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84 Cards in this Set
- Front
- Back
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What are the elements of negligence
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1) duty of care exists: duty to do something to prevent harm occurring to my neighbour, defined by proximity and foreseeability tests
2) breach of duty 3) harm occurred because of breach |
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Define duty of care
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1) duty to avoid acts or omissions that can be reasonably foreseen to adversely affect persons closely and directly affected by them (proximity test)
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Define the 4 elements of proximity would a doctor need to consider whether he is legally obligated to atttend an emergency
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1) causal proximity (the act would have caused/prevented harm)
2) physical proximity 3) circumstantial proximity (what barriers prevented minimising harm eg patient bookings) 4) relationship proximity (would a reasonable doctor make a relationship between the act and harm/prevention of harm) |
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What are the 3 tests of duty of care as incorporated in the Civil Liabilities Act qld
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from Civil Liabilities Act the risk must not ne insignificant and the following tests apply:
1) foreseeability 2) proximity (temporal, physical, circumstantial) 3) reasonableness: (probability, seriousness, burden of precautions, social utility of the risky activity) |
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What is the test for medical negligence
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1) duty of care exists as in Civil Liabilities Act
2) Breach of duty occurred, incorporating higher duty/skills expected of ordinary physician in that field 3) breach causes harm |
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When is there a duty for a doctor to act in an emergency
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proximity tests:
1) relationship: dr foresaw that harm could have been avoided if he attends 2) circumstance: dr not otherwise busy 3) physical: dr close by 4) causal: dr could have prevented harm |
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How does good samaritan act apply to doctors
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1) protected if actions are in good faith and avoid gross negligence
2) no consideration expected |
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List 3 examples of crimes committed by a doctor
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1) assisted suicide
2) illegal abortion 3) gross crimminal negligence or wilful killing, including euthanasia |
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List the roles of the medical board
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1) registration of doctors to legally practice
2) discipline misconduct 3) rehabilitate impaired doctors |
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When does duty of care exist
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1) proximity (physical, causal, circumstantial)
2) foreseeability of potential harm 3) reasonableness test (excludes trivia, includes particular circumstances) |
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What are the 3 elemts of negligence
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1) Duty of care established (proximity, foreseeability, reasonableness)
2) Breach of duty of care 3) Causal link between breach and harm caused |
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What are the factors of the Qld Civil Liability Act
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1) Risk (seriousness of harm x probability of occurrance)
2) Burden of reducing risk 3) Social utility of the act 4) Ignore trivial harm |
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How is a health professional protected in resuing an indicidual in an emergency after working hours
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IF no fee then:
1) Good Samaritan act protects acts in good faith. 2) Health worker relieved of duty of care and risk of negligence |
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How is a health professional protected in resuing an indicidual in an emergency after working hours
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IF no fee then:
1) Good Samaritan act protects acts in good faith. 2) Health worker relieved of duty of care and risk of negligence |
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What are the 4 dimensions of medical ethics
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1) beneficience
2) non-malfiesance 3) autonomy 4) justice (treatment must be fair, comparative, unbiased, non-judgemental) |
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What is the experience of families of diabled patients
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1) blurring of private & public life: marginalisation, blame, guilt
2) medicalisation, objectification of the individual 3) scrutiny by many professionals with no responsibility: fragmentation of care 4) 2nd class citizen: role is burdensome, unproductive service user & not 1st class productive citizen |
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what is the public health impact of intellectual diability
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1) high numbers (> 500,000)
2) high morbidity (>5 medical conditions per patient) 3) high mortality 4) high rate of misdiagnosis (40%) |
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What is "the inverse law" of health care regarding intellectually disabled and why
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Those in need of health care are least likely to receive it
1) communication, capacity and consent difficulties 2) generall devaluing by society |
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What is the current focus on improving the lives of the intellectually disabled
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Normalisation: focus on abilities, not disabilities eg
learning time management, self-care, health management, as seamless as possible ingegration with "normal" society |
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What is required during a dr's consultation to ensure an intellectually diabled person gets appropriate care
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1) longer consultation
2) communication: a) talk directly to patient b) age specific language c) concrete examples & diagrams |
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when does the guardianship act apply in the health care setting
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When one of the following fails:
1) ability to understand necessity, consequenses & risks of medical intervention 2) free to voluntarily make decisions 3) able to communicate their decision |
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What is the hierarchy of decision making regarding giving consent to a medical intervention
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self (advance directive) > guardian > appointed attorney > statutory health attorney > the adult guardian
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What are the difficulties confronting a doctor treating an intellectually diabled patient
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1) communication of history & symptoms
2) proxy (3rd party) history, incomplete or unknown history 3) Atypical expression of signs (eg not showing pain in "normal" way) 4) Aggression, non-cooperation |
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What are the 3 roles of the adult guardian
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1) Investigate abuse, neglect
2) Attorney 3) statutory health authority of last resort |
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What questions must be answered for a person without capacity for life sustaining treatment to be withdrawn
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1) Obtain consent from guardian -> attorney -> statutory attorney
3) If no guardian/attorney/statutory attorney & situation non-acute then the adult guardian requires justification in terms of good medical practice. |
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What must be obtained from a person with capacity for life sustaining treatment to be withdrawn. (list the requirements for capacity)
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1) Must obtain consent if person has capacity ie
a) Understanding the nature & effect of the decision b) Freely and voluntarily making decisions c) Communicating the decision |
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What is the order of priority of a statutory health authority
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spouse > non-paid carer > close friend or relative
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What decisions cannot a substitute decision maker make for a person lacking capacity
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Special health care decisions:
1) pregnancy termination 2) sterilisation 3) tissue donation 4) medical research/experimentation |
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describe 2 ways the health system is attempting to improve health outcomes for intellectually diabled patients
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1) Medicare health assessment
2) CHAP: 2 part questionnaire (patient/carer section, GP section) |
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What are 7 elements of the Civil Liability Act 2003
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1) risk was foreseeable
2) risk was substantial 3) taken precautions appropriate to person's position taking into account (a) probability of harm (b) severity of harm (c) burden of taking precautions (4) social utility of the activity that may cause harm |
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In the situation of a normal doctor-patient relationship, what are the legal duties of a doctor
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1) diagnose & treat
2) confidentiality 3) attend (+ house calls & emergencies in NSW but uncertain in others) 4) disclose (risks, benefits, errors - specifically in NSW) 5) report colleagues who are impaired, incompetent or behaving grossly unprofessionally (eg sexual conduct with patients) 6) Duty to passers by only in emergencies if Civil Liability tests apply, otherwise no obligation. |
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What are the 6 necessary elements of consent
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1) Dr to inform: risks, benefits, side effects & alternatives
2) Patient must comprehend, retain & recall 3) Evaluate risks & benefits using personal values 4) Choose or refuse 5) Communicate reasons for choice 6) Show committment: perservere with choice |
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When is an adult unable to consent ot medical treatment
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Lacks capacity ie
1) cannot understand nature & effect of decisions or 2) cannot make decisions voluntarily or 3) cannot communicate decision |
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Who may give consent to forbit futile treatment
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1) the patient (written Advanced Health Directive)
2) Legal guardian 3) Power of attorney 4) Statutory health authority |
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Who can be a statutory health authority
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1) spouse
2) non-paid carer 3) close family member 4) close friend 5) The Adult Guardian |
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Can a brain dead patient's spouse allow donation of organs in the absence of prior patient consent
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No if no Advance Healthcare Directive. A substitute guardian is forbidden to make Special Health Care decisions. Done by qld Civil & administrative Tribunal
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How does autonomy apply to healthcare
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1) Provision of consent to treatment
2) Confidentiality |
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What 2 things can occur when autonomy is overridden
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Weak paternalism: doctor overrides patients wishes when they lack capacity
Strong paternalism: overriding competent refusal - unacceptable |
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What is a doctor's duty when a patient refuses treatment
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1) if the patient is competent, is he rational
2) if the refusal is based on mistaken beliefs, the doctor's duty is to educate |
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What are 3 situations where consent is not required
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1) Emergencies - implied
2) Patient lacks capacity: must obtain consent from advanced health directive or statutory health authority 3) Mature minors may consent ot treatment buy refusal may be overridden where harm is likely. |
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What is a doctor's duty when a patient refuses treatment
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1) if the patient is competent, is he rational
2) if the refusal is based on mistaken beliefs, the doctor's duty is to educate |
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What are 3 situations where consent is not required
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1) Emergencies - implied
2) Patient lacks capacity: must obtain consent from advanced health directive or statutory health authority 3) Mature minors may consent ot treatment buy refusal may be overridden where harm is likely. |
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When is a Child Gillick Competent and what rights does it confer
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GC: If a maturre minor demonstrates sufficient itelligence and understanding of condition and treatment
Rights: autonomy to consent to treatment without parental right to veto Right to confidentiality from parents |
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How have children's rights evolved in the 20th century
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Declaration of Geneva (1942): priority of children to obtain basic material and spiritual needs, health care, support, education
Dec of Human Rights (1948): children have right to special care and assistance Gillick Case (1985): right of mature minors to consent ot treatment |
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What is authorisation
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Giving authorisation is an element of consent: while competent, to perform a specific procedure.
Competence means: comprehends, believes, understands, accepts and is adequately informed. |
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What are the elements of consent
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Must cover the actual procedure
Only given to the actual performing physician The procedure must be legal |
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What are the consequences of not obtaining consent
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assault (crimminal law) - threat of an iminent violent act against another person
battery is an intentional physical act of harm trespass (actionable even if life is saved eg Jehovahs Witness) |
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An error put on a consent form is.
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Invalid consent, poor quality consent
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Capacity
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believe, comprehend, eigh up, decide, act, communicate
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To make an adequate decision, what is needed
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Capacity and good quality information
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Under Qld law, what is required to withdraw treatment
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Need consent from (substitute) decision maker or adult guardian. Must argue that maintaining treatment is poor medical care (other states allow doc to decide)
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How does consent apply to emergencies
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Can proceed until patient has capacity, then need concent
Implied consent by turning up for minor procedures or examinations |
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Elements of negligence.
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A duty of care
B reach C ausation D amages |
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Does the advising ethicist accept some duty of care making them liable for damages
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No, the clinician and, to some extent, the hospital is liable
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Define standard of care
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Exercise of Reasonable care (Bolam case) to avoid foreseeable risk that is limited by proximity
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What is the duty of providing material risk re Rogers v Whittaker
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Doc has duty to inform even rare must explain material risk (common plus rare but serious harm) if it is likely that it may be significant to the patient (blindness), or else informed consent has not been obtained
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What are the NHMRC guidelines re communicating risk
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assess communication level, involve family, use plain language and diagrams, include common and rare severe consequences
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When can a doctor withold medical information
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Must have a strong belief that the information will cause severe physical or mental harm (risk of distress is not enough - must disclose the bad news)
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What are the two ways to untertake duty to warn
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proactive (patient is expressely informed)
reactive (doctor knows that patient understands eg common knowledge) |
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In Qld, what is the law regarding withdrawal of life support in futile treatment
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Consent must be obtained from either the patient or the substitute decision maker and deadlocks are broken by the adult guardian. Law is under review
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In refusing treatment, what is the ethical dilemma and what is the overriding principal
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1) Autonomy and consent vs duty of care and benefiesance
2) Assumption of competence is automatic in the absence of evidence of lack of capacity, hence, autonomy and consent prevails |
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What are 4 one word elements of consent
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1) informed
2) voluntary 3) competent 4) specific |
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A patient with signs of depression and with a severe but treatable medical condition refuses treatment. What next?
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Depression does no negate competence but necessitates exploration of each element of the patient's competence - especially reasons for refusal (belief, comprehension of effects with/wo treatment, evaluation, retention, justification, communication)
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A patient refuses treatment and you suspect the patient is depressed and their judgement is impaired; loss of competence. What are the risks of this assessment
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1) bias
2) transference of values |
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A man writes an AHD to not resuscitate if he becomes mentally impaired. What is the issue
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AHD is binding except for emergency resuscitation
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A Gillick competent female refuses treatment for anorexia. What next
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Can consent to treatment but not refuse if minor, even mature minor
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A surgeon performs an operation with consent but wants to use the results for research. What are the issues
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Need separate consent for the research
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How is competence assessed with treatment refusal
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The belief to refuse treatment is consistent with their value system. Usually clearer when it's religeous doctrine
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A person with an AHD loses competence soon after and asks that the AHD be disregarded and to please resuscitate. What happens
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AHD stands if patient is not competent
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A child requires a splenectomy and the parents refuse the surgery, the blood transfusion and the Pneumovax follow up. What is the law on the matter
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If life threatening, then all procedures can be performed including the vaccination, normally volumtary, but essential in this case. Court order is needed.
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What is the difference between stereotyping and countertranference
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CT: applies in close situations, individual, may be negative or positive feelings about a patient, especially difficult patients. Negative feelings can impact on level of care
Steteotyping: a cognitive shortcut causing leaps of logic, culturally based, causes attribution bias and selective attention to history, symptoms, ddx, screening, treatment options |
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What are causes and effects of paternalism in the consultation room
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Naternalism
Narrows the spectrum of the ddx Focus on disease not person Rationing of health care |
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What are the 3 elements of the doctor patient contract
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treatment, transference, countertransference
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What are aspects of difficult patients
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undiagnosed psych disorder
somatization substance dependency somatization egocentric personality disorder |
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what are doctor factors contributong to difficult patients
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narcissim or arrogance
cultural gaps doctor overworked poor communication skills |
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What is transference
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Patient's developing pos or negative feelings about a doctor affecting autonomy, compliance and over dependence on the doctor or, conversely, mistrust, conflicts and
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Factors that increase transference
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vulnerable personality esp people with bpd
Anxiety about physical or psychological safety Frequent contact with health care providers |
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What are the benefits of positive transfetence
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Maximises placebo effect
Expectations of a successful outcome Feeling that you the doctor cares |
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What are some negative effects of countertransference
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Feeling of helplessness
Punishment or conflict with the patient Extrude the patient from the care giving system |
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What are the negatives of positive transference
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Idealising transference (eg doctor you're the only person I can trust)
Erotic transference (remain aloof) |
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How can you respond to countertransference
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Identify reasons
Erotic vigilance Avoid overreacting (conflict, over accomodating or avoidane) |
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How can stereotyping and countertransference cross ethical boundaries
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Both cause malifiesance, non beneficience and may cause crossing of professional boundaries with positive transference and erotic signs
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What are the two models regarding lifestyle change
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Individual responsibility model
Structural: housing, sanitation, access to healthcare, availability of healthy food, overcrowding |
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List the elements of consent
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The person must have capacity to consent
Legal Specific Limited Covers the broad nature of the procedure |
