Part C Text 1: Witnessed resuscitation attempts - a question of support. ‘The idea of supporting relatives who witness resuscitation is nothing new, with research and roports going back to the 1980s. In 1996, the Research Councils UK (RCUK) published a booklet called Should Relatives WitnessResuscitation? Since then, practice has moved on, but many of its core elements are still considered valid today. It was suggested that family members who witness the resuscitation process may have a healthier bereavement, as they will find it easier to come to terms with the reality of their relative's death, and may feel reassured that everything possible has been done. It acknowledged that the reality of CPR may be distressing, but argued that it is “more distressing for a relative to be separated from their family member" at this critical time. In the latest edition of its Advanced Life Support manual, the RCUK remains adamant that “many relatives want the opportunity to be present during the attempted resuscitation of their loved one.” But do they have the right to demand it? ‘The resuscitation team and the nurse caring for the patient have the responsibility of deciding whether to offer relatives the opportunity to witness a resuscitation attempt’ says Judith Goldman, clinician and researcher at the University of Michigan, USA. ‘Sometimes resuscitation teams may decide not to offer relatives the option of witnessing resuscitation; but this should never be based on their own anxieties rather than on evidence- based practic When a patient is admitted to intensive care the question may be asked by the medi team whether the patient would want CPR. This would also provide an opportunity for witnessed resuscitation to be discussed with patients and relatives upon admission. ‘The subject would have to be approached sensitively, but ascertaining patients’ and/or relatives’ wishes before an admission to intensive care would certainly help’ says Frank Lang, researcher for the European Resuscitation Council. ‘Recent studies show both public support for witnessed resuscitation and a desire to be included in the resuscitation process and of those who have had this experience; over 90% would wish do so again’ he says. ‘Still, the decision regarding whether to be present during resuscitation should be left to the individual person because it's certainly not for everyone,’ he adds. ‘Medical teams also need to gauge whether witnessed resuscitation would have benefits for the patient andlor the relatives, which can only be done through a holistic assessment of the specific situation at the time. It needs to remain a personal approach’ he says. What this way of thinking suggests Is that regardless of research, witnessing resuscitation can be traumatic for Scanned with CamScannerall involved, particularly for family members, so it seems appropriate that health professionals explain everything that is happening. Even more so that a member of the team, ideally the nurse caring for the patient in cardiac arrest, be designated for that role and remain with the family during the whole process. ‘Nurses need to discuss the wishes of the patient and/or relatives as soon as possible to Actin the best interests of both while remaining non-judgemental whatever the relatives decide, whether they choose to be present or not, and support them in making the decision’ says Judith Goldman. ‘Once it has been established that relatives want to be Present, the nurse should inform the resuscitation team leader, seek their approval and ask them when the relatives should enter the resuscitation area. The team who are providing direct care retains the option to request that the family be escorted away from the bedside and/or out of the room if deemed appropriate’, she says. Such decisions to request family removal are not taken lightly. ‘There are the more obvious occasions that family members must be removed, for instance, if they disrupt the work of the resuscitation team either through excessive grief, loss of self- control, exhibit violent or aggressive behaviour or try to become physically involved in the CPR attempt’ she says. ‘But the team also need to consider times when during a resuscitation attempt all members of staff are fully occupied and there is no one available to stay with the family. This is especially hard for them to take.’ If the family do remain present, and regardless of patient outcome, providing assistance is crucial for families to get through such a stressful and shocking event. Frank Lang recommends that ‘the nurse who is directing the family should point them towards all or any available support service within the hospital as well as towards professional bereavement counselling outside of the hospital. The latter provides distance from the scene and can help with symptoms of post-traumatic stress disorder.’ Throughout any decision-making, however, it Is clear that the patient's welfare, privacy and dignity must remain the utmost priority of the resuscitation team. 7.In the first paragraph, the writer quotes the RCUK in order to A. stress the significance of family involvement in resuscitation attempts. B. show the significant benefits of family presence during resuscitation. C. highlight that many now consider witnessed resuscitation outdated. D. demonstrate that being witness to a resuscitation attempt is traumatic. 8.In the second paragraph, Judith Goldman says that witnessed resuscitation A. should not be the sole decision of the resuscitation team. B. needs to be made available to all families. Scanned with CamScannerC. must not be denied because of personal feelings. D. is requested by a large number of relatives. 9. In the second paragraph, the phrase ‘remains adamant’ is used to A. argue that relatives should have the ultimate decision. B, show that the opinion of the RCUK has not changed. C. express that greater understanding is needed from staff. D. emphasise RCUK's opposition to excluding family. 10. In the third paragraph, Frank Lang suggests that patients and family members ‘A. would struggle to comprehend the process of CPR. B. require follow up support from resuscitation teams. . have a good understanding of witnessed resuscitation. D. would benefit from early consultation with staff. 411. In paragraph four, the writer believes that a team member present at resuscitation attempts ‘A. should provide the family with constant reassurance. B. will find the experience as stressful as family members. , should focus on the patient rather than the relatives. D, needs to explain the process to each individual family member. 12. What does Judit Goldman regard as important during resuscitation? A. establishing that the resuscitation team are in charge. B. that relatives are instructed on whether to be present or not. €. the point at which family members enter or leave the scene. D. remaining courteous when requesting relatives to leave. 13, _ Inthe sixth paragraph, Judith Goldman suggests that families who wish to be present A. must understand that extra staff may not always be available. B. at times struggle to understand why they cannot enter. C. prefer to remain with the allocated member of staff. D. are sometimes concemed about witnessing the resuscitation. Scanned with CamScanner14, _ Inthe final paragraph, Frank Lang insists that despite the outcome of the resuscitation attempt, families A. are required to seek counselling as soon as appropriate. B.should utilise the hospital network before outside assistance. C. sometimes regret their decision to remain present. D. wil stl often struggle to overcome the experience. Scanned with CamScannerText 2: A smoker's right to surgery ‘Smokers who do not try or do not succeed in quitting should not be offered a wide range of elective surgical procedures, according to an editorial published in The Medical Journal of Australia. The authors acknowledge this would be a controversial, overtly discriminatory approach, but they say itis also evidence-based. Dr Matthew Peters and colleagues from Concord Repatriation General Hospital say smokers who undergo surgery have substantially higher risks, poorer surgical outcomes and therefore consume more healthcare resources than non-smokers. Surprisingly, these new concerns are not based on cardiac and respiratory risks, but increased wound infection. “A randomised study examining smoking cessation intervention before joint replacement surgery, saw wound infection rates reduced from 27 per cent in continuing smokers to zero In those who quit smoking," Dr Peters said, “Almost 8 per cent of breast reconstruction patients who smoke experience abdominal wall site necrosis, compared with 1 per cent of non- smokers. These resulls are obviously significant.” He believes that it is much better that the prioritisation occurs on the basis of good evidence rather than on a whim or some political influence, “If there was a health care system that had everything patients need and ‘want immediately, there wouldn't be a problem. But we don't have that and as far as I'm aware no country truly does. You have to determine priorities,” Peters says. However, not everyone agrees. Professor Andrew Coats, dean of the University of Sydneys faculty of medicine believes this is not accepted medical treatment. “You do not arrange patients based on them being more deserving or less deserving. You give treatment based on need and how a person will benefit. I's the urgency of that need that's the main factor." Coats says lifestyle factors should only affect treatment in very limited circumstances. “If, because of lifestyle factors, a treatment is not likely to work or it will be harmful, then obviously it should not proceed. But we don't take these factors into account In prioritising; that would be the end of the healthcare system as we know il." He says if a doctor believes a patient could give up smoking and therefore reduce complication rates, they should encourage the patient to quit, but he says you cannot withhold an operation as punishment for not giving up. "Many people are not able to give up cigarettes. It is a real chemical condition.” Dr Mike Kramer, the Royal College of Surgeons representalive agrees that smokers need to be treated differently. "You need to take risk into account. The risks of procedure versus Scanned with CamScannerthe benefits, and that is affected by the smoking status of the patient,” he says. Kramer, a cardiothoracic surgeon, says complications associated with smoking are so significant he will delay an operation for the removal of a lung cancer so a patient can stop smoking for a minimum of four weeks before an operation. “This is not a moral judgement or an ethical judgement. itis a pure clinical judgement for the benefits of a patients outcome,” he says. ‘There is also the heavy burden of financial pressure that must be considered when dealing with the limited health dollar. Reverend Norman Ford, the director of the Caroline Chisholm Centre for Health Ethics, says while there should be no blanket ban or refusal for any surgery, the allocation of public health funds needs to be taken into account."Why should non-smokers fork out for smokers?” Ford says the additional costs of wound infection complications should be calculated and smokers who refuse to quit before surgery should pay the additional expense if wound infections occur. “If they give up smoking they should be treated the same as non-smokers. If they dont give up smoking they should pay the difference,” he says. *Youve got to motivate them to stop smoking and the pocket is a great motivator - if theyve got it. So their ability to pay should be means tested.” The essence of this argument comes down to the question of whether people who are knowingly doing things that may be harmful to their health are entitled to health care. ‘Surgery is routinely performed on diabetics, who also are at risk of increased postoperative complications. If surgery can be denied to smokers, or even delayed, should the same treatment, or lack thereof be given diabetics with poor glycaemic control because they don't comply with diet or medications? Refusing to operate on smokers could land us on a very slippery slope, eventually allowing surgeons to choose to operate only on low risk patients. Perhaps it would be more prudent for physicians to educate their patients about the risks of smoking, as well as other risk factors, prior to surgery and entitle patients to make an informed decision about their healthcare. 15. What possible reason does the writer give for refusing current smokers the opportunity for surgery? A the negative effects seen in systematic research B. the overall increased costs to the hospital system. C. the known impact on the patient's heart and lungs D. the higher possibility of post- operative infection ‘Scanned with CamScanner16. In the second paragraph, Dr Peters says that prioritising patients A. is unfortunately necessary. B.is less expensive in the long run. C. should start at a government level D. has been shown to reduce harmful outcomes. 17. _ Inthe second paragraph, the writer uses the term ‘on a whim’ to show Dr Peters’ belief that A. further research should be carried out B. current healthcare systems are not adequate. C. the findings of recent research are remarkable. D. careful consideration is extremely important. 18. _ In the third paragraph, Professor Coates says that treatment should be provided A.to all patients based on a system of merit. B. according to the necessity of the individual patient. C. regardless of a patient's lifestyle factors. D. once a patient has reduced their intake of cigarettes. 19. What does Dr Mike Kramer regard as a significant factor when treating a smoker? ‘A. the length of time a patient has refrained from smoking B. providing an unbiased assessment of each individual C. considering the ethical implications of each case D. the patient's attitude towards smoking cessation 20. In the fifth paragraph, Reverend Norman Ford says that when considering the financial burden of healthcare ‘A. smokers should fund their own operations. ‘Scanned with CamScanner20. In the fifth paragraph, Reverend Norman Ford says that when considering the ithcare financial burden of he ‘A. smokers should fund their own operations. B. more public funding is needed to help smokers quit. . making a smoker pay incentivises change. D. patients who smoke should not be held accountable. 21. _ Inthe fifth paragraph, what opinion is highlighted by the phrase ‘fork out’? A. Patients that continue to smoke should still have rights. B. Those that don't smoke have less complications. C. The public should not bear the cost of smokers’ healthcare. D. Non-smokers are less of a burden on public funding. 22.In the final paragraph, the writer argues that treating smokers differently A. is fair as other patients haven't made such poor lifestyle choices. B. could in turn lead to poor decisions concerning other patients. C. may ultimately cause such patients to avoid having health checks. D. may lead surgeons to discriminate against patients with diabetes. Scanned with CamScanner