values: a scenario adam pearce & emily matthews. values: a scenario as the orthopaedic registrar...

VALUES:A SCENARIO

Adam Pearce & Emily Matthews

Values: A Scenario

As the orthopaedic registrar on-call, you are bleeped to see a patient in A&E

Values: A Scenario

Mrs Bump, a 75 year-old lady has fallen over on some ice and sustained a #NOF

Before meeting the patient, you read her notes and discover she was diagnosed with Alzheimer’s Disease 4 years ago.

You recommend surgery and need to obtain consent.

Values: A Scenario

Values: A Scenario

As the orthopaedic registrar on-call, you are bleeped to see a patient in A&E.

Mrs Bump, a 75 year-old lady has fallen over on some ice and sustained a #NOF.

Before meeting the patient, you read her notes and discover she was diagnosed with Alzheimer’s Disease 4 years ago.

You recommend surgery and need to obtain consent.

3 minutes to discuss how you will approach gaining consent for surgery

Values: A Scenario

Valid consent

Capacity InformationVoluntariness

(free from coercion)

What THREE things are required for valid consent?

What FOUR things are required to demonstrate capacity?

Understand info Retain info Weigh-up Communicate

decision

Capacity

N.B. Assume Mrs Bump has capacity unless proven otherwise

Values: A Scenario

Valid consent

Capacity InformationVoluntariness

(free from coercion)

What information is required?

Information

Broad infoRisks,

benefits, alternatives

Defence against BATTERY Defence against NEGLIGENCE

Values: A Scenario

You decide Mrs Bump does NOT have capacity to consent to the surgery.

What next?

Assess capacityA

fram

ewor

k1.

• Understand• Retain• Weigh-up information• Communicate decision

Assess capacity

Facilitate a capacitous decision if possible

A fr

amew

ork

1.

2.• Communication aids• Time of day• Remove sedation

• Understand• Retain• Weigh-up information• Communicate decision

Assess capacity

Facilitate a capacitous decision if possible

Does patient have a valid advance refusal?

A fr

amew

ork

1.

2.

3.

• Communication aids• Time of day• Remove sedation

• Understand• Retain• Weigh-up information• Communicate decision

• Over 18 years of age• Relevant circumstances• Patient not done anything inconsistent with

directive• For refusal of life-sustaining treatment

• Written• Signed• witnessed

Assess capacity

Facilitate a capacitous decision if possible

Does patient have a valid advance refusal?

Does patient have someone with lasting Power of Attorney?

A fr

amew

ork

1.

2.

3.

4.

• Communication aids• Time of day• Remove sedation

• Understand• Retain• Weigh-up information• Communicate decision

• Over 18 years of age• Relevant circumstances• Patient not done anything inconsistent with

directive• For refusal of life-sustaining treatment

• Written• Signed• witnessed

• Can only give or refuse life-sustaining treatment if this was specifically stated

Assess capacity

Facilitate a capacitous decision if possible

Does patient have a valid advance refusal?

Treat in patient’s “Best Interests”(another topic in itself!)

Does patient have someone with lasting Power of Attorney?

A fr

amew

ork

1.

2.

3.

4.

5.

• Communication aids• Time of day• Remove sedation

• Understand• Retain• Weigh-up information• Communicate decision

• Over 18 years of age• Relevant circumstances• Patient not done anything inconsistent with

directive• For refusal of life-sustaining treatment

• Written• Signed• witnessed

• Can only give or refuse life-sustaining treatment if this was specifically stated

Values: A Scenario

If the patient were a 15 year-old child,

Is anything different?

Values: A Scenario

• Adults over 16 are presumed to have capacity, until proven otherwise

• Children under 16 are presumed to lack capacity, unless proven otherwise

Is the child GILLICK COMPETENT ?

FRASER GUIDELINES- contraception

Values: A Scenario

You assess the child as NOT being Gillick competent.

Who do you look to for consent?

Values: A Scenario

Person with parental responsibility, (who must have capacity)

• Mother• Married father• Unmarried father to a child born after 1st

December 2003 and named on birth certificate

• Adoptive parents• Person with Parental Responsibility Order

e.g. civil partner, step-parent• Local Authority for a child in care

If the parents are divorced, can the father still give consent?

Yes, once parental responsibility is acquired, it remains even after divorce

Values: A Scenario

What if the parents disagree with each other on the course of treatment?

Legally only consent of one parent is needed BUT, Good practice to:

- Work with both parents and if possible informally resolve the dispute

- Involve child in the decision-making process

- Act in child’s best interests

http://www.gmc-uk.org/guidance/20473.asp#Case

GMC interactive case studies - useful for revision

Values: A Scenario