Ethical and moral issues are integrally involved with patient care, particularly with respect to controversial topics such as euthanasia, organ donation and genetic technology. A doctor with clinical responsibility for a patient has three corresponding duties of care:
■ Protect life and health. Clinicians should practise medicine to a high Standard and not cause unnecessary suffering or harm. Treatment should only be given when it is thought to be beneficial to that patient. Competent patients have the right to refuse treatment, but decisions not to provide life-sustaining treatment should only be taken with their informed consent on the basis of a clear explanation about the consequences of their refusal.
■ Respect autonomy. Clinicians must respect the need to maintain the autonomy and self-determination of patients, and thus recognize that the patient has the ability to reason, plan and make choices about the future. Wherever possible patients should remain responsible for themselves. Informed consent and confidentiality are fundamental parts of good medical practice and respect for human dignity. Medical information belongs to the patient and should not be disclosed to any other parties, including relatives, without the informed consent of the patient. However, the right to privacy does not entail the right to harm others in exercising it, and in certain circumstances clinicians must breach confidentiality, e.g. infectious patients who pose a threat to specific individuals through undisclosed risks. Breach of confidentiality in these circumstances is usually only done after informing the patient of the intent to do so.
■ Protect life and health, and respect autonomy with fairness and justice. All patients have the right to be treated equally regardless of race, fitness, social worth, class, or any other arbitrary prejudice or favouritism.
Various regulatory bodies, common law and the Human Rights Act 1998 regulate medical practice and ensure that doctors take their duties of care seriously. The standards expected of healthcare professionals by their regula-tory bodies (for example in the UK, the General Medical Council (GMC), the
Royal College of Physicians and British Medical Association) may at times be higher than the minimum required by law.
It is a general legal and ethical principle that valid consent must be obtained before starting treatment or physical investigation, or providing personal care, for a patient. This principle reflects the right of patients to determine what happens to their own bodies. For instance, common law has established that touching a patient without valid consent may constitute the civil or criminal offence of battery. Furthermore, failure to obtain adequate consent may be a factor in a claim of negligence against the health professional involved, particularly if the patient suffers harm as a result of treatment.
The amount of information doctors provide to each patient will vary according to factors such as the nature and severity of the condition, the complexity of the treatment, the risks associated with the treatment or pro-cedure and the patient's own wishes.
In the consent process enough information must be provided in order that the patient's decisions are informed. This should be in the form of a discus-sion with the patient and written information leaflets. For a patient who does not speak the native language this must be done with the aid of a health advocate. The type of information provided includes:
■ The purpose of the investigation or treatment
■ Details and uncertainties of the diagnosis
■ Options for treatment including the option not to treat
■ Explanation of the likely benefits and probabilities of success for each option
■ Known possible side-effects: decide what information about risks a ‘rea-sonable person' in the position of the patient would want before agreeing to treatment
■ The name of the doctor who will have overall responsibility
■ A reminder that the patient can change his or her mind at any time
■ An opportunity to raise with patients the possibility of additional problems coming to light during the procedure, and discussion of possible action in this event.
For consent to be valid it must be given voluntarily after providing the patient with a reasonable amount of information about the risks of the proposed treatment or investigation. In addition, the patient must have the capacity to consent to the treatment in question, i.e. the patient must be able to comprehend and retain information about the treatment and use this information in the decision-making process. The clinician providing the treat-ment or investigation is responsible for ensuring that the patient has given valid consent before treatment begins. Consent may be verbal (e.g. for venepuncture) or written (e.g. always for a surgical procedure) depending on the proposed treatment or intervention. However, it should be remembered that a signed consent form is not legal or professional proof that proper informed consent has been obtained. The person obtaining consent should be the surgeon/physician who is doing the procedure or an assistant who is fully competent to carry out the procedure and therefore understands the potential complications. It is not acceptable for a junior doctor who does not perform and fully understand the procedure to obtain consent.
Emergencies Treatment can only be given legally to adult patients without consent if they are temporarily or permanently incompetent to provide it and the treatment is necessary to save their life, or to prevent them from incurring serious and permanent injury.
Adults who lack capacity to consent In the case of adults who cannot give informed consent because of brain damage, the doctor must decide if the proposed treatment is in the best interests of the patient. The treatment should be discussed with the relatives but they should not be asked to provide consent. It must also be determined if the person has previously expressed any opinions regarding certain procedures, perhaps on the grounds of reli-gious or moral beliefs. This wish must be respected. It is only when the patient may die if an intervention is not made that this can be carried out without consent. However, if the patient had already expressed a clear opinion on this matter, the doctor cannot override this, whatever the consequences.
Children In the UK, the legal age of presumed competence to consent to treatment is 16 years. Below this age, those with parental responsibility are the legal proxies for their children and usually consent to treatment on their behalf. At any age, an attempt should be made to explain fully the procedures and potential outcomes to the child, even if the child is too young to be fully competent. Children under 16 years can give legally effective consent to medical treatment provided they have sufficient understanding and intelligence.
Research procedures Doctors must ensure that patients asked to con-sider taking part in research are given written information presented in terms and in a form that they can understand. Patients must be aware that they are being asked to participate in a research project and that the results are not predictable. Adequate time must be given for reflection prior to the patient giving consent. Retention of human tissue for research or teaching requires written consent from the donor, or the next of kin of deceased patients or those who cannot speak for themselves.
Teaching It is necessary to obtain a patient's consent if a student or other observer would like to sit in during a consultation. The patient has the right to refuse without affecting the subsequent consultation. Consent must also be obtained if any additional procedure is to be carried out on an anaes-thetized patient solely for the purposes of teaching. Consent must also be obtained if a video or audio recording is to be made of a procedure or con-sultation and subsequently used for teaching purposes.
Human immunodeticiency virus (HIV) testing Doctors must obtain consent from patients before testing for HIV, except in rare circumstances, such as in unconscious patients, where testing would be in their immediate clinical interests, for example to help in making a diagnosis. In other circum-stances, doctors must make sure that patients are given appropriate inform-ation about the implications of the test, including the advantages and disadvantages, and wherever possible allow patients appropriate time to consider and discuss them.
Advance directives Competent adults acting free from pressure and who understand the implications of their choice(s) can make an advance state-ment (sometimes known as a living will) about how they wish to be treated if they suffer loss of capacity. The advance statement may be a clear instruc-tion refusing one or more medical procedures or a statement that specifies a degree of irreversible deterioration after which no life-sustaining treatment should be given. It is legally binding provided that the patient criteria outlined above are fulfilled, the statement is clearly applicable to the current circum-stances and there is no reason to believe that the patient has changed his or her mind.
Communication is the way in which clinicians integrate clinical science with patient-centred, evidence-based shared healthcare. It is the process of exchanging information and ideas and also making a trusting relationship on which the collaborative partnership between patients and their families and healthcare workers depends. Good communication improves health out-comes and symptom resolution, increases patient adherence to therapies, increases patient and clinician satisfaction, reduces litigation and increases patient safety. Failure of communication leads to poor delivery of information and lack of patient understanding, and ultimately the patient feeling deserted and devalued. The majority of complaints against doctors are not based on failures of biomedical practice but on poor communication. Patients have identified qualities used by the doctor in the interview that lead to good relationships. Doctors who were considered to have communicated well:
■ Orientated patients to the process of the visit, e.g. introductory com-ments: ‘We are going to do this first and then go on to that'
■ Used facilitative comments, e.g. ‘uh huh, I see'
■ Asked the patient their opinion
■ Used active listening
■ Checked understanding
■ Used humour and laughter when appropriate
■ Conducted slightly longer visits (18 versus 15 minutes).
Clinicians must use their time to the greatest benefit of their patients. It is essential to find out not only the medical facts in detail but also what patients have experienced and what impact this experience has had on them. There are seven essential steps in the medical interview:
The start of the interview will be helped by well-organized arrangements for appointments, reception and punctuality. The doctor should come out of the room to greet the patient, establish eye contact and shake hands if appropri-ate. Clinicians should introduce themselves by telling patients their name, status and responsibility to the patient; a name badge will reinforce this information. The patient should sit beside the clinician and not on the far side of a desk.
The aim is to address all the patient's concerns and usually they have more than one. Start by asking a question such as: ‘What problems have brought you to see me today?'. Listen to the patient's answer attentively without interrupting. Then ask ‘And is there something else?' to screen for problems before exploring the history in detail.
The components of a complete medical interview are: the nature of the key problems and clarification, date and time of onset, development over time, precipitating factors, help given to date, impact of the problem on patient's life and availability of support. This information is best obtained if the clinician encourages the patient to talk openly (nod occasionally, smile appropriately, avoid interrupting before the patient has finished talking and tell the story in their own words from start to finish). Starting with open questions ('Tell me about the pain you have been having' rather than ‘You say chest pain, where is the pain?') and then moving on to screening, focused and more closed questions will help. Leading questions (‘You have given up drinking alcohol, haven't you') should be avoided. In addition the patient's ideas, concerns and expectations, and their attitude to similar problems in the past must be assessed.
Demonstrating empathy is a key skill in building the patient—clinician relation-ship and involves the patient's experiences being seen, heard and accepted with some feedback to demonstrate this. For instance, ‘The last point made you look worried. Is there something more serious about that point you would like to tell me?' demonstrates that the patient's experiences have been seen.
Patients generally want to know whether their problem is serious and how will it affect them, what can be done about it and what is causing it. Verbal information provided to the patient can be supported by written information leaflets, diagrams, information provided by patient support groups and web-sites. A copy of the clinic letter that is sent to the patient's general practitioner is helpful, provided that the information in the letter was included with this in mind. Verbal information is best provided in assimilable chunks in a logical sequence, using simple language and avoiding medical terminology. It is helpful to check with the patient that they have understood what has been said and ask them if you can move on to the next section of the information.
At this stage the clinician and patient need to agree on the best course as regards possible investigations and treatment. Some patients will want to be more involved than others in the decision-making process and this will become apparent during the interview. Any options for management should be discussed. Summarizing at the end will allow the patient to correct any misunderstandings.
Closing the interview may start with a brief summary of the patient's agenda and then of that of the clinician. The patient should be told the arrangements for further interviews and the commitment to informing other healthcare professionals involved with the patient. It is useful to make a written record in the patient's notes as to what the patient has been told and what has been understood. In some situations it is useful if the patient knows how to contact an appropriate team member as a safety net before the next interview. The interview is closed with an appropriate farewell and some words of encouragement.
Breaking bad news can be difficult, and the way that it is broken has a major psychological and physical effect on patients. In these situations patients usually know more than one thinks they do, they welcome clear information and do not want to be drawn into a charade of deception that does not allow them to discuss their illness and the future. The S-P-I-K-E-S strategy sets a framework for breaking bad news:
S - Setting The patient should be seen as soon as information is available in a quiet place with everyone seated. Ask not to be disturbed and hand bleeps and mobile phones (if necessary to leave switched on) to a col-league. If possible the patient should have someone with them and be introduced to everyone who is with you, e.g. specialist nurse. Indicate your status and the extent of your responsibility towards the patient.
P - Perception The clinician should begin the interview by finding out how much the patient knows and if anything new has developed since the last encounter.
I - Invitation Indicate to the patient that you have the results and ask if they would like you to explain the results to them. A few patients will want to know very little information and they will indicate that they would prefer for you to talk to a relative or friend.
K - Knowledge The clinician should give the patient a warning that the news is bad or more serious than initially thought (‘I am afraid it looks more serious than we had hoped'), and then pause to allow the patient to think this over and only continue when the patient gives some lead to follow. The clinician should then give small chunks of information and ensure that the patient understands before moving on (‘Is this making sense so far?'). Frequent pauses allow the patient to think. The interview should be stopped and resumed at a later date if necessary. The patient should be provided with some positive information and hope tempered with realism. The patient may ask for a time frame of events but it is often impossible to give an accurate time frame for a terminal disease. The importance of maintaining a good quality of life during this time must be stressed. The patient must be given the opportunity for any family members to meet the clinician.
E - Empathy The clinician will need to understand and respond appropriately to a range of emotions that the patient may express (denial, despair, anger, bargaining, depression, acceptance). These must be acknow-ledged and where necessary, the clinician should wait for them to settle before moving on. The clinician will also need to judge which patients want to be touched as part of the process and also when the patient has ‘shutdown' and the interview needs to be paused. Sometimes the inter-view will need to be stopped and resumed later.
S - Strategy and summary The clinician must ensure that the patient has understood what has been discussed. The interview should close with a further interview date (preferably soon) and giving a contact name as a safety net before the next interview and details regarding further sources of information. The clinician should offer the patient the opportunity to meet their relatives if they could not be there at this time. Finally, the clinician should bid everyone goodbye, starting with the patient.
Many complaints result from poor communication or miscommunication. A lawsuit is the most extreme form of complaint and any clinician faced with such a scenario must seek specialist advice. The majority of complaints stem from the exasperation felt by patients who:
■ Have not been able to get clear information
■ Feel that they are owed an apology
■ Are concerned that other patients will go through what they have. Complaints should be dealt with as soon as possible. It is helpful to make an apology as an expression of regret; this is not an expression of guilt. Explain the reasons and circumstances behind the facts and explain how things will improve. Be honest and never alter the medical records.
Patients from minority cultures tend to get poorer healthcare than others of the same socioeconomic status, even when they speak the same language. Consultations tend to be shorter and with less engagement of the patient by the clinician. Cultural issues will affect the patient's behaviour, e.g. when to seek medical care, preference for a clinician of the same sex and family members talking for the patient. If an interpreter is necessary for the medical interview this should not be a family member, friend or even child. Advocates (interpreters from the patient's culture who can do more than translate) or the Language Line services should be used wherever possible. In these situ-ations the clinician should still look and speak directly to the patient and not the interpreter.
Patients with impaired hearing who use sign language may be helped by a signer. However, very few use sign language but many will lip-read. The latter can be facilitated by using a good light, using plain language, and checking for understanding and writing some things down. Conversation aids (micro-phones and amplifier, adapted textphones) and mobile phones with text messages can help. Patients with impaired Vision will be helped by large print information sheets, Braille versions if available and audiotapes. Clinicians should avoid sudden touch during the interview, make more conscious efforts to use the patient's name and clearly explain what they are doing as they go along. Patients with impaired understanding or expression of words (aphasia) will be helped by speaking slowly with frequent pauses in a quiet place without distractions. In this situation, closed questioning is often easier with a few key headings written down.
Clinical records are an integral part of healthcare. They should contain a complete record of every encounter with the patient (history, examination, differential diagnosis, investigations and results, information given to the patient, consent, decisions made, treatment prescribed, follow-up and refer-rals) and a summary of any discussions with relatives (after obtaining patient consent). The records should also contain copies of any e-mail and text cor-respondence. When entering into e-mail or text correspondence with a patient, confidentiality must be respected and due thought given to who else might read the information.
A patient has a legal right to see their records and these are an essential part of the investigation into any complaint or claim for negligence. Computer records (electronic patient records, EPRs) are increasingly replacing written records; EPRs are more understandable, contain more information and reduce prescribing errors. Criteria for good records are:
■ Clear, accurate and legible
■ Every entry should be signed, dated and time of consultation recorded. The healthcare worker should also print their name and record where they have seen the patient e.g. emergency department, ward name, outpatients
■ Entries should be written in pen and not retrospectively
■ Records should never be altered. An additional note should be made, signed and dated alongside any mistake
■ Records should always be kept secure. Any patient details kept electron-ically requires the computer to be encrypted.
1. Ethics and communication
2. Infectious diseases
3. Gastroenterology and nutrition
4. Liver, biliary tract and pancreatic disease
Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER DISEASE IN PREGNANCY
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS
5. Haematological disease
Assessment and treatment of suspected neutropenic sepsis
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
6. Malignant disease
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
8. Water, electrolytes and acid–base balance
WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
9. Renal disease
INVESTIGATION OF RENAL DISEASE
URINARY TRACT INFECTION
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
10. Cardiovascular disease
COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
ISCHAEMIC HEART DISEASE
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
ARTERIAL AND VENOUS DISEASE
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS
11. Respiratory disease
12. Intensive care medicine
13. Drug therapy, poisoning, and alcohol misuse
14. Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
15. Diabetes mellitus and other disorders of metabolism
16. The special senses
COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES