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Dr Chris CresswellED PhysicianWhanganui HospitalNew Zealand
   BIBA after low speed motorcycle crash after    taking handful of sleeping pills   Police officer   Hx Depression, un...
   He doesn’t want to take time off, doesn’t want    his employer informed.   What do you do?
   Encourage him to take sick leave   Inform NZ Transport Agency – recommend    drivers licence be revoked
   I spoke to his senior officer   Lost his job   Suicided
   Known to be abusive to staff   Police request opinion re gun licence   What do you do?
   Get patients permission to disclose your    opinion to the police!   GP didn’t discuss with patient   Medical Counci...
   Patient has a right to privacy of his/her health    information unless there is a serious and    imminent risk of deat...
   Agitated, demanding to leave CCU   What are you going to do?
   This patient can not be assumed to be    competent       Septic       Hepatic encephalopathy       Withdrawal   Wa...
   Taken 30g of paracetamol (potentially lethal)   She refuses to allow you to take a blood sample   What do you do?
   We assume this girl is being adversely effected by    depression which is preventing her from making an    autonomous ...
   In a fight, several punches to the head   In the waiting room, getting stroppy and    abusive, throwing things around...
   Talk him down   Offer him eg analgesia, a bed, phone a friend   If necessary restrain / sedate / scan   Call police...
   In practice:       Are they orientated?       Do they understand enough to be able to tell you        the risks of w...
   A doctor or nurse can restrain/sedate any    patient if you have good reason to believe they    are not competent and ...
   Which drug to use   Controversial   I recommend haloperidol/droperidol rather than benzos       Less risk of airway...
   Demented, double incontinence   Should we fix the NOF?
   There is no NFR form / advance directive   Should we / who should fill in the DNR form?
   Difficult area   Next of kin / EPOA do not have the legal ability to agree    to / sign a DNR.   If the patient is n...
   Jehovah’s witness child is in an car crash,    bleeding +++ into belly and externally, shocked   You are struggling t...
   They may give permission   If they don’t?
   Give blood.
Medical law and ethics 2012
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Medical law and ethics 2012

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Medical law and ethics 2012

  1. 1. Dr Chris CresswellED PhysicianWhanganui HospitalNew Zealand
  2. 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. 3.  He doesn’t want to take time off, doesn’t want his employer informed. What do you do?
  4. 4.  Encourage him to take sick leave Inform NZ Transport Agency – recommend drivers licence be revoked
  5. 5.  I spoke to his senior officer Lost his job Suicided
  6. 6.  Known to be abusive to staff Police request opinion re gun licence What do you do?
  7. 7.  Get patients permission to disclose your opinion to the police! GP didn’t discuss with patient Medical Council not impressed
  8. 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. 9.  Agitated, demanding to leave CCU What are you going to do?
  10. 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. 11.  Taken 30g of paracetamol (potentially lethal) She refuses to allow you to take a blood sample What do you do?
  12. 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. 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. 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. 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. 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. 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. 18.  Demented, double incontinence Should we fix the NOF?
  19. 19.  There is no NFR form / advance directive Should we / who should fill in the DNR form?
  20. 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. 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. 22.  They may give permission If they don’t?
  23. 23.  Give blood.

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