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Medical law and ethics 2012




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  • 1. Dr Chris CresswellED PhysicianWhanganui HospitalNew Zealand
  • 2.  BIBA after low speed motorcycle crash after taking handful of sleeping pills Police officer Hx Depression, under psych s/b psych, for OP follow-up, cleared for discharge Alert now ? Fit to work ?
  • 3.  He doesn’t want to take time off, doesn’t want his employer informed. What do you do?
  • 4.  Encourage him to take sick leave Inform NZ Transport Agency – recommend drivers licence be revoked
  • 5.  I spoke to his senior officer Lost his job Suicided
  • 6.  Known to be abusive to staff Police request opinion re gun licence What do you do?
  • 7.  Get patients permission to disclose your opinion to the police! GP didn’t discuss with patient Medical Council not impressed
  • 8.  Patient has a right to privacy of his/her health information unless there is a serious and imminent risk of death to the patient or others Can only disclose information to someone who can do something about it Only give sufficient information to address concern
  • 9.  Agitated, demanding to leave CCU What are you going to do?
  • 10.  This patient can not be assumed to be competent  Septic  Hepatic encephalopathy  Withdrawal Was allowed to leave Found dead in a nearby garden next day
  • 11.  Taken 30g of paracetamol (potentially lethal) She refuses to allow you to take a blood sample What do you do?
  • 12.  We assume this girl is being adversely effected by depression which is preventing her from making an autonomous decision in her best interests We must act in her best interests Usually when we tell them they we will take blood they allow us to Next step: threaten with being sectioned under the Mental Health Act Section Restrain/sedate if necessary
  • 13.  In a fight, several punches to the head In the waiting room, getting stroppy and abusive, throwing things around. What are you going to do?
  • 14.  Talk him down Offer him eg analgesia, a bed, phone a friend If necessary restrain / sedate / scan Call police if necessary Generally safer to do this than to send an aggressive patient to the cells.
  • 15.  In practice:  Are they orientated?  Do they understand enough to be able to tell you the risks of what would happen to them if the self discharged?  Are they free from a mental illness that is making them making a choice that is not in their best interests  If so they are competent to self discharge and accept that risk for themselves
  • 16.  A doctor or nurse can restrain/sedate any patient if you have good reason to believe they are not competent and are a harm to themselves or others
  • 17.  Which drug to use Controversial I recommend haloperidol/droperidol rather than benzos  Less risk of airway/breathing compromise  Exceptions: use benzos for  Alcohol withdrawal  Stimulants such as cocaine, methamphetamine For the really difficult ones:  IM ketamine 5mg/kg  IV ketamine 1mg/kg  Call in a senior
  • 18.  Demented, double incontinence Should we fix the NOF?
  • 19.  There is no NFR form / advance directive Should we / who should fill in the DNR form?
  • 20.  Difficult area Next of kin / EPOA do not have the legal ability to agree to / sign a DNR. If the patient is not competent and no advance care plan / advance directive -> medical decision We take into account the opinion of the family We inform the family of the decision Sometimes we give into families’ requests, make the patient for resus, to give them time to get used to idea. The conversation can be had again the next day.
  • 21.  Jehovah’s witness child is in an car crash, bleeding +++ into belly and externally, shocked You are struggling to stop the bleeding Do you give blood?
  • 22.  They may give permission If they don’t?
  • 23.  Give blood.