Frcem Success Ethics PDF

7/31/2017 Law & Ethics - FRCEM Success
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Law & Ethics
Question 1 of 8 1 Current Question
You are asked to give a teaching session on consent to a group of medical students. You 2 Unanswered
decide to create a list of questions to pre-test the students at the start of the session. Create
3 Unanswered
your answers to the following questions:
4 Unanswered
a. When consenting an individual for a particular procedure or treatment, give
three factors that should be explained to the patient. (1 mark) 5 Unanswered
b. Give two situations in which an individual can consent on behalf of another person. (1
6 Unanswered
mark)
c. What factors need to be true in order for consent to be considered valid? (1 mark) 7 Unanswered
8 Unanswered
You did not answer this question
Answer
a. Any three of:
The purpose of the treatment/procedure
What the procedure/treatment will involve
The risks and bene ts of the treatment/procedure
http://intermediate.frcemsuccess.com/rev/lawethics/ 1/4
Alternative options for treatment/investigation (including the option of no treatment/investigation)

and the risks and bene ts of these options
b. Any two of:
In children 0 – 15 years of age by an adult with parental responsibility
In children 16 – 17 years of age who lack capacity by an adult with parental responsibility
In an adult who lacks capacity by a Lasting Power of Attorney (LPA)
c. All of:
Consent must be voluntary (not coerced)
Consent must be informed
Patients must have capacity to consent
Notes
Explicit or implied patient consent is needed for all examinations, treatments, or interventions, with the exceptions
of emergency treatment or when prescribed by law (for example compulsory treatment under mental health
legislation).
Explicit or expressed consent is when a person actively agrees verbally or in writing.
Implied consent is signalled by the behaviour of a person who is aware of and understands, the proposed course of
action.
Consent is not a one-off event — ongoing discussion is needed as treatment evolves.
In order to consent, a person must have the proposed action explained to them and have the mental capacity to
make an informed and voluntary decision.
You must give patients the information they want or need about:
the diagnosis and prognosis

any uncertainties about the diagnosis or prognosis, including options for further investigations
options for treating or managing the condition, including the option not to treat
the purpose of any proposed investigation or treatment and what it will involve
the potential bene ts, risks and burdens, and the likelihood of success, for each option; this should include
information, if available, about whether the bene ts or risks are affected by which organisation or doctor is
chosen to provide care
whether a proposed investigation or treatment is part of a research programme or is an innovative
treatment designed speci cally for their bene t
the people who will be mainly responsible for and involved in their care, what their roles are, and to what
extent students may be involved
their right to refuse to take part in teaching or research
their right to seek a second opinion
any bills they will have to pay
any con icts of interest that you, or your organisation, may have
any treatments that you believe have greater potential bene t for the patient than those you or your
organisation can offer
How you discuss a patient’s diagnosis, prognosis and treatment options is often as important as the information
itself. You should:
share information in a way that the patient can understand and, whenever possible, in a place and at a time
when they are best able to understand and retain it
give information that the patient may nd distressing in a considerate way
involve other members of the healthcare team in discussions with the patient, if appropriate
give the patient time to re ect, before and after they make a decision, especially if the information is
complex or what you are proposing involves signi cant risks
make sure the patient knows if there is a time limit on making their decision, and who they can contact in the
healthcare team if they have any questions or concerns
A young person under 16 may have capacity to make decisions, depending on their maturity and ability to
understand what is involved.
At 16 a young person can be presumed to have capacity to make most decisions about their treatment and care.
For young people aged 16 – 17 years who lack capacity, parents can consent on their behalf if the decision to be
made is felt to be within parental control. Adults with parental responsibility can consent on the behalf of young
people aged 0 – 15 years.
A Lasting Power of Attorney (LPA) can consent on the behalf of an adult patient once capacity is lost.
Refusal of consent:
Refusal of consent:
Doctors must respect a refusal of treatment if the patient is a competent, who is properly informed, and not
being coerced.
Parents cannot override the competent consent of a young person to treatment that you consider is in their
best interests.
Cases of refused consent in a young person with capacity, or in parents of a young person who lacks
capacity, in whom you feel treatment is in their best interest should be formally reviewed.
In an emergency situation where consent cannot be obtained, medical treatment that is in the patient’s best
interest, and is immediately necessary to save a life or prevent signi cant deterioration of the patient, should be
provided.
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Law & Ethics
Question 2 of 8 1 Unanswered
A 50 year lady with early onset dementia, is brought into hospital with breathlessness by 2 Current Question
her husband, who has been authorised as her Lasting Power of Attorney (LPA). X-ray shows a
3 Unanswered
large unilateral pleural effusion and you wish to perform a pleural aspiration.
4 Unanswered
a. What is an LPA? (1 mark)
b. Give two situations in which an LPA cannot consent/refuse treatment. (1 mark) 5 Unanswered
c. If hospital staff had concerns about decisions made by the LPA, who should these
6 Unanswered
concerns be reported to? (1 mark)
7 Unanswered
8 Unanswered
Answer
a. An LPA is a document in which an individual can nominate another person to make (best interest) decisions
on their behalf when they lack capacity to do so
b. Any two of:
When the donor has the capacity to consent
When the donor has made an advance decision to refuse treatment (unless the LPA was appointed
after the AD and the donor gave permission to the LPA to override the AD)
When the decision relates to life-sustaining treatment and this has not been expressly authorised
When the donor is detained under the Mental Health Act
c. Court of Protection
Notes
Lasting power of attorney (LPA):
LPA is a document in which a person can nominate someone else to make certain decisions on their behalf (for
example on nances, health, and personal welfare) when they are unable to do so themselves. The LPA must make
decisions in the individual’s best interest.
The Mental Capacity Act 2005 provides the legal framework to give a named person authority to make these
decisions on another person’s behalf. LPA replaces what was previously known as ‘enduring power of attorney’.
To be valid, LPA documents must be registered with the Of ce of the Public Guardian. If there are concerns relating
to decisions taken under the authority of a LPA, the case can be referred to the Court of Protection.
Speci c situations when the LPA cannot consent to/refuse treatment:

When the donor has made an advance decision to refuse treatment (unless the LPA was appointed after the
AD and the donor gave permission to the LPA to override the AD)
Advance Decisions:
Advance decisions allow people who understand the implications of their choices to state their treatment wishes in
advance. They can be used to:
Authorise or request speci c procedures.

Refuse treatment in a prede ned future situation (also called an advance directive).
Advance refusals of treatment are legally binding (under common law) if:
The person is an adult, and

Was competent and fully informed when making the decision, and
The decision is clearly applicable to the current circumstances, and
There is no reason to believe that they have since changed their mind.
Advance requests for treatment do not have the same binding status but should be considered when assessing best
interests.
Court of Protection [HM Government, 2015]:
The Court of Protection makes decisions on nancial and welfare issues for people who lack mental capacity. It is
responsible for:
Deciding if a person has the capacity to make a particular decision for themselves.
Appointing deputies to make decisions for people lacking capacity.
Giving permission to make one-off decisions on behalf of a person without capacity.
Dealing with urgent applications where a decision must be made on behalf of another without delay.
Making decisions on LPA (or enduring power of attorney made and signed before October 1, 2007) and
considering objections to these.
Consideration of applications to make statutory wills or gifts.
Making decisions about when someone can be deprived of their liberty under the Mental Capacity Act
(2005).
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Law & Ethics
A 25 year old man is brought into hospital after a seizure. Seizure activity was witnessed by 2 Unanswered
the paramedics. The patient denies any alcohol or illicit drug consumption. He is otherwise t
3 Current Question
and well, with no medical history and no regular medications. A CT scan is performed which is
normal. The patient is completely recovered and you have arranged neurology follow-up in the 4 Unanswered
rst- t clinic.
5 Unanswered
a. What advice should you give to the patient about driving? (1 mark)
6 Unanswered
b. The patient is a frequent attender over the next few months with further ts. He has
been diagnosed with epilepsy by a neurology specialist. You are aware the patient is still 7 Unanswered
driving despite advice from the medical team. How should you proceed? (1 mark)
8 Unanswered
c. In a patient with epilepsy, when will the DVLA consider allowing a patient to drive again?
(1 mark)
Answer
a. The patient should notify the DVLA and stop driving for 6 months
b. You should make every reasonable effort to persuade the patient to stop, but if the patient is continuing to
drive against advice, you should inform the patient that you must notify the DVLA and contact the DVLA to
disclose relevant medical information
c. 5 years seizure free (with treatment if necessary)
Notes
As per GMC guidance:
The Driver and Vehicle Licensing Agency (DVLA) and Driver and Vehicle Agency (DVA) are legally responsible for
deciding if a person is medically un t to drive. This means they need to know if a driving licence holder has a
condition or is undergoing treatment that may now, or in the future, affect their safety as a driver.
The driver is legally responsible for informing the DVLA or DVA about such a condition or treatment. However, if a
patient has such a condition, you should explain to the patient: that the condition may affect their ability to drive (if
the patient is incapable of understanding this advice, for example, because of dementia, you should inform the DVLA
or DVA immediately), and that they have a legal duty to inform the DVLA or DVA about the condition.
If a patient refuses to accept the diagnosis, or the effect of the condition on their ability to drive, you can suggest
that they seek a second opinion, and help arrange for them to do so. You should advise the patient not to drive in the
meantime.
If a patient continues to drive when they may not be t to do so, you should make every reasonable effort to
persuade them to stop. As long as the patient agrees, you may discuss your concerns with their relatives, friends or
carers.
If you do not manage to persuade the patient to stop driving, or you discover that they are continuing to drive
against your advice, you should contact the DVLA or DVA immediately and disclose any relevant medical
information, in con dence, to the medical adviser.
Before contacting the DVLA or DVA you should try to inform the patient of your decision to disclose personal
information. You should then also inform the patient in writing once you have done so.
Condition Group 1 (car and motorcycle) Group 2 (bus and lorry)
Epilepsy or Must not drive and must notify the DVLA. The
http://intermediate.frcemsuccess.com/rev/lawethics/ Must not drive and must notify the DVLA. 2/3
Epilepsy or Must not drive and must notify the DVLA. The Must not drive and must notify the DVLA.
multiple person must remain seizure free for 5 years, The person must remain seizure free for 10
unprovoked with medication if necessary, in order to drive years, without medication, in order to drive
seizures again. again.
First/isolated Must not drive and must notify DVLA. The Must not drive and must notify the DVLA.
seizure person must remain seizure free for 6 months The person must remain seizure free for 5
in order to drive again. years in order to drive again.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/ le/618072/assessing- tness-to-drive-

a-guide-for-medical-professionals.pdf

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Law & Ethics
A 17 year old boy, with known asthma, is brought into AED with a severe asthma attack. 2 Unanswered
The paramedics have started high ow oxygen through a rebreather mask and given him a
3 Unanswered
salbutamol nebuliser. You wish to perform an arterial blood gas to further assess the patient.
4 Current Question
a. At what age is a child presumed to have capacity to consent for their own treatment and
care. (1 mark) 5 Unanswered
b. Give two methods by which the patient could consent. (1 mark)
6 Unanswered
c. Give three possible complications of arterial blood gas sampling. (1 mark)
7 Unanswered
8 Unanswered
Answer
a. At 16 years old
b. Implied (e.g. holding out an arm) or Expressed/explicit consent (e.g. verbal or written consent)
c. Any three of:
Local hematoma
Artery vasospasm
Arterial occlusion
Air or thrombus embolism
Local anesthetic anaphylactic reaction
Infection at the puncture site
Needle stick injury to health care personnel
Vessel laceration
Vasovagal response
Hemorrhage
Local pain
Notes
Explicit or implied patient consent is needed for all examinations, treatments, or interventions, with the exceptions
of emergency treatment or when prescribed by law (for example compulsory treatment under mental health
legislation).
Explicit or expressed consent is when a person actively agrees verbally or in writing.
Implied consent is signalled by the behaviour of a person who is aware of and understands, the proposed course of
action.
Consent is not a one-off event — ongoing discussion is needed as treatment evolves.
In order to consent, a person must have the proposed action explained to them and have the mental capacity to
make an informed and voluntary decision.
You must give patients the information they want or need about:
the diagnosis and prognosis

any uncertainties about the diagnosis or prognosis, including options for further investigations
options for treating or managing the condition, including the option not to treat
the purpose of any proposed investigation or treatment and what it will involve
the potential bene ts, risks and burdens, and the likelihood of success, for each option; this should include
information, if available, about whether the bene ts or risks are affected by which organisation or doctor is
treatment designed speci cally for their bene t
the people who will be mainly responsible for and involved in their care, what their roles are, and to what
extent students may be involved
their right to refuse to take part in teaching or research
their right to seek a second opinion
any bills they will have to pay
any con icts of interest that you, or your organisation, may have
any treatments that you believe have greater potential bene t for the patient than those you or your
organisation can offer
How you discuss a patient’s diagnosis, prognosis and treatment options is often as important as the information
itself. You should:
share information in a way that the patient can understand and, whenever possible, in a place and at a time
when they are best able to understand and retain it
give information that the patient may nd distressing in a considerate way
involve other members of the healthcare team in discussions with the patient, if appropriate
give the patient time to re ect, before and after they make a decision, especially if the information is
complex or what you are proposing involves signi cant risks
make sure the patient knows if there is a time limit on making their decision, and who they can contact in the
healthcare team if they have any questions or concerns
A young person under 16 may have capacity to make decisions, depending on their maturity and ability to
understand what is involved.
At 16 a young person can be presumed to have capacity to make most decisions about their treatment and care.
For young people aged 16 – 17 years who lack capacity, parents can consent on their behalf if the decision to be
made is felt to be within parental control. Adults with parental responsibility can consent on the behalf of young
people aged 0 – 15 years.
A Lasting Power of Attorney (LPA) can consent on the behalf of an adult patient once capacity is lost.
Refusal of consent:
Doctors must respect a refusal of treatment if the patient is a competent, who is properly informed, and not
being coerced.
Parents cannot override the competent consent of a young person to treatment that you consider is in their
best interests.
Cases of refused consent in a young person with capacity, or in parents of a young person who lacks
capacity, in whom you feel treatment is in their best interest should be formally reviewed.
In an emergency situation where consent cannot be obtained, medical treatment that is in the patient’s best
interest, and is immediately necessary to save a life or prevent signi cant deterioration of the patient, should be
provided.

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Law & Ethics
A 15 year old presents to AED alone asking for emergency contraception. 2 Unanswered
a. What does the patient need to demonstrate before you can prescribe emergency 3 Unanswered
contraception? (1 mark) 4 Unanswered
b. Name four of the criteria that you must be satis ed of before prescribing the medication.
(2 marks) 5 Current Question
6 Unanswered
You did not answer this question 7 Unanswered
8 Unanswered
Answer
a. That she meets the Fraser criteria for competence to consent to treatment
b. Any four of:
She understands the practitioner’s advice.
She cannot be persuaded to inform her parents, or will not allow the practitioner to inform her parents,
that contraceptive advice has been sought.
She is likely to begin or to continue having intercourse with or without contraceptive treatment.
Unless she receives contraceptive advice or treatment, her physical or mental health (or both) are likely
to suffer.
Her best interest requires the practitioner to give contraceptive advice or treatment (or both) without
parental consent.
Notes
If a girl younger than 16 years of age requests emergency contraception without parental consent:
Counsel her on the emotional and physical implications of sexual activity, including the risks and
consequences of pregnancy and the risk of sexually transmitted infections.
Assess her competency to make an independent consent to treatment, and document in her case notes that
she meets (or does not meet) the Fraser criteria for competence to independently consent.
If she meets the Fraser criteria, emergency contraception can be prescribed.
Consider offering ongoing contraception.
In the UK, people older than 16 years of age are presumed to be competent to consent to medical treatment. In
contrast, competence to consent to medical treatment must be demonstrated in children younger than 16 years of
age. In England and Wales, it is lawful to provide contraceptive advice and treatment to young people without
parental consent, provided that the practitioner is satis ed that the Fraser criteria for competence are met.
Other considerations:
The legal age of consent to sexual activity is 16 years in the United Kingdom.
Sexual activity under the age of consent is an offence even if consensual.
Offences are considered more serious (statutory rape) when the person is younger than 13 years of age.
With all people, but particularly with the young or vulnerable, be satis ed that sexual intercourse has been
consensual and is not occurring in an abusive relationship.
The woman is considered vulnerable if she:
Is younger than 16 years of age.
Is from a disadvantaged background.
Is in, or is leaving, care.
Has low educational attainment.
Consider informing young people of the law in relation to sexual activity.
If non-consensual sex or sexual abuse is suspected, follow appropriate child protection procedures and refer
to a paediatrician if necessary.
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Law & Ethics
A 59 year old homeless man is brought in by ambulance with a painful, offensive smelling, 2 Unanswered
and necrotic left leg. He was found on the oor and persuaded to come into hospital but he is
3 Unanswered
refusing to have any investigations or treatment.
4 Unanswered
a. What group of individuals are presumed to have capacity? (1 mark)
b. Your consultant wishes for you to assess and record overall capacity for this patient. 5 Unanswered
Explain why this is not possible. (1 mark)
6 Current Question
c. What three key principles should be followed when assessing capacity? (1 mark)
7 Unanswered
8 Unanswered
Answer
a. All individuals > 16 years of age
b. Mental capacity refers to the ability of a person to make a decision – it is time and decision speci c. Capacity
may uctuate e.g. due to changing level of consciousness or due to effects of substances, and may also vary
according to the decision that needs to be made e.g. a patient could have capacity to consent to have blood
taken, but not to undergo neurosurgery.
c. All three of:

Adults should always be presumed to have capacity; the health professional must prove otherwise
Time and support must be given to maximise the decision-making capacity
Individuals should be given the freedom to make seemingly unwise decisions
Notes
Mental capacity refers to the ability of a person to make a decision. It may change over time, for example, with
changing levels of consciousness, emotional distress, or due to the effects of alcohol and/or drugs. Capacity may also
vary according to the decision that needs to be made.
The Mental Capacity Act (2005) states that all people aged 16 years and over are presumed to have capacity. It aims
to balance a person’s right to make decisions for themselves with their right to be protected from harm.
The Mental Capacity Act (2005) has ve key principles:
Presumption of capacity — adults should always be presumed to have the capacity to make a decision,
unless the healthcare professional can prove otherwise.
Maximising decision-making capacity — the person must be given all practical support before it can be
decided that they lack capacity. Support may involve extra time for assessment, repeating the assessment if
capacity uctuates, or using an interpreter, sign language, or pictures.
The freedom to make seemingly unwise decisions — if the person makes a seemingly unwise decision, this in
itself is not proof of incapacity. Proof of incapacity depends on the process by which the decision is made,
not the decision itself.
Best interests — any decision or action taken on behalf of the person must be in their best interests. If the
decision can be delayed until the person regains capacity, then it should be. A decision taken on another’s
behalf should take account of their wishes, including those expressed in an advance decision, and their
beliefs and values. The decision-making process should involve, when appropriate, family, carers, and
signi cant others.
The least restrictive alternative — when a decision is made on the person’s behalf, the healthcare
professional must choose the alternative that interferes least with the person’s rights and freedoms while
still achieving the necessary goal.
To assess capacity, con rm that the person has an impairment of the mind or brain, which means they are unable to:
Understand relevant information about the decision to be made,

Understand relevant information about the decision to be made,
Retain that information,
Use or weigh that information as part of the decision-making process, or
Communicate their decision (by talking, non-verbal communication, or any other means).

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A 4 year old child is brought into AED by mum. His dad arrives later. His parents have 2 Unanswered
divorced in the past year. You suspect the child has meningitis and wish to perform a lumbar
3 Unanswered
puncture. Mum refuses to give consent but dad agrees.
4 Unanswered
a. Who is able to consent for a child under 16 years of age? (1 mark)
b. What two factors give a dad parental responsibility for a child? (2 marks) 5 Unanswered
6 Unanswered
You did not answer this question 7 Current Question
8 Unanswered
Answer
a. An adult with parental responsibility (only need one parent to consent)
b. Both of:
Married to mother at time of birth
Listed on birth certi cate (from 1st December 2003)
Notes
A mother automatically has parental responsibility for her child from birth.
A mother automatically has parental responsibility for her child from birth.
A father usually has parental responsibility if he:
Is married to the child’s mother when the child is born (and keeps parental responsibility if they later
divorce)
Is listed on the birth certi cate (from 1 December 2003)
An unmarried father can get parental responsibility for his child in 1 of 3 ways:
jointly registering the birth of the child with the mother (from 1 December 2003)
getting a parental responsibility agreement with the mother
getting a parental responsibility order from a court

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A 35 year old woman with motor neurone disease is brought into AED moribund with 2 Unanswered
sepsis. It is quickly learned that she has an advance directive (AD) in place that states she does
3 Unanswered
not wish to receive any life-saving treatment if she becomes unwell.
4 Unanswered
a. What four factors need to be true for an AD to be legally binding? (2 marks)
b. The husband, who was appointed Lasting Power of Attorney before the AD was created, 5 Unanswered
wants you to do everything you can to save her. Does this overrule the AD? (1 mark)
6 Unanswered
7 Unanswered
8 Current Question
Answer
a. All four of:
b. No – the AD is still valid (unless the LPA was appointed after the AD and the donor gave permission to the
LPA to override the AD)
Notes
Lasting power of attorney (LPA):
LPA is a document in which a person can nominate someone else to make certain decisions on their behalf (for
example on nances, health, and personal welfare) when they are unable to do so themselves. The LPA must make
decisions in the individual’s best interest.
The Mental Capacity Act 2005 provides the legal framework to give a named person authority to make these
decisions on another person’s behalf. LPA replaces what was previously known as ‘enduring power of attorney’.
To be valid, LPA documents must be registered with the Of ce of the Public Guardian. If there are concerns relating
to decisions taken under the authority of a LPA, the case can be referred to the Court of Protection.
Speci c situations when the LPA cannot consent to/refuse treatment:

When the donor has made an advance decision to refuse treatment (unless the LPA was appointed after the
AD and the donor gave permission to the LPA to override the AD)
Advance Decisions:
Advance decisions allow people who understand the implications of their choices to state their treatment wishes in
advance. They can be used to:
Authorise or request speci c procedures.

Refuse treatment in a prede ned future situation (also called an advance directive).

Advance requests for treatment do not have the same binding status but should be considered when assessing best
interests.
Court of Protection [HM Government, 2015]:
The Court of Protection makes decisions on nancial and welfare issues for people who lack mental capacity. It is
responsible for:
Deciding if a person has the capacity to make a particular decision for themselves.
Appointing deputies to make decisions for people lacking capacity.
Giving permission to make one-off decisions on behalf of a person without capacity.
Dealing with urgent applications where a decision must be made on behalf of another without delay.
Making decisions on LPA (or enduring power of attorney made and signed before October 1, 2007) and
considering objections to these.
Consideration of applications to make statutory wills or gifts.
Making decisions about when someone can be deprived of their liberty under the Mental Capacity Act
(2005).
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You did not answer this question

Alternative options for treatment/investigation (including the option of no treatment/investigation)

Explicit or expressed consent is when a person actively agrees verbally or in writing.

Consent is not a one-off event — ongoing discussion is needed as treatment evolves.

the diagnosis and prognosis

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Lasting power of attorney (LPA):

Speci c situations when the LPA cannot consent to/refuse treatment:

When the donor has the capacity to consent

Authorise or request speci c procedures.

The person is an adult, and

Court of Protection [HM Government, 2015]:

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You did not answer this question

As per GMC guidance:

Condition Group 1 (car and motorcycle) Group 2 (bus and lorry)

https://www.gov.uk/government/uploads/system/uploads/attachment_data/ le/618072/assessing- tness-to-drive-

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Explicit or expressed consent is when a person actively agrees verbally or in writing.

Consent is not a one-off event — ongoing discussion is needed as treatment evolves.

the diagnosis and prognosis

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You did not answer this question 7 Unanswered

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c. All three of:

The Mental Capacity Act (2005) has ve key principles:

Understand relevant information about the decision to be made,

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You did not answer this question 7 Current Question

A father usually has parental responsibility if he:

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LPA to override the AD)

Lasting power of attorney (LPA):

Speci c situations when the LPA cannot consent to/refuse treatment:

When the donor has the capacity to consent

Authorise or request speci c procedures.

The person is an adult, and

Court of Protection [HM Government, 2015]:

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