3. legal ethical issues - nhs wales. legal ethical issues.pdf · legal & ethical issues of...
TRANSCRIPT
Legal & Ethical Issues of Patient
Transfers
The Situation
• Scott a 30yr old is in the ED with meningococcal meningitis; he is very sick and requires Intensive Care.
• The hospital’s ICU is full although there are some stable patients but they still require critical care.
• The nearest ICU bed is 50 miles away
The Situation
� Evidence shows that premature discharges from ICU increase mortality (Goldfrad & Rowan 2000; Blunt & Burchett 2001 etc,
etc)
� However non-clinical transfers increase morbidity (Kollef et al.1997; Duke & Green 2001;
Durai et al. 2003; Welch, Harrison & Rowan 2008)
The Reality
• Mr Keith Abel (retired surgeon) sustained a cerebral haemorrhage whilst being driven to High Wycombe hospital.
• He was unconscious, intubated and ventilated and required immediate neurosurgery but there were no neurocritical care beds available & considerable time was spent trying to locate one.
• Mr. Keith Abel: Death in hospital (Hansard, 14 February 1995).
Duty of Care
• Health professionals in an ICU have a duty of care to their patients and must act in their patients’ best interests.
• Consider the difficulty in making a decision that is not entirely in this patient’s best interest.
• Does the intensive care team also have a duty of care to a patient who is currently physically elsewhere in the hospital but who is in need of intensive care treatment?
www.ethics-network.org.uk/Ethics
www.gmc-uk.org/standards
Duty of Care
• Who has this duty during a transfer?
• Consultant in charge
• The transferring team
• The receiving unit
Legal Responsibilities
• Many staff however are unsure of their roles and responsibilities in their interactions with the legal system.
• This is not surprising, given the increased requirements imposed on practitioners by legislation, regulations and guidelines.
Legal Responsibilities
• The first duty of a doctor must be to ensure the wellbeing of patients and to protect them from harm (this responsibility lies at the heart of the medical profession)
• Nurses must protect and promote the health and wellbeing of those in your care, their families and carers (Code of conduct).
• Patients expect staff to be technically competent, open and honest, and to show them respect.
Reality Conflict
� Critical care is in an emerging crisis of conflict
between what individuals expect and the
economic burden society and government are
prepared to provide
�Demand exceeds capacity
�Pressure of targets
�GP OOH contracts
�Junior doctors hours
�Patients’ expectation
Risks of Transfer
� How good is the care patients receive during interhospital transfer?
� Adverse events occur in about one-third of cases.
� Half the time this can be related to not following advice from the receiving centre.
� Of these events, 70% are probably avoidable and 30% are related to technical problems (Ligtenburg et al. 2005).
How to make things
better
• Essentially, why you are here today…….:– Training.
– Equipment safety.
– Publication of European Standards for ambulance vehicles, i.e. (CEN 1789) compliance
• Noncompliance will technically invalidate any EU ambulance's motor insurance policy.
– Each hospital must nominate a specialist with responsibility for critical care received during transfer.
• They would then be responsible for guidelines, training and equipment.
– Adverse events can then be fed back immediately so they can be acted upon.
• Negligence
“We must take reasonable care to avoid acts and omissions which you can reasonably foresee would be likely to injure your neighbour ...”
Lord Atkin in Donoghue v Stevenson (1932)
(Medical) Negligence
Medical Negligence
• If a patient is not treated with the proper amount of care, resulting in an injury or death, medical negligence has been committed (by the physician or any the relating staff members).
• Requirements for proving negligence:– Duty of Care
– Breach
– Causation
Doctors charged with manslaughter in the
course of medical practice, 1795–2005
Who should transfer?
• Is inexperience a defence?
Inexperience as a
defence?
• “In my view, the law requires the trainee or learner to be judged by the same standard as his more experienced colleagues. If it did not, inexperience would frequently be urged as a defence to an action for professional negligence.”
• LJ Glidewell (Wilsher v Essex AHA 1987)
Inexperience as a
defence?
• Two SHOs were convicted of manslaughter by
gross negligence, following the death of 31yr old
Sean Phillips.
– He developed toxic shock syndrome, which the two
doctors were accused of failing to treat, and died four
days later.
• Earlier this year a doctor was convicted of
manslaughter after her ICU patient died
– She failed to gain advice of seniors and gave adrenaline after ignoring the advice of colleagues.
Staying out of trouble
• Effective communication with patients, their families and other healthcare providers
• Staying up-to-date clinically
• Realising and practising within the limits of your skills, knowledge and experience.
• Utilise published guidelines
Guidelines
• In 1993 Professor Ian Kennedy commented that:
“the role of protocols and guidelines will become more and more important”.
• His words remain apt, although in England and Wales clinical practice guidelines donot yet constitute legally binding standards of care, nor have they replaced expert testimony.
Guidelines
• In the case of Early v Newham HA, the 13yr old claimant recovered consciousness while still paralysed from an unsuccessful attempt to intubate her in preparation for appendix surgery. – She panicked and was in great distress until she had
recovered.
• The anaesthetic SHO had followed the health authority’s written “Failed Intubation Procedure’’correctly.– The guideline had been drawn up by the hospital’s
division of anaesthesia, which included eight consultant anaesthetists
Guidelines
• The claimant sued the health authority, claiming that the doctor was incompetent and negligent, and that the guidelines he followed were faulty and flawed.
• The claim failed.• Bennett QC concluded that the small risk of
transient consciousness was far outweighed by the avoidance of the far greater risk of injury due to hypoxia.
• He also found the guidelines to be reasonable in that ‘a reasonably competent medical authority would have adopted them for their use’.
“Where clinical guidelines have been developed in a robust manner, which reflects wide consultation and best
practice, then it is unlikely that a health professional who follows such guidelines
would be held to be negligent for the outcome of the treatment or process
used.”
Code of Ethics
• Professional responsibilities• duties and obligations
• Professional relationships• professional behaviour
• good communication
• Accountability
Bioethical Principles
• Four Major Bioethical Principles in
Healthcare
– The Principle of Autonomy
– The Principle of Non-Maleficence
– The Principle of Beneficence
– The Principle of Justice
Resource Allocation
• Article 2 - Right to life
• “Treatment that could prolong life may sometimes be withheld on the grounds of scarce resources.”
• “The court is unlikely to interfere in a particular case with a Health Authority's decisions on allocation of resources.”
• http://www.bma.org.uk/ethics/human_rights/HumanRightsAct.jsp?page=4
BENEFITS
RISKS
RISKS