Serial results Instead of simply writing blood results in the notes try writing them on ser ial results sheets (with a column for each day \200\231s results). This makes patterns easi er to spot and saves time. Timetables Along with ward rounds and clinical jobs there will be numerous extra meetings, teaching sessions, and clinics to attend. There are three blank timetables at the end of th is book. Important numbers It can take ages to get through to switchboard so carrying a list of comm on numbers will save you hours (eventually you will remember them). At the end of this book there are three blank phone number lists for you to fi ll in. Blank stickers on the back o f ID badges can hold several numbers. Ward cover equipment Finding equipment on unfamiliar wards wastes time and is frustrating. You can speed up your visits by keeping a supply of equipment in a box. Try to fi ll them w ith equipment from store- rooms instead of clinical areas. Alternatively if you are bleeped by a nurse to put in a cannula, you could try asking them nicely to prepare the equip- men t ready for you for when you arrive (it works occasionally). _OHFP.indb 17 _OHFP.indb 17 30/05/2014 16:17 30/05/2014 16:17 18 CHAPTER 1 Being a doctor Being effi cient Despite the many years spent at medical school preparing for fi nals and b ecoming a doctor, being effi cient is one of the most important skills you can learn as a h ouse offi cer. Working hours When you fi rst start as an F1, you will always work longer ho urs than those you are paid for, especially towards the beginning of your career. The best way to make your day run as smoothly as possible is to come in early to prepare for the war d round \200\223 you will be expected to have the latest bloods, investigation results, an d any overnight interventions at hand, before your seniors arrive. Time management You will nearly always seem pressed for time, so it is important to organiz e your day effi ciently. Prioritize tasks in such a way that things such as blood tests can be in progress while you chase other jobs. Requesting radiology investigations early in th e day is important as lists get fi lled quickly, whereas writing blood forms for the next d ay and prescribing warfarin can wait till later on. TTOs should also be written as soon as the team decides a patient is almost ready for discharge \200\223 this will save any unnec essary delays on the day they go home. On-call It will seem like your bleep never stops going off , especially when you are at you r busiest. Always write down every job, otherwise you run the risk of forgetting what you w ere asked to do. Consider whether there is anyone else you could delegate simple tasks to, such as nurse practitioners or ward staff whilst you attend to more urgent tasks. How to be effi cient \200 Make a list of common bleeps/extensions (see b p608) \200 Est ablish a timetable of your fi rm \200\231s activities (see b p609) \200 Make a folder/cli pboard (see b p17) \200 Prioritize your workload rather than working through jobs in orde r. Try to group jobs into areas of the hospital. If you \200\231re unsure of the urgency of a job or why you are requesting an investigation, ask your seniors \200 If you are worki ng with another house offi cer split the jobs at the end of the ward round so that you share the workload Submit phlebotomy requests at the start/end of each day (fi nd out what time the phlebotomi sts come); if a patient will need bloods for the next 3 days then fi ll them all out togeth er with clear dates Be aware of your limitations, eg consent should only be done by the surgeon doing the procedure or one trained in taking consent for that particular procedure Bookmark online or get a copy of your hospital guidelines/protocols, eg pre-op investigations, anticoagulation, DKA, pneumonia etc Get a map of the hospital if you haven \200\231t got your bearings. OHFP.indb 18 OHFP.indb 18 30/05/2014 16:17 30/05/2014 16:17 19 PATIENT-centered CARE Patient-centered care The traditional medical model made the patient a passive recipient of care. Healthcare was done to people rather than with them. Many patients were happy with t his, but the patient should be able to be in charge of their own healthcare should they so wish. Our task as clinicians is to fi nd out our patients \200\231 expectations of their relation ship with their doctors and then try to fulfi l these. From \200\230what- ever you feel is best doc \200\231 to reams of printouts and self-diagnoses from the internet, neither extr eme is wrong and our task is to help. Patient expectations Find out whether your patient wa nts guidance regarding what treatment may be best. Respect their right to make a decision you believe may be wrong. If you feel that they are doing so because they do not fully understand the situ- ation or because of fl awed logic, then alert your team to this so that things can be explained again. Find out their other infl uences, these can be very powerful. Examples include: religious b eliefs, friends, the internet, and death/illness of rela- tives with similar conditions. Tr eatment expectations Patients may have clear expectations of their treatment (eg an operati on or being given a prescription). These expectations are important sources of discontentme nt when not ful- fi lled. Find out what their expectations are and why. Useful questions ma y include: \200\230What do you think is wrong with you? \200\231 \200\230What are you wor ried about? \200\231 \200\230What were you expecting we \200\231d do about this? \200\231 Yourself in their shoes Make time to imagine yourself in your patient \200\231s place. Isol ation or communication diffi culties will heighten fear at an already frightening time. Lon g waits without explanation are sadly common. Aggression from friends or relatives is often simply a mani- festation of anxiety that not enough is being done. Ask yourself \200\230H ow would I want my family treated under these circumstances? \200\231 then do this for ever y patient. Ensuring dignity Hospitals can rob people of their dignity. Wherever and whenever possible help restore this: \200 Keep your patients covered (including during resuscitation) \200 Ensure the curtains are around the bed on the ward round \200 Make sure they have their false teeth in to talk and glasses/wigs on whenever possible Help them self-care when possible. Over-examination Patients are often clerked over four ti mes for a single admission. This is frustrating for them and often seen as indicative of a lack of coordination within the hospital. Patients may need to be clerked and examined more than once, but the context of this should be explained carefully \200\223 is this to gain more insight about their condition or to allow a training doctor to learn? People rarely m ind when they understand the reasons. Keep examinations which are invasive or cause discomf ort to an absolute minimum. _OHFP.indb 19 _OHFP.indb 19 30/05/2014 16:17 30/05/2014 16:17 20 CHAPTER 1 Being a doctor Communication and conduct Good communication with patients and colleagues is a vital part o f the job. All communication Whenever you are communicating with another health professional you shoul d include the following details: \200 Your name and role (eg Dr Charles Flint, F1 on Merc ury Ward) \200 The patient \200\231s name, location, and primary problem (eg Eleanor Rigb y who has suspected appendicitis in bed B4 on Neptune Ward) \200 What you wish them to do ( eg please keep her nil by mouth) \200 Urgency (eg immediately) \200 How to contact you if there are any problems (eg I \200\231m on bleep 3366). Handover1 Reductions in working hours, a move towards shift-based rotas and the increased c ross-cover between specialties mean that the number of doctors caring for a patient during their hospital stay has increased, making the eff ective transfer of critical information m ore important than ever. Handover occurs at the beginning and end of every shift and it is vital that suffi cient time is set aside to allow for this. Some hospitals will have formal handover meetings with a senior doctor chairing and a standardized approach to the discuss ion of sick patients. However, very often the handover process may just involve you sitting down with a colleague to discuss a list of jobs and patients. Whatever the setting, it is important that the incoming doctor receives a clear over- view of the situation within the area that they are covering, including the names, locations and clinical details of acutely unwell patients and those patients requiring review, as well as outstanding tasks requirin g completion and their order of priority. Giving and receiving a good handover is a key ski ll and one you should pride yourself on perfecting. 1 Safe handover: Safe patients. Junio r Doctors Committee, BMA (2004) available at (cid:27)bma.org.uk Written communication Clinical notes see b p74 Sick notes see b p80 Self-discharge If your patient decides to discharge themselves, try to explain why they need hospital management a nd what could happen if they leave. If you think the patient lacks capacity to make this de cision (b p28), consult your seniors urgently. If they are capable to make the decision the n ask them to sign a self-discharge form to indicate they are taking their own discharge against medical advice. You, the patient, and a second witness (eg nurse) should sign it, r ecording the time, date, and the patient \200\231s decision. Keep it in the notes and infor m the GP if relevant. Arrange follow-up and TTOs as usual. Referral letters see b p82 TTOs see b p78 Professional conduct As a doctor you are a respected member of the community and a rep- res entative of the medical profession. People will expect you to act in a professional manner; this does not mean you cannot be yourself, but you must be aware of expectations: \200 A lways introduce yourself, especially over the telephone or when answering a bleep; \200\230Hello \200\231 is not enough \200 Wear your ID badge at all t imes in hospital OHFP.indb 20 OHFP.indb 20 30/05/2014 16:17 30/05/2014 16:17 21 COMMUNICATION AND CONDUCT Never be rude to colleagues/ward staff ; you will get a bad reputation \200 Never be rude to patients, no matter how they treat you \200 Never: shout, swear, scream, hit things, or wear socks with sandals \200 Do not gossip about your work colleagues; address any pro blems you have with a colleague directly and in private When you do something wrong, apologize and learn from your mistake; it \200\231s a natural part of the learning curve If you are going to be late, let the person know in advance especially for handover or ward rounds If you think it is not appropriate for you to do a job then run it by the ward staff or you r seniors. Ask for help if you feel overrun with tasks. Patients \200\231 relatives Communication with relatives can be diffi cult if done badly, o r rewarding when things go well. They may be scared, assuming the worst and be in the frust rating position of not knowing what is going on. They could have a full time job that preve nts them coming in during the day: \200 If you are on-call and do not know the patient we ll then be honest about this, but attempt to answer simple questions as best possible using the notes; explain what times the usual ward staff will be present \200 Try to arrange a time when you can discuss the patient \200\231s progress in a quiet room (ask a colleague to hold your bleep) To avoid repeating yourself, speak to the family collectively or ask them to appoint a representative Check the patient is happy to have their confi dential medical details discussed (b p27) an d encourage them to be present if possible Address concerns and answer each question in turn \200 Be honest and aware of your limita tions; if necessary ask them to arrange a time to meet with a senior Document the date, time, what was discussed, and who was present in the notes. Patient communication A patient \200\231s perception of your abilities as a doctor depends largely on your communication skills. Remember that patients are in an alien envi- ronment and are often worried about their health. Introductions Always introduce yourself to patien ts and clearly state your name and position. Ask your patient how they wish to be addressed (eg Denis or Mr Smith). Patients meet many staff members daily so reintro- duce yourself e ach time you see them. General advice Try to avoid using medical jargon. Be honest with you r replies to them, and give direct answers when asked a direct question. If you do not know the answer, be honest about this too. Results Explain why the investigation was performed, what it shows and what this means. Diagnosis Try to give the everyday name rather than a m edical one (heart attack instead of MI). Explain why this has happened. A patient who under stands their condition is more likely to comply with treatment. Prognosis Along with the ob vious questions about life expectancy (b p22), patients are most interested in how their li fe will be aff ected. Pitch your explanation in terms of activities of daily living (ADLs), walking, driving (b p605) and working. Bear in mind that patients may want to know about h aving sex, but are often too embarrassed to ask. _OHFP.indb 21 _OHFP.indb 21 30/05/2014 16:17 30/05/2014 16:17 22 CHAPTER 1 Being a doctor Breaking bad news Ideally, breaking bad news should always be done by a senior at a pre- de termined time when relatives and friends specialist nurses can be present. In reality yo u are likely to be involved in breaking bad news, often whilst on-call. It can be a positiv e experience if done well. Preparation Read the patient \200\231s notes carefully and ensur e that all results are up to date and for the right patient. Be clear in your mind about th e sequence of events and the meaning of the results. Consider the further management and li kely prognosis \200\223 discuss with a senior. Consent and con \201 dentiality (b p29 and b p27) A patient has a right to know what is going on or to choose not to know. Ask before the investigations are done and document their response. If a patient does not want their relatives to know about their diagnosis you must respect this. Always ask, do not assume \200\223 many families have complex dynamics. Warning shot Give a suggestion that bad news is imminent so it is not completely out of the blue, eg \200\230I have the results from \200 would you like anyone else here when I tell you them/shall we go to a quiet room? \200\231. How to do it The SPIKES model is often used: Setting Ask a colleague to hold your bleep and set aside suitable time (at least 30min); use a quiet room and invite a nurse wh o has been involved in the patient \200\231s care. Arrange the seats so you can make eye co ntact and remove distractions. Introduce yourself and fi nd out who everyone is. Perception Find out what the patient already knows by asking them directly; this will give you an idea of how much of a shock this will be and their level of understanding to help yo u give appropriate information. Invitation Explain that you have results to give them and ask if they are ready to hear the m. It helps to give a very brief summary of events so they understand what results you are talking about. Knowledge Break the bad news, eg \200\230A doctor has looked at the sample and I \200\231m sorry to say it shows a cancer \200\231. Give the information time to sink in and all pres ent to react (shock, anger, tears, denial). Once the patient is ready, give further informa tion about what this means and the expected management. Give the information in small segme nts and check under- standing repeatedly. Prognosis can be diffi cult; never give an exact time ( \200\230months \200\231 rather than \200\2304 months \200\231). Be honest and reali stic. Try to off er hope even if it is just symptom improvement or leaving hospital. Empath y Acknowledge the feelings caused by the news; off er sympathy. This will take place alongs ide the \200\230Knowledge \200\231 step. Listen to their con- cerns, fears, worries. This will guide what further information you give and help you to understand their reactions. Summary Repeat the main points of the discussion and arrange a time for further questions, ideally with a senior and yourself present. Give a clear plan of what will happen over the next 48h. Remember to document the discussion in the patient \200\231s notes (diagnosis, prognosis, e xpectations) with your name and contact details. OHFP.indb 22 OHFP.indb 22 30/05/2014 16:17 30/05/2014 16:17 23 CROSS-CULTURAL COMMUNICATION Cross-cultural communication For patients who can \200\231t understand or speak the same la nguage as you, the consultation can leave them feeling isolated, frustrated and anxious. Yo u may have to rely on a third party to translate for you. Professional interpreters Professional interpreters can be arranged before the appointment \200\223 ask ward staff or phone switchboard: \200 Allow extra time for the consultation and check the interpreter is acceptable to the patient Address both the patient and the interpreter and look at the patient \200\231s non-verbal response to gauge their level of understanding Ask simple, direct questions in short sentences to avoid overloading or confusing the interpreter; avoid jargon Use pictures or diagrams to explain things wherever possible; provide written/audiovisual m aterial in the patient \200\231s own language to take away If you cannot organize an interpreter, you may be able to contact a telephone interpreting service who translate for you and the patient directly over the phone (ask nurses or switch board) Document that a trained interpreter has been used with their name and contact details so th at the same interpreter can accompany the patient for future appointments. Never assume you know what the patient wants without asking them. Family members as interpreters There are many reasons why family members and friends should not be used as interpreters. Nevertheless, in emergency situations, this may prove necessa ry. Address the patient directly and look carefully at the patient \200\231s response to ga uge their understanding. Record the fact that a family member was used for interpretation i n the notes. Friends and relatives are commonly used as informal interpreters. The main drawbacks are th e lack of confi dentiality and the bias the relative may have on the patient \200\231s deci sion-making \200\223 particularly when under- lying family issues are present (you may be unaware of these). Children can interpret for their parents from an early age, but again their views can bias the consultation and its outcome (eg sexual health and vulnerable adults) and even routine clinical questions can be very fright- ening or inappropriate for children. Use only as a p oint of last resort. Con \202 ict of interests if you think the relative is biasing the conversation or it is a n important issue then explain that you are professionally obliged to request a trained int erpreter. Consent relatives cannot consent on behalf of adults, see b p29. Who can interpret \200 Hospital interpreters \200 Local interpreting agencies \200 Ho spital staff (switchboard may have a list) \200 Telephone service with which the hospital has a contract \200 Family and friends \200\223 as a last resort \200\223 see above. _OHFP.indb 23 _OHFP.indb 23 30/05/2014 16:17 30/05/2014 16:17 24 CHAPTER 1 Being a doctor Outside agencies Outside agencies who could enquire about your patients include: police, me dia, solicitors, fi re brigade, paramedics, general practitioner, researchers, and the pati ent \200\231s employer. Patient confi dentiality must be respected. The rules \200 Do you really know who you are talking to? \200 Check and arrange to cal l them back unless certain \200 Do they have any right to the information they are seekin g? GPs, healthcare professionals and ambulance staff may well do, police have limited rights (see below), many others do not \200 Should you be the one dis cussing this or should a more senior member of the team? Do not talk to the media about a patient/your hospital unless: You have the patient \200\231s permission and: \200 You have permission from your consult ant/management (for trust issues) and: You are accompanied by the trust public relations offi cer Do not \200\230chat \200\231 to a police/prison offi cer about a patient, no matter what t he alleged circumstances; all patients have an equal right to privacy \200 Breaching a pa tient \200\231s confi dentiality without good cause is treated as misconduct by the GMC. Con \201 dentiality and the police Immediate investigation of assaults The police may well ask the clinical condition of an assault victim. \200\230Is it life-threatening, doctor? \200\231 The purpose of this question is to know how thoroughly to investigate the crime sc ene. It is reasonable to give them an assessment of severity. In the public interest In situations where someone may be at risk of serious injury, disclo sure is permitted by the GMC. This should be a consultant- level decision. The Road Traffi c Act Everyone has a duty to provide the police with infor- mation which ma y lead to the identifi cation of a driver who is alleged to have committed a driving off en ce. You are obliged to supply the name and address, not clinical details. Discuss with your seniors fi rst. Being a witness in court Inform your clinical supervisor; they should accompany you to cour t. Remember you are a professional witness to the court so your evidence should be an impar tial statement of the facts. Do not get rattled by the bar- risters \200\223 stick to the facts, do not give opinions, explain the limits of your knowledge/experience. Address your remarks to the judge. Wear your best suit. Get an expenses form from the witness unit to cl aim your costs back. Medical research You may be asked to provide patient details for research. Ask the research er to provide you with ID and if they have consent from the patient. It is rea- sonable to direct researchers towards appropriate patients to get consent. OHFP.indb 24 OHFP.indb 24 30/05/2014 16:17 30/05/2014 16:17 25 CLINICAL GOVERNANCE/QUALITY Clinical governance/quality DH defi nition: \200\230Clinical governance is the system thro ugh which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clin ical excellence will fl ourish. \200\231 What this means for you as an individual \200 You are responsible for your clinical pract ice which you should be aiming to improve continuously You need a mechanism for assessing the standard of your practice \200 Whilst in training this is done for you by your consultant/trainer as part of your regular appraisal process. Additionally you may have audits and regular departmental meetings You should be aiming to continuously learn and improve your care for patients. Again, whils t still in training, this almost goes without saying; revising for endless examinations and diplomas helps too. What this means for you as part of a team \200 You should ensure you stick to departmenta l or hospital protocols and don \200\231t undertake procedures for which you have not been trained \200 You will be asked to participate in regular departmental audits, usually of morbidity and mortality. These are used to ensure consistency of practice and to pick up problems early You should attend departmental and hospital-wide audit meetings and grand rounds to keep up to date with changes You should answer any responses to complaints promptly. Clinical governance/quality mechani sms The clinical governance structure in every hospital includes: \200 Audit of practice (eg reattendances within 1wk or wound infections) \200 Appraisal and revalidation structu res \200 Regular departmental meetings (eg morbidity and mortality) to allow clinicians to compare their care and highlight common concerns \200 Clear routes of accou ntability for all staff . It can be obvious when these have broken down, leading to problem s which everyone can identify but seemingly no one is responsible for fi xing A risk management structure to identify practices which jeopardize high-quality patient care (critical incident reporting, b p32) \200 A complaints departme nt to respond to complaints and ensure lessons are learned from them; may be part of the risk management department A clinical governance/quality committee structure which oversees and ensures compliance with all of the above. Compliance with clinical governance/quality mechanisms are measured both regionally and nat ionally through quality boards. _OHFP.indb 25 _OHFP.indb 25 30/05/2014 16:17 30/05/2014 16:17 26 CHAPTER 1 Being a doctor Medical ethics What is medical ethics? Ethics are moral values, and in the context of medicine are support ed by four main underlying principles: Autonomy is the right for the individual to make decisions for themselves, and not be overt ly pressurized or swayed by others (namely doctors, nurses, relatives, etc). Patients shoul d be allowed to contribute when decisions are made about their care. If an individual lacks capacity (b p28) then it might not be appropriate to let them make important autonomous de cisions. Bene \201 cence is concerned with doing what is right for the patient and what is in their best interests. This does not necessarily mean we should do every- thing to keep a 90-year -old patient alive who has widespread metastatic disease. There will be times when it is be nefi cent to keep a patient comfort- able, and allow them to die naturally. Non-male \201 cence ensures care-givers refrain from doing harm to the patient, whether ph ysical or psychological. An example of a breach in non- malefi cence would be if a patient came to harm as a result of a doctor per- forming a procedure in which they had inadequate training or supervision. Justice requires that all individuals are treated equally and that both the benefi ts and b urdens of care are distributed without bias. Justice also covers openness within medical pr actice and the acknowledgement that some activities may have certain consequences \200\223 specifi cally legal action. Two further principles are important to consider: Dignity should be retained for both the patient and the people delivering their healthcare. Honesty is a fundamental quality which doctors (as well as other care- givers) and patients should be expected to exhibit in order to strengthen the doctor \200\223patient relationsh ip. Ethical con \202 ict Ethical dilemmas frequently arise in clinical practice and while the prin- ciples listed do not necessarily provide an immediate answer, they do create a framew ork on which the various components of the confl ict can be teased out and addressed indivi dually, which often allows a harmo- nious solution to be identifi ed. Ethics and communication It is quite common that apparently complex ethical issues arise be cause of a failure in communication between the patient or their loved ones and healthcare professionals. The solution to most of these confl icts is the establishment of eff ective and transparent lines of communication. OHFP.indb 26 OHFP.indb 26 30/05/2014 16:17 30/05/2014 16:17 27 PATIENT CONFIDENTIALITY Patient con \201 dentiality To breach patient confi dentiality is unlawful and unprofessio nal; several doctors are disciplined and even struck off the medical register each year for this. You should be careful when talking about patients in public places, including within the hospital environment, and only disclose patient infor- mation to recognized healthcare staff as appropriate. Pieces of paper with patient information on must never leave the hos pital and should be shredded if they are no longer required. Do not leave patient lists lyi ng around. Personal electronic databases of patients should be disguised so individual pati ents cannot be identifi ed. Electronic devices on which patient information is stored outsi de of the hospital should be encrypted and reg- istered under the Data Protection Act. You avoid giving any information (names or nature of injuries) to the police, press, or other e nquirers; ask your seniors for advice when dealing with these (see b p24). Publications Med ical journals will often insist that any article which involves a patient must be accompani ed by written consent from the patient for the publication of the material, irrespective of how diffi cult it would be to track down and identify that patient. Presentations and images If you are talking about a patient to a group of healthcare worker s in your own hospital you do not need to obtain consent, but doing so is courteous. If you are talking to an audi- ence from outside your hospital it is advisable you seek the patie nt \200\231s consent unless the patient is fully anonymised. Equally, if you want to keep c opies of radiographs or digital images, ensure these are made anonymous and if this isn \200\231t possible obtain the patient \200\231s written consent. Bear in mind that presenta tions can easily end up online and be accessed by those other than your original audience.1 Relatives Your duty lies with your patient and if a relative asks you a question about the patient, it is essential you obtain verbal consent from the patient to talk to the relative ; alternatively off er to talk to the relative in the presence of the patient. Relatives do not have any rights to know medical information. If the patient lacks capacity then seek s enior advice before talking to the relatives. Document all conversations in the notes. Children As described for adults, if the child has capacity to give consent (see \200\230G illick competence \200\231/Fraser guidelines, b p28), you must seek verbal consent from the patient to tell the relatives (parents) about their health. If the patient refuses, then o ff er to talk to the patient about their condition in the presence of their relatives. If y ou sense the situa- tion will be diffi cult, seek senior advice/support. Telephone calls Wards receive many telephone calls asking how patients are and if they have had tests or operations yet. The potential to break patient confi dentiality here is great . Often there is a telephone by each bed, so encourage callers to speak to the patient dire ctly. Otherwise, inform the patient who the caller is and relay a message from the patient to the caller. Apologize to the caller for not being able to off er any further information and suggest that you could talk things over with both them- selves and the patient when th ey visit. See \200\230Outside agencies \200\231, b p24. 1 For a good discussion of the ethical issues, see Draper, H. and Rogers, W. APT 2005 11:11 5 available free at (cid:27)apt.rcpsych.org/content/11/2/115.full.pdf _OHFP.indb 27 _OHFP.indb 27 30/05/2014 16:17 30/05/2014 16:17 28 CHAPTER 1 Being a doctor Capacity Someone who has capacity can comprehend and retain information material relevant t o the decision, especially as to the consequences of not having the intervention in questio n, and must be able to use and weigh this information in the decision-making process. For a patient to have capacity they must: \200 Be able to understand the information rele vant to making the decision and consequences of refusal Retain the information long enough to allow for decision-making \200 Weigh up the informa tion to arrive at a decision \200 Be able to communicate the decision they have made. Rem ember that: \200 Patients may have the capacity to make certain decisions and not others \200 Capacity in the same patient may fl uctuate over time. Capacity is most often impair ed by chronic neurological pathology such as dementia, learning diffi culties, and psychiat ric illness, but is also impaired by acute states such as delirium, acute severe pain, alco hol and drug intoxication (both recreational and iatrogenic \200\223 eg morphine). Childre n and capacity Children under 16yr of age were once regarded as lacking capacity to give co nsent, but now if the child meets the criteria then they are regarded as having \200\230Gi llick \200\231 competence (Fraser guidelines1), and may give consent. It is always advisabl e, however, to involve the parent or guardian in discussions about the patient \200\231s ca re if the patient allows (see also b p403). No capacity When the patient does not have capacity and is over 18, family and friends are not able to make a decision on the patient \200\231s behalf; their views should, however, b e listened to. Where the patient lacks capacity and there is no next of kin to consult an I ndependent Mental Capacity Advocate (IMCA)2 may need to be appointed who advises cli- nicia ns in making decisions on behalf of the patient in their best inter- ests. In an emergency situation, the patient is treated under the \200\230doctrine of necessity \200\231, that i s, doing what is in the patient \200\231s best interests until they attain capacity to make the decisions themselves. Gillick competence/Fraser guidelines Although 16 is the usual age at which people are autom atically allowed to give their own consent, younger people can consent to most treat- ments or operations if they are capable. This follows a famous case in 1986 when Victoria Gillic k went to the courts to get authority to be informed if her daughters sought contraceptive treatments. The law dis- agreed and decided that if a child was competent, he/she could con sent to treatment without parental knowledge \200\223 this is often referred to as being \200\230Gillick \200\231 competent when a child meets the criteria in that case. 1 Gillick or Fraser? A plea for consistency over competence in children. BMJ 2006; 332:807. 2 Mental Capacity Act (2005); (cid:27)www.legislation.gov.uk/ukpga/2005/9/section/35 OHFP.indb 28 OHFP.indb 28 30/05/2014 16:17 30/05/2014 16:17 29 CONSENT Consent Understanding consent and obtaining it satisfactorily can be diffi cult. If you are ever unsure seek senior help. Obtaining consent The individual who obtains consent from th e patient should be aware of the risks and benefi ts and be able to com- municate the proce dure in a language that the patient will understand. If you do not regularly perform the pr ocedure yourself or are not trained to take consent for the procedure then you must not obt ain consent for it. Obtaining consent satisfactorily is a skill that can be learned from se nior colleagues, so initially shadow your seniors when they are taking consent from a patie nt to learn how to do it properly, then have a senior colleague supervise you the fi rst fe w times to ensure you include all the relevant information. Informed consent In order to give informed consent, patients must fi rst be deemed to have capacity to consent under the specifi c circum- stances (b p28). Consent should refl ect th e fact that the patient is aware of what is going to happen and why. They should be aware o f the consequences of not undergoing the procedure, the potential benefi ts, and any altern atives, and be free from any coercion. The common risks and side eff ects should be discuss ed, as should the potentially rare but serious consequences of the procedure. As a rule, an y risks which might aff ect the decision of a normal person should be discussed \200\223 p lus any risks that might be of specifi c importance for the individual patient, such as whe re the profession of the patient makes a normal trivial risk of special importance (eg a ti ny risk of post-operative vertigo might be of particular importance for a window cleaner). The patient should be pro- vided with information well in advance of the procedure to allow them to think it over and prepare any questions they may wish to ask. Types of consent There are three main types of consent: \200 Implied The patient off ers you their arm as you approach them with a needle and syringe to take blood Expressed \200\223 verbal You explain that you are going to perform a lumbar puncture, by describing the procedure and potential complications and the patient agrees to have it done Expressed \200\223 written The patient is given an extensive explanation of the procedure and complications and informed of the alternatives. A record of the consultation is made wh ich both patient and doctor sign. This document should be completed prior to the planned tr eatment or procedure, and consent verifi ed at the time of the procedure. Diffi cult situations There are many situations where problems arise with consent issues. I f in doubt seek senior advice or consult one of the medical defense unions (b p600) which h ave 24h telephone support. If a patient has capacity to give or withhold consent, and choos es not to receive treatment even in the face of death, then treating that patient against t heir will is potentially a criminal off ence. This includes patients with psychiatric illne ss. Note that this situation is distinct from that of a patient with a psychiatric illness who may lack capacity to make decisions regarding psychiatric treatment, and may be detaine d and given psychiatric (but not medical treatment) under the Mental Health Act (b p364). _OHFP.indb 29 _OHFP.indb 29 30/05/2014 16:17 30/05/2014 16:17 30 CHAPTER 1 Being a doctor Medical errors Every doctor makes mistakes varying from the trivial and correctable to the severe and avoidable. What to do at once/within an hour \200 Stabilize the patient, call for senior help early \200 Do not compound the error by trying to cover it up or ignoring it \200 Correct whe re possible, apologizing to the patient as appropriate \200 Don \200\231t underestimate t he seriousness of the situation; have a low threshold for asking for help to ensure things do not get any worse \200 If serious and you have time, start documenting events, includi ng times \200 If, sometime after an error, you realize you wish to add further details to the notes then do so but make it clear when these additions have been written by timing an d dating them. This is perfectly acceptable \200 Amending notes, without making it clear that your entry was made retrospectively and with a clear date and time, is serious misconduct. Serious untoward incidents \200\223 rare \200 An apology is not an admission of guilt, s o apologize and explain to the patient early. Apologize that the event has taken place, it is not necessary to \200\230give confession \200\231 at this stage \200 Inform your seni or/consultant immediately \200 If you believe your error has caused the patient signifi c ant harm then you should speak to your defense organization (b p600) as soon as practical.