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    (Original post by CasualSoul)
    Even if the potential harm could be something as severe as paralysis you would not be allowed to breach the confidentiality and tell the coach providing the 17 year had capacity and clearly understood what he had been told/ he could become paralysed if he played?

    Or in this particular case because paralysis is so severe/irreversible then on this occasion the consequences of playing would override the confidentiality and the coach could be informed?

    I am under the impression that confidentiality can only be broken should there be considerable risk to a third party.
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    (Original post by CasualSoul)
    An adult patient has capacity and wants to be resuscitated. However, everyone in the multidisciplinary team comes to a unanimous decision that resuscitation would NOT be in their best interests.
    Obviously they all try and speak to the patient and explain all the details risks etc etc but this patient is having none of it and insists they wanna be resuscitated.

    Here’s my question:

    Because all the members of the team agreed, is it possible for them to make a decision to NOT resuscitate WITHOUT going to court even though this is against the patients wishes? Or because what they have decided it is against the persons wishes will it go to court in order for an independent ruling to be achieved?

    Clearly the resuscitation is not in the patients best interests . Other senior members of the med team have all been consulted and they all agree. Also docs promise 2 harm and not heal etc etc so I’m thinking that they can decide without the case going to court..is that right ?
    Hey

    I saw a real life example of this at work, a patient was going to die eventually but she still had capacity to express her wishes, as long as the patient has capacity and wants to stay alive, the team must do their best to help the patient regardless of best interests.

    Edit: but CPR wasn't involved at all so this is different
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    (Original post by sailorben)
    I am under the impression that confidentiality can only be broken should there be considerable risk to a third party.

    I don't think it necessarily has to involve a third party.
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    (Original post by CasualSoul)
    An adult patient has capacity and wants to be resuscitated. However, everyone in the multidisciplinary team comes to a unanimous decision that resuscitation would NOT be in their best interests.
    Obviously they all try and speak to the patient and explain all the details risks etc etc but this patient is having none of it and insists they wanna be resuscitated.

    Here’s my question:

    Because all the members of the team agreed, is it possible for them to make a decision to NOT resuscitate WITHOUT going to court even though this is against the patients wishes? Or because what they have decided it is against the persons wishes will it go to court in order for an independent ruling to be achieved?

    Clearly the resuscitation is not in the patients best interests . Other senior members of the med team have all been consulted and they all agree. Also docs promise 2 harm and not heal etc etc so I’m thinking that they can decide without the case going to court..is that right ?
    There are 2 important points to consider here.

    Resuscitation is a medical intervention and it is the doctor's job to decide when a particular medical intervention is necessary, this is exactly the same for CPR as it is for giving antibiotics. If it is decided that resuscitation is not in the patient's best interests, and usually after discussion with the patient and family (to ensure they understand) a DNAR order can be issued.

    It is obviously very important to take into account the patient's wishes, but DNARs are usually placed onto patients where CPR would probably not work. There is a common misconception that "CPR = brings them back to life", which isn't true. It may bring them back, but they will still have the severe disease that indicated the DNAR and more than likely will have additional severe injuries and/or brain damage as well.

    (Original post by lovelycup7)
    As the adult has the capacity to make an informed decision I don't think there is any way the medical team can get away with disregarding the patient's wishes - I think the patient's wishes overrule what the medical team think is best...I am quite sure that is always the case although I'm not certain. It's like the whole Jehovah's witness blood transfusion situation - if the patient refuses to have a blood transfusion he/she cannot be given one, regardless of how beneficial/life-saving it would be. I think this goes as far as the law allows - i.e. if a patient requests active euthanasia the doctor would not be able to permit this, as it is illegal, despite it being the patient's wishes. (Correct me if I am wrong please- I am learning and bound to be making a mistake).

    Also - this is a genuine question - in what kind of case would resuscitation not be in the patient's best interests?
    A patient has the absolute right to refuse treatment (e.g. the blood transfusion in your example), but never to demand treatment that is not medically indicated. CPR is a medical treatment, thus cannot be demanded anymore than antibiotics can.

    Resuscitation may not be in the patient's best interests when you have a very old, severely demented patient with end-stage multiple organ failure with a couple of days left to live. CPR isn't pretty like it is in the films, it's a violent, difficult process and the outcome is usually poor. It comes down to letting the patient die in peace and in dignity and without causing unnecessary distress by jumping on their chest.
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    (Original post by Beska)
    There are 2 important points to consider here.

    Resuscitation is a medical intervention and it is the doctor's job to decide when a particular medical intervention is necessary, this is exactly the same for CPR as it is for giving antibiotics. If it is decided that resuscitation is not in the patient's best interests, and usually after discussion with the patient and family (to ensure they understand) a DNAR order can be issued.

    It is obviously very important to take into account the patient's wishes, but DNARs are usually placed onto patients where CPR would probably not work. There is a common misconception that "CPR = brings them back to life", which isn't true. It may bring them back, but they will still have the severe disease that indicated the DNAR and more than likely will have additional severe injuries and/or brain damage as well.



    A patient has the absolute right to refuse treatment (e.g. the blood transfusion in your example), but never to demand treatment that is not medically indicated. CPR is a medical treatment, thus cannot be demanded anymore than antibiotics can.

    Resuscitation may not be in the patient's best interests when you have a very old, severely demented patient with end-stage multiple organ failure with a couple of days left to live. CPR isn't pretty like it is in the films, it's a violent, difficult process and the outcome is usually poor. It comes down to letting the patient die in peace and in dignity and without causing unnecessary distress by jumping on their chest.

    Thank you so much this has really cleared things up, makes a whole lot more sense now
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    (Original post by lovelycup7)
    Thank you so much this has really cleared things up, makes a whole lot more sense now
    No probs. Initiating CPR is a difficult issue.
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    What would you do in a case where an incompetent patient who is pregnant and her life is in danger due to the pregnancy, how would we act in her best interests, especially if it's in e.g. the second trimester?
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    (Original post by fluteflute)
    I've moved this into The Official 2014 Medicine Interview Preparation Thread for you
    thank you
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    (Original post by Secret.)
    What would you do in a case where an incompetent patient who is pregnant and her life is in danger due to the pregnancy, how would we act in her best interests, especially if it's in e.g. the second trimester?
    Try and meet her needs, I'm guessing she wanted to be pregnant so aborting the baby might go against her wishes, plus abortion can cause some complications. Talk to her family and see what she have wanted before she became incompetent. Communication and a good multi-disciplinary team is essential in this case.

    If her life is in danger, I would try and do a ceaserean(awful spelling!) depending on how many weeks the baby is...ideally, after 24 weeks a baby can survive outside with medical intense care.

    The baby is still in the womb and therefore hasn't got any legal rights, probably moral rights as we can know the sex and feel the baby move. We can't act in the foetus best interests, the mother comes first.

    Also, move the mother to ICU if she's not there already
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    I have a question for you guys one that I am dreading is:

    How or what aspect would you like to change about the current NHS?

    This is a pretty open question so feel free to interpret it how you like.

    From my work experience in A&E which was only for two days, i asked the junior doctor the same question. She said that she would like to implement some form of teaching/education of basic medical conditions. As often she sees many patients that don't really need to be in A&E or even visit their GP. They see a lot of minor things but sometimes patients kind of freak out. I thought it was a good idea but could be considered risky in case something appears minor but has a worse underlying cause. Another thing is the amount of patients who come into A&E drunk, doctors can't really help them and they are just kind of made to wait around till they are sober which wastes valuable time. When I asked a friend, I initially stated that they should not be seen but he replied with that's unethical since your denying them treatment/favouritism in a way. So I said ok good point so perhaps there can be a separate department in A&E dealing with these kind of things? I know there is a minor unit in A&E but this is probably more minor than that.

    What do you guys think?
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    (Original post by Beska)
    There are 2 important points to consider here.

    Resuscitation is a medical intervention and it is the doctor's job to decide when a particular medical intervention is necessary, this is exactly the same for CPR as it is for giving antibiotics. If it is decided that resuscitation is not in the patient's best interests, and usually after discussion with the patient and family (to ensure they understand) a DNAR order can be issued.

    It is obviously very important to take into account the patient's wishes, but DNARs are usually placed onto patients where CPR would probably not work. There is a common misconception that "CPR = brings them back to life", which isn't true. It may bring them back, but they will still have the severe disease that indicated the DNAR and more than likely will have additional severe injuries and/or brain damage as well.



    A patient has the absolute right to refuse treatment (e.g. the blood transfusion in your example), but never to demand treatment that is not medically indicated. CPR is a medical treatment, thus cannot be demanded anymore than antibiotics can.

    Resuscitation may not be in the patient's best interests when you have a very old, severely demented patient with end-stage multiple organ failure with a couple of days left to live. CPR isn't pretty like it is in the films, it's a violent, difficult process and the outcome is usually poor. It comes down to letting the patient die in peace and in dignity and without causing unnecessary distress by jumping on their chest.
    Hey im confused about that bit Beska, I get what you are saying but if the patient requests CPR but the team decides its not in their best interest, would they not get in trouble for not intervening when they could have or trying their absolute best to keep the patient alive despite foreseen difficulties if resuss is successful, since the patient requested it, your kind of letting them die. I know that is acceptable as passive euthanasia but the patient requested to kind of not die :/
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    Hey how many mock interviews do all of your schools do?
    Mine arranged one but it didn't even remotely resemble an interview and that was supposed to be the only one I'm going to get I'm really concerned as it feels like everyone is getting lots of practice through mocks and courses (which I can't afford). Sorry if this reads a little paranoid but I'm feeling quite stressed about it. Any advice?
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    (Original post by zaramo)
    Hey how many mock interviews do all of your schools do?
    Mine arranged one but it didn't even remotely resemble an interview and that was supposed to be the only one I'm going to get I'm really concerned as it feels like everyone is getting lots of practice through mocks and courses (which I can't afford). Sorry if this reads a little paranoid but I'm feeling quite stressed about it. Any advice?
    My doesn't do mocks as far as I know :/ and I can't afford a course.
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    (Original post by raveen789)
    Hey im confused about that bit Beska, I get what you are saying but if the patient requests CPR but the team decides its not in their best interest, would they not get in trouble for not intervening when they could have or trying their absolute best to keep the patient alive despite foreseen difficulties if resuss is successful, since the patient requested it, your kind of letting them die. I know that is acceptable as passive euthanasia but the patient requested to kind of not die :/
    Doctors are not obliged to provide any treatment if they do not think it is likely to be successful and/or is not in the patient's best interests. Even in the "best" of circumstances, (a witnessed, monitored arrest with a shockable rhythm and a reversible cause) the survival rate from cardiac arrest is poor. In anything other than the best of circumstances, it's extremely poor, and a full resuscitation attempt is a messy and horrible way to go. CPR is not something you want to inflict on anybody unless you think they have a good chance of surviving and surviving well.

    Everyone has to die of something one day, and sometimes one of the best things you can do as a doctor is let them do that. It's not even passive euthanasia, it's just death.
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    (Original post by Helenia)
    Doctors are not obliged to provide any treatment if they do not think it is likely to be successful and/or is not in the patient's best interests. Even in the "best" of circumstances, (a witnessed, monitored arrest with a shockable rhythm and a reversible cause) the survival rate from cardiac arrest is poor. In anything other than the best of circumstances, it's extremely poor, and a full resuscitation attempt is a messy and horrible way to go. CPR is not something you want to inflict on anybody unless you think they have a good chance of surviving and surviving well.

    Everyone has to die of something one day, and sometimes one of the best things you can do as a doctor is let them do that. It's not even passive euthanasia, it's just death.
    Thank you for this.
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    (Original post by Helenia)
    Doctors are not obliged to provide any treatment if they do not think it is likely to be successful and/or is not in the patient's best interests. Even in the "best" of circumstances, (a witnessed, monitored arrest with a shockable rhythm and a reversible cause) the survival rate from cardiac arrest is poor. In anything other than the best of circumstances, it's extremely poor, and a full resuscitation attempt is a messy and horrible way to go. CPR is not something you want to inflict on anybody unless you think they have a good chance of surviving and surviving well.

    Everyone has to die of something one day, and sometimes one of the best things you can do as a doctor is let them do that. It's not even passive euthanasia, it's just death.
    Oh right thanks as well I just thought since they kind of requested not dying then the Doctor would oblige but if its not in their best interest then I suppose its fine.
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    (Original post by raveen789)
    Oh right thanks as well I just thought since they kind of requested not dying then the Doctor would oblige but if its not in their best interest then I suppose its fine.
    Requesting not to die is all very well, but if there is no treatment to stop the progression of their disease, they will die from it. Even in the unlikeliest of circumstances that CPR actually works, they will have a prolonged ICU stay (which is also deeply unpleasant) and at the end of it still be dying from whatever pathology they had in the first place.

    What you really need to do is have a very difficult conversation with the patient about death, about why CPR will not work and what you can do to ensure that they do not suffer whatever happens. Most people, when the stark realities of the end of life and resuscitation are clearly and sensitively explained, usually end up agreeing that CPR is probably not a great idea. If after all that they're still insistent that they want it and are getting really distressed, you have to think about whether getting rid of the DNAR form might be the most sensible option, and plan with the team for what will actually happen if/when the patient does die.

    Do remember that a DNAR is not a death sentence, or being "left to die," it just means that if the patient has a cardiac arrest, they will not be resuscitated. They can still have full active appropriate treatment up to that point, but if it doesn't work and they die, then they're allowed to do so with some dignity.
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    (Original post by Helenia)
    Requesting not to die is all very well, but if there is no treatment to stop the progression of their disease, they will die from it. Even in the unlikeliest of circumstances that CPR actually works, they will have a prolonged ICU stay (which is also deeply unpleasant) and at the end of it still be dying from whatever pathology they had in the first place.

    What you really need to do is have a very difficult conversation with the patient about death, about why CPR will not work and what you can do to ensure that they do not suffer whatever happens. Most people, when the stark realities of the end of life and resuscitation are clearly and sensitively explained, usually end up agreeing that CPR is probably not a great idea. If after all that they're still insistent that they want it and are getting really distressed, you have to think about whether getting rid of the DNAR form might be the most sensible option, and plan with the team for what will actually happen if/when the patient does die.

    Do remember that a DNAR is not a death sentence, or being "left to die," it just means that if the patient has a cardiac arrest, they will not be resuscitated. They can still have full active appropriate treatment up to that point, but if it doesn't work and they die, then they're allowed to do so with some dignity.
    Right ok, Thanks a lot Helenia!
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    (Original post by zaramo)
    Hey how many mock interviews do all of your schools do?
    Mine arranged one but it didn't even remotely resemble an interview and that was supposed to be the only one I'm going to get I'm really concerned as it feels like everyone is getting lots of practice through mocks and courses (which I can't afford). Sorry if this reads a little paranoid but I'm feeling quite stressed about it. Any advice?
    Mine is apparently arranging one but my first interview is next week so I doubt I'll have any proper mocks before then. Im just practising with friends

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    It might be worth remembering that even if your school doesn't arrange organised mock interviews, there's nothing to stop you setting up your own between yourself and other people either applying for Medicine, or for other degrees that require interviews eg Oxbridge applicants.
    Mine set up one mock interview that involved me and another applicant from my school being asked questions by a GP who was a friend of the Head of Sixth Form. I didn't find it particularly useful as it was a joint interview and the GP aimed all of his questions at the other person because he was applying to Cambridge. I wasn't therefore apparently didn't need to be asked anything..
    So I set up interview style things with friends who were applying to Oxbridge (not for Medicine, but for MFL and law). It was good for general practice, not necessarily for Medicine-specific questions, but it helped nonetheless.
    Your teachers will often be supportive as well, though. I asked one of my Maths teachers who had helped previous Medicine applicants to give me some guidance, and she put together a list of questions they had been asked in their interviews and we did our own mock interview during a lunch break.

    A little bit of asking goes a long way!
 
 
 
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