boyfriend is 25 and the Maths
teacher at a local, but not her, state school. She is not pregnant and her last period was 3 weeks ago.
She asks you not to tell anyone, especially her father who is also one of your patients. What do you
do?

Inform her that you need to tell social services and child protection due to the age and position of
trust of her boyfriend. Try to get her consent but explain you will still need to tell them if she doesn't
consent

Inform her that you need to tell social services and child protection due to the age and position of
trust of her boyfriend. Try to get her consent. If she refuses then accept you cant tell anyone as she
has demonstrated Gillick competency
Phone up the boyfriend and check he is ok with this decision.

Prescribe The contraceptive pill, but document in her notes your discussion and concerns about her
boyfriend to be brought up at the next appointment

Inform her boyfriends school about their relationship, and the fact they are seeking contraception.

Answer is A because of the age of the boyfriend and also that he is the teacher.

#ethics

While on placement in the GP practice you are sitting in with one of the partners in his morning
clinic. During this you notice them prescribe nicotine replacement gum to a pregnant woman who is
21 weeks pregnant. You know from your studies this is not licensed for pregnancy, what do you do?

Stop the consultation mid way and inform the GP and patient that it is not licenced in pregnancy

Do nothing at the time, but phone the patient back later to talk through the fact it is an unlicensed
medication

Do nothing at the time but inform one of the other partners of this GPs practice

Find the midwife at coffee time and pass on the patient details so this can be discussed at a later
appointment

Nothing, the GP is taking responsibility for the prescription of an unlicensed medication

Answer is E, the Gp is taking responsibility for his actions

#ethics

You are working on a team caring for a 54-year-old patient with metastatic prostate cancer. He has
multiple co-morbidities and its been decided that CPR would not be clinically beneficial. However on
consultation of this with him he gets incredibly distressed and agitated. He requests that he would
still like CPR and feels as if you are giving him a death sentence by suggesting this. He refuses the
DNACPR. What do you do?

Remove the DNACPR as he has full capacity to refuse this decision, but don't inform your consultant

Remove the DNACPR as he has full capacity to refuse this decision, document this clearly in his
notes

Inform him that this is a professional judgement and you he cant refuse the DNACPR, but offer some
sedatives to help his agitated state

Pretend to accept his decision but leave the DNACPR in place

 Inform him that this is a professional judgement and he can't refuse the DNACPR, but offer
counselling to process this information

Answer is E

#ethics

A twenty-four-year old patient is undergoing an elective procedure for treatment of Crohn's disease.
During his pre-operative assessment, he expresses that he would like a do not attempt
cardiopulmonary resuscitation order (DNACPR) placed on him during his admission. His father
underwent CPR following a heart attack and spent several months in intensive care before dying and
the patient is keen to avoid a similar fate. He is physically fit and the operation is unlikely to result in
an arrest but the anaesthetist will not proceed with the operation with the DNACPR in place. How
should you proceed?

Refuse to perform the procedure unless the patient changes his mind

Inform the patient that the DNACPR is in place, but if he arrests resuscitate anyway

Allow the DNACPR to be signed but ask the patient to agree to temporary suspension during the
operation itself as the likely outcomes of CPR on an anaesthetised patient are much better than an
arrest such as his fathers

Perform a capacity assessment. If the patient is found to lack capacity proceed with the operation
acting in best interest and in absence of the DNACPR

Refer to a new anaesthetist until one can be found that will perform the procedure

Answer is C

#ethics

You are a FY1 assisting in gynaecology day surgery, one of your procedures to get signed off is an
internal examination and female catheter, you mention this to the surgeon before he starts his list
and he agrees to allow you to do this is theatre.

He tells you not to bother talking with the patients to get consent as they will be under anaesthetic
and so unaware. What do you do?

Accept what the surgeon said as he is your senior and preform the procedures

Accept what the surgeon said as he is your senior but claim you don't feel well during the list and
leave before doing any procedures
Refuse to do this and go and tell the patients what he said

Refuse to do this as its not following consent guidance

Report him to the GMC

Answer is E. He needs to be reported as what he is suggesting is wrong.

#ethics

A 28-year-old female is admitted to the emergency department and is subsequently sectioned under
section 2 of the mental health act for a drug induced psychosis. She brings with her two children
aged 4 and 8. While being assessed she attempts to pick out dirt from her children's skin. They are
clearly distressed but the mother is assuring you they are going to stay with grandparents and be
looked after. She is admitted, but refuses consent to allow you to inform the grandparents of what
has happened. What should you do?

Give the grandparents limited information but contact social services to inform them of the
situation

Don't tell the grandparents anything to protect the mothers confidentiality, but make detailed notes
of the assessment in her notes

Admit the children to the paediatrics ward for a full assessment

Tell the grandparents exactly what has gone on so they can keep the children safe but don't tell the
mother or document this in the notes

Tell the grandparents exactly what has gone on so they can keep the children safe.

Answr is A