Ethics & Law

Ethics & Law UK Medical PG Question 1: A 49-year-old woman with widely metastatic cervical cancer is dying in hospital. She has capacity and pain is well controlled. She specifically requests that her elderly mother, who lives abroad and has dementia, not be informed of her deterioration or death. Her brother strongly objects, saying their mother has a 'right to say goodbye'. What should you do?

• A. Inform the mother as she has a right to know about her daughter's condition
• B. Support the brother to inform the mother as this is a family matter
• C. Respect the patient's confidentiality and wishes (Correct Answer)
• D. Arrange a best interests meeting to decide what to tell the mother
• E. Compromise by informing the mother only after the patient dies

Ethics & Law Explanation: ***Respect the patient's confidentiality and wishes***- A **capacitous patient** has the absolute right to **autonomy** and confidentiality, including the right to restrict who is informed about their medical condition or death.- The legal and ethical duty of **confidentiality** persists even after death; therefore, the patient's specific request must be honored over the wishes of family members.*Inform the mother as she has a right to know about her daughter's condition*- Relatives do not have a legal **"right to know"** medical information if the patient explicitly withholds consent.- Overriding a patient's wishes without a **public interest justification** is a breach of professional guidance and medical ethics.*Support the brother to inform the mother as this is a family matter*- While healthcare is often family-centered, the clinician's primary duty is to the **patient**, not the family unit.- Supporting the brother to bypass the patient's refusal would facilitate a **breach of confidentiality** and undermine the patient's trust.*Arrange a best interests meeting to decide what to tell the mother*- **Best interests meetings** are utilized for patients who **lack capacity**; they are not applicable when a capacitous patient has made a clear decision.- The mother's dementia does not grant the medical team the authority to override the **capacitous daughter's** explicit instructions.*Compromise by informing the mother only after the patient dies*- This approach is incorrect because the patient specifically requested not to be informed of her **deterioration OR death**.- Respecting a patient’s wishes regarding **post-mortem confidentiality** is a requirement of GMC and other professional standards.

Ethics & Law UK Medical PG Question 2: A 68-year-old woman with advanced ovarian cancer has capacity and refuses further chemotherapy. Her daughter, who has Lasting Power of Attorney for Property and Financial Affairs, insists that her mother continue treatment and threatens to sue if treatment is stopped. The patient remains adamant she wants to stop. What is the most appropriate course of action?

• A. Follow the daughter's wishes as she holds Lasting Power of Attorney
• B. Respect the patient's decision and discontinue chemotherapy (Correct Answer)
• C. Apply to the Court of Protection for a decision
• D. Continue chemotherapy until family consensus is reached
• E. Refer to the hospital ethics committee for guidance

Ethics & Law Explanation: ***Respect the patient's decision and discontinue chemotherapy***- A patient with **mental capacity** has the absolute legal and ethical right to refuse any medical treatment, even if that refusal may result in death.- The principle of **autonomy** dictates that a capacitous patient's decision overrides the views of family members, including those with certain types of power of attorney.*Follow the daughter's wishes as she holds Lasting Power of Attorney*- The daughter holds a **Lasting Power of Attorney (LPA) for Property and Financial Affairs**, which grants no authority over **health and welfare** decisions.- An LPA for Health and Welfare would only become active if the patient **loses capacity**, which is explicitly stated not to be the case here.*Apply to the Court of Protection for a decision*- The **Court of Protection** is typically involved when a patient **lacks capacity** and there is a dispute regarding their best interests or treatment.- Since the patient has **undisputed capacity** and has made a clear decision, her wishes are legally binding and do not require judicial intervention.*Continue chemotherapy until family consensus is reached*- Forcing medical treatment on a patient who has **capacity** and refuses it constitutes **medical battery** and is a violation of their rights.- Healthcare professionals must respect the **autonomy** of a competent patient; family consensus is not required when the patient's wishes are clear.*Refer to the hospital ethics committee for guidance*- While an **ethics committee** can be helpful in morally ambiguous situations, the legal and ethical framework concerning a capacitous patient's right to refuse treatment is clear.- The patient's **right to autonomy** is paramount and does not necessitate committee approval to be upheld.

Ethics & Law UK Medical PG Question 3: A 54-year-old man with metastatic colorectal cancer and hepatic encephalopathy is admitted confused (MMSE 14/30). His wife produces a Lasting Power of Attorney for Health and Welfare document appointing her as his attorney, which was registered 2 years ago. She refuses palliative chemotherapy on his behalf, but his oncologist believes treatment would improve his quality of life and potentially extend survival. What factor should primarily guide the decision?

• A. The wife's decision as LPA attorney must be followed
• B. The patient's best interests, considering all relevant factors (Correct Answer)
• C. The oncologist's clinical judgment about treatment benefits
• D. The patient's previously expressed wishes about cancer treatment
• E. A Court of Protection decision given the disagreement

Ethics & Law Explanation: ***The patient's best interests, considering all relevant factors*** - Under the **Mental Capacity Act (MCA) 2005**, all decisions for a person lacking capacity must be made in their **best interests**, which requires a holistic assessment of various factors. - This assessment considers the patient's **past wishes and feelings**, beliefs, values, and the views of the Lasting Power of Attorney (LPA), as well as clinical opinion on treatment efficacy and quality of life. *The wife's decision as LPA attorney must be followed* - While the wife holds a valid **Lasting Power of Attorney (LPA)** for Health and Welfare, her decisions are legally bound to be in the **patient's best interests**, not necessarily her own preferences. - If there is a concern that the attorney is not acting in the patient's best interests according to the **MCA principles**, their decision can be challenged, and further discussion is required. *The oncologist's clinical judgment about treatment benefits* - The oncologist's assessment of potential improvement in **quality of life** and **survival** is a crucial element in determining the patient's best interests. - However, clinical judgment alone is not sufficient; it must be weighed against the patient's known wishes, values, and the LPA's perspective within the overall **best interests framework**. *The patient's previously expressed wishes about cancer treatment* - A patient's **previously expressed wishes and feelings** are a significant factor that must be taken into account when assessing best interests under the MCA. - However, unless formalized as an **Advance Decision to Refuse Treatment (ADRT)**, these wishes are not legally binding and must be considered alongside the patient's current situation and other relevant factors. *A Court of Protection decision given the disagreement* - Referral to the **Court of Protection** is generally a last resort, pursued only when all attempts to resolve disagreements through discussion, mediation, and a formal **best interests meeting** have failed. - The primary step is to attempt to resolve the disagreement through a comprehensive **best interests assessment** involving all relevant parties before escalating to legal intervention.

Ethics & Law UK Medical PG Question 4: According to the Mental Capacity Act 2005, which of the following statements about the hierarchy of decision-makers for a patient lacking capacity is correct?

• A. Court-appointed deputy takes precedence over a registered Lasting Power of Attorney
• B. Valid advance decision to refuse treatment takes precedence over Lasting Power of Attorney for Health and Welfare (Correct Answer)
• C. Lasting Power of Attorney for Health and Welfare takes precedence over advance decisions
• D. Next of kin have legal authority to make treatment decisions if no LPA exists
• E. Independent Mental Capacity Advocate can make binding treatment decisions

Ethics & Law Explanation: ***Valid advance decision to refuse treatment takes precedence over Lasting Power of Attorney for Health and Welfare*** - Under the **Mental Capacity Act 2005**, a valid and applicable **Advance Decision to Refuse Treatment (ADRT)** represents the patient's own autonomous choice and is legally binding on clinicians. - If an **ADRT** is made and is applicable to the current situation, a **Lasting Power of Attorney (LPA)** for Health and Welfare cannot override it unless the LPA was granted after the ADRT was signed and explicitly allows for such an override. *Court-appointed deputy takes precedence over a registered Lasting Power of Attorney* - A **Court-appointed Deputy** is typically assigned by the **Court of Protection** when no **LPA** is in place, or an existing LPA is deemed problematic or insufficient by the court. - An **LPA** is a direct appointment by the individual themselves when they have capacity, and generally holds authority in its designated areas over a subsequently appointed deputy for the same matters. *Lasting Power of Attorney for Health and Welfare takes precedence over advance decisions* - This statement is incorrect; a valid and applicable **Advance Decision to Refuse Treatment (ADRT)** generally takes precedence over a **Lasting Power of Attorney (LPA)** for Health and Welfare. - An **ADRT** is a direct expression of the individual's will regarding specific treatments, whereas an LPA appoints an attorney to make decisions in their best interests, which must respect any valid ADRT. *Next of kin have legal authority to make treatment decisions if no LPA exists* - In the UK, **Next of Kin** have no legal authority to consent to or refuse treatment for an adult who lacks capacity. - While their views must be considered as part of determining the patient's **best interests**, the final clinical decision remains with the **treating clinician** or a legally appointed representative. *Independent Mental Capacity Advocate can make binding treatment decisions* - An **Independent Mental Capacity Advocate (IMCA)** is appointed to support and represent individuals who lack capacity and have no family or friends to consult for serious decisions. - An **IMCA's role** is to provide an independent report to help the decision-maker determine the patient's **best interests**; they do not have the power to make binding medical decisions themselves.

Ethics & Law UK Medical PG Question 5: A 71-year-old woman with metastatic lung cancer and capacity is receiving end-of-life care at home. Her pain is increasingly difficult to control and the palliative care team recommends a continuous subcutaneous infusion of diamorphine and midazolam. She agrees but says 'I don't want to become unconscious - I want to stay alert to talk to my family'. The doses proposed would likely cause significant sedation. How should this be managed?

• A. Start the infusion as planned - adequate pain control is the priority
• B. Reduce the doses even if pain control is suboptimal to maintain alertness
• C. Explain the likely effects of medication and explore her priorities regarding symptom control versus alertness (Correct Answer)
• D. Defer starting the infusion until she becomes less concerned about sedation
• E. Start lower doses and increase without further discussion once she becomes too drowsy to participate

Ethics & Law Explanation: ***Explain the likely effects of medication and explore her priorities regarding symptom control versus alertness*** - Respecting **patient autonomy** requires a shared decision-making process where the patient is fully informed of the trade-offs between **analgesia** and **sedation**. - The patient possesses **capacity**, meaning her personal values and preferences for **alertness** over complete pain relief must be prioritized and documented in her care plan. *Start the infusion as planned - adequate pain control is the priority* - Prioritizing pain control against the patient's explicit wish to remain alert violates the principle of **informed consent** and self-determination. - Clinicians must not paternalistically decide that **symptom relief** is more important than the patient's desire for **social interaction** at the end of life. *Reduce the doses even if pain control is suboptimal to maintain alertness* - While this respects her wish for alertness, it should not be done unilaterally without discussing the potential for **distressing pain** and exploring other **palliative options**. - The goal is to reach a **consensual plan** where the patient accepts the specific level of pain relief achieved by a lower dose. *Defer starting the infusion until she becomes less concerned about sedation* - Deferring necessary treatment without further discussion risks leaving the patient in **unnecessary pain** and avoids addressing her actual concerns. - It fails to utilize the patient's current **mental capacity** to make a proactive, informed choice about her **end-of-life care**. *Start lower doses and increase without further discussion once she becomes too drowsy to participate* - Increasing doses without discussion as the patient's condition changes ignores the need for **ongoing consent** and transparency in clinical management. - This approach disregards the **patient-centered** model of care and removes her ability to dictate the terms of her remaining **lucid time**.

Ethics & Law Flashcard 1 of 3

Question: Patients with suspected carbon monoxide poisoning should have a _____ in addition to an ECG, ABG, LDH and U&Es done

Answer: direct spectrophotometric measurement of HbCO ("direct spec")

Ethics & Law Flashcard 2 of 3

Question: The management of severe/refractory serotonin syndrome involves _____

Answer: cyproheptadine

Ethics & Law Flashcard 3 of 3

Question: _____ and U&Es are the most important investigations for suspected lithium toxicity

Answer: Serum lithium level