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  • 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 do not 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

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