Turn on thread page Beta
    Offline

    13
    (Original post by spk)
    The point is in the UK it is not the opinion of the doctor or the family that counts but that of the patient.

    If, however, a patient is not competent to make decisions about their care (i.e. if they cannot understand, retain and weigh the information), it is the duty of the doctor to act in the patient's best interests, not those of the family, although of course, friends and relations do have an input, especially in ascertaining what the wishes and views of the patient were thought to be, if the patient was previously competent.

    This is not arrogance but merely respecting patient autonomy.
    Whilst remembering that this website's membership comprises people from all the the world, emboldening in the UK gives the impression of a poster who is determined to be arrogant. ....but anyway:

    Now you see, this is where you are confusing me. :confused:

    If a patient is not competent to make decisions about their own care, how is it respecting patient autonomy for a doctor to make decisions for them, in some cases even going against the wishes of those who love them? That would seem to suggest that the doctor is the one seeking autonomy.
    Offline

    0
    ReputationRep:
    (Original post by yawn)
    If a patient is not competent to make decisions about their own care, how is it respecting patient autonomy for a doctor to make decisions for them, in some cases evenen going against the wishes of those who love them?
    Legally, families have no right to make decisions, i.e. to consent to treatment or withdrawal of treatment, on behalf of their relatives. In fact, no one can give proxy consent on another's behalf - this includes courts and doctors.

    If a patient is temporarily incompetent to make a decision themselves (e.g. if they are unconscious after a traffic accident), or if they have become incompetent, after having previously been a competent individual (e.g. Alzheimer disease), the doctors must respect the wishes and beliefs of the patient when they were competent, which can be determined from advance directives (living wills) or in their absence from their known views as expressed to relatives, friends, carers etc.

    If a patient is incompetent and there is no time to determine their views (i.e. in a life or death situation, e.g. heart attack), a doctor has a duty to act according to the principle of necessity and do enough to save the patient's life but to do no more than is necessary and to wait until the patient is conscious and competent before continuing with further medical interventions, e.g. corrective surgery.

    Failing to treat would be a breach of care, leading to prosecution for negligence. Treating without consent is battery. That is a dilemma. But a non-competent person cannot consent to treatment and since no one else has the right to give consent on their behalf, it is the doctor's legal duty to act in the patient's best interest.

    The default position is competence. Patients must be regarded as competent until proved otherwise, e.g. by psychiatric evaluation.

    The doctor does not just go ahead and do whatever the hell they want - they must make an informed, balanced decision, taking into consideration such factors as:

    length of life
    absence of pain
    mental abilities/level of awareness
    physical abilities
    appearance
    patient's former character and wishes

    And to reiterate, under current law, the decision about the patient's best interests is in te hands of the doctor, not the family but friends, relatives and others are relevant as providers of information about the kind of care available and the patient's views.

    This is only right, after all, as doctors are supposed to act with professional detachment, whereas families are likely to make decisions based on the stress and emotion of the moment, not in the immediate or longterm interests of the patient. There may be family conflicts or even a desire to hasten the death of the patient to obtain an inheritance, etc., so families are not reliable in this circumstance.

    The law is set to change in a couple of years, however, making the status of advance directives much clearer and providing patients with the opportunity to nominate a trusted proxy to give consent (this could be a doctor, friend or relative).

    At least that is the situation in the UK.

    Still confused? Think how doctors must feel.
    Offline

    13
    (Original post by spk)
    Legally, families have no right to make decisions, i.e. to consent to treatment or withdrawal of treatment, on behalf of their relatives. In fact, no one can give proxy consent on another's behalf - this includes courts and doctors.

    If a patient is temporarily incompetent to make a decision themselves (e.g. if they are unconscious after a traffic accident), or if they have become incompetent, after having previously been a competent individual (e.g. Alzheimer disease), the doctors must respect the wishes and beliefs of the patient when they were competent, which can be determined from advance directives (living wills) or in their absence from their known views as expressed to relatives, friends, carers etc.

    If a patient is incompetent and there is no time to determine their views (i.e. in a life or death situation, e.g. heart attack), a doctor has a duty to act according to the principle of necessity and do enough to save the patient's life but to do no more than is necessary and to wait until the patient is conscious and competent before continuing with further medical interventions, e.g. corrective surgery.

    Failing to treat would be a breach of care, leading to prosecution for negligence. Treating without consent is battery. That is a dilemma. But a non-competent person cannot consent to treatment and since no one else has the right to give consent on their behalf, it is the doctor's legal duty to act in the patient's best interest.

    The default position is competence. Patients must be regarded as competent until proved otherwise, e.g. by psychiatric evaluation.

    The doctor does not just go ahead and do whatever the hell they want - they must make an informed, balanced decision, taking into consideration such factors as:

    length of life
    absence of pain
    mental abilities/level of awareness
    physical abilities
    appearance
    patient's former character and wishes

    And to reiterate, under current law, the decision about the patient's best interests is in te hands of the doctor, not the family but friends, relatives and others are relevant as providers of information about the kind of care available and the patient's views.

    This is only right, after all, as doctors are supposed to act with professional detachment, whereas families are likely to make decisions based on the stress and emotion of the moment, not in the immediate or longterm interests of the patient. There may be family conflicts or even a desire to hasten the death of the patient to obtain an inheritance, etc., so families are not reliable in this circumstance.

    The law is set to change in a couple of years, however, making the status of advance directives much clearer and providing patients with the opportunity to nominate a trusted proxy to give consent (this could be a doctor, friend or relative).

    At least that is the situation in the UK.

    Still confused? Think how doctors must feel.
    Thanks for the clarification.
    Offline

    0
    ReputationRep:
    (Original post by yawn)
    Thanks for the clarification.
    No problem - it was largely cribbed from my lecture notes from this morning, rather coincidentally. So, in a bizarre way I can trick myself into believing I am studying!
    Offline

    13
    (Original post by spk)
    No problem - it was largely cribbed from my lecture notes from this morning, rather coincidentally. So, in a bizarre way I can trick myself into believing I am studying!
    Ha ha.

    There is one thing about the clarification that I would question. You say that the doctor has a duty, in an emergency to do everything to help the patient survive (in as many words anyway)

    In some hospital trusts they have a policy of not ventilating patients in ICU who have COPD. Has anything been said to you about this?
    Offline

    20
    ReputationRep:
    (Original post by yawn)
    Ha ha.

    There is one thing about the clarification that I would question. You say that the doctor has a duty, in an emergency to do everything to help the patient survive (in as many words anyway)

    In some hospital trusts they have a policy of not ventilating patients in ICU who have COPD. Has anything been said to you about this?
    COPD is a difficult situation when it comes to ventillation, I can't really tell you about the law behind this policy however there are complications with the ventilation of COPD patients if I remember correctly. I believe it is something to do with giving them too much oxygen can cause respiritory arrest. This might have something to do with the policy. I can go and check my notes if you are really interested.
    Offline

    13
    (Original post by randdom)
    COPD is a difficult situation when it comes to ventillation, I can't really tell you about the law behind this policy however there are complications with the ventilation of COPD patients if I remember correctly. I believe it is something to do with giving them too much oxygen can cause respiritory arrest. This might have something to do with the policy. I can go and check my notes if you are really interested.
    Aww - thanks. That's kind of you to offer. When you have some free time I would like to know what the position is, perhaps you could just post it on this thread?

    Ta very much.
    Offline

    20
    ReputationRep:
    (Original post by yawn)
    Aww - thanks. That's kind of you to offer. When you have some free time I would like to know what the position is, perhaps you could just post it on this thread?

    Ta very much.
    Ok well as I said I have no idea why people in icu would not ventillate people with COPD at all. However you have to be more carefull when ventillating people with COPD as they are used to funtioning at a lower concentration of oxygen, if they are given too much oxygen (eg 80%) then you run the risk of switching off their respiritory drive (due to over correction of their pO2) which causes them to retain carbon dioxide causing their body to become more acidic which can lead eventually to death. However this can be solved by starting with a low concentration of oxygen which Is why I am confused as to why they would just not ventillate copd patients.

    Info pasted directly from lecture slide (sorry can't link to it, it needs a password)

    Chronically hypoxaemic patients with COPD who have an acute exacerbation

    They often rely on their hypoxaemic drive
    if you over-correct their pO2 you may switch off their respiratory drive leading to CO2 retention, narcosis & acidosis (& death)
    you can kill the patient with oxygen
    Hypoxaemia may still be a risk to them
    Offline

    13
    (Original post by randdom)
    Ok well as I said I have no idea why people in icu would not ventillate people with COPD at all. However you have to be more carefull when ventillating people with COPD as they are used to funtioning at a lower concentration of oxygen, if they are given too much oxygen (eg 80%) then you run the risk of switching off their respiritory drive (due to over correction of their pO2) which causes them to retain carbon dioxide causing their body to become more acidic which can lead eventually to death. However this can be solved by starting with a low concentration of oxygen which Is why I am confused as to why they would just not ventillate copd patients.

    Info pasted directly from lecture slide (sorry can't link to it, it needs a password)

    Chronically hypoxaemic patients with COPD who have an acute exacerbation

    They often rely on their hypoxaemic drive
    if you over-correct their pO2 you may switch off their respiratory drive leading to CO2 retention, narcosis & acidosis (& death)
    you can kill the patient with oxygen
    Hypoxaemia may still be a risk to them
    Yeah - I thought that might have something to do with it. I have just had a look at the website for the Intensive Care Society and they have a case study research on the subject. Apparently, the outcome of mechanical ventilation for exacerbations of COPD patients is much better if weaning off the venilator is done with NIV.
    Offline

    12
    ReputationRep:
    *Nods head knowingly and strokes beard*
    Offline

    20
    ReputationRep:
    (Original post by Calvin)
    *Nods head knowingly and strokes beard*
    huh?
    Offline

    11
    ReputationRep:
    (Original post by randdom)
    Ok well as I said I have no idea why people in icu would not ventillate people with COPD at all. However you have to be more carefull when ventillating people with COPD as they are used to funtioning at a lower concentration of oxygen, if they are given too much oxygen (eg 80%) then you run the risk of switching off their respiritory drive (due to over correction of their pO2) which causes them to retain carbon dioxide causing their body to become more acidic which can lead eventually to death. However this can be solved by starting with a low concentration of oxygen which Is why I am confused as to why they would just not ventillate copd patients.

    Info pasted directly from lecture slide (sorry can't link to it, it needs a password)

    Chronically hypoxaemic patients with COPD who have an acute exacerbation

    They often rely on their hypoxaemic drive
    if you over-correct their pO2 you may switch off their respiratory drive leading to CO2 retention, narcosis & acidosis (& death)
    you can kill the patient with oxygen
    Hypoxaemia may still be a risk to them
    Actually thats not quite right. Although hypercapnia and acidosis is a concern in AECOPD patients (Acute exacerbation of COPD), much more of a concern is them getting any oxygen at all. It is much worse to be hypoxic. Thus it is better to give them oxygen and risk acidosis than to hold it back - oxygen is the immediate concern.
    The key reason why NIV is used is due to numerous studies showing its increased efficacy above other treatments. it is non invasive - involves an airtight mask attached to the face that essentially forces air in when you breathe in - getting much better oxygenation than by passive oxygen therapy.
    In more severely acidotic patients (between 7.2 and 7.35 usually) NIV is the ideal treatment, although in sicker patients it may be given in intensive care/HDU rather than the ward. its advantage over intubating is principally the decreased pneumonia risk, as well as other complications with intubating. NIV patients spend less time in hospital on average as a result of the reduction in pneumonia rates.

    However the idea that COPD patients would not be intubated in some ICUs is erroneous. There are simply other more effective therapies for them which are not very useful for others. Although COPD is often compared with asthma, NIV is often found to be pretty poor for asthma rather than COPD.
    thus the threshold for intubating in COPD is much higher than in other respiratory diseases.
    Of course every trust is different. Some have specialist units - called HDUs where NIV is routinely done. Other hospitals rarely do NIV and so rely more on intubating in ICU.

    I might be wrong though. thats what they tought us in GCSE biology..
    Offline

    0
    ReputationRep:
    Wow. glad I did double award science then...
    Offline

    0
    ReputationRep:
    wow, thats pretty clever stuff!
    Offline

    20
    ReputationRep:
    (Original post by Saffie)
    Actually thats not quite right. Although hypercapnia and acidosis is a concern in AECOPD patients (Acute exacerbation of COPD), much more of a concern is them getting any oxygen at all. It is much worse to be hypoxic. Thus it is better to give them oxygen and risk acidosis than to hold it back - oxygen is the immediate concern.
    The key reason why NIV is used is due to numerous studies showing its increased efficacy above other treatments. it is non invasive - involves an airtight mask attached to the face that essentially forces air in when you breathe in - getting much better oxygenation than by passive oxygen therapy.
    In more severely acidotic patients (between 7.2 and 7.35 usually) NIV is the ideal treatment, although in sicker patients it may be given in intensive care/HDU rather than the ward. its advantage over intubating is principally the decreased pneumonia risk, as well as other complications with intubating. NIV patients spend less time in hospital on average as a result of the reduction in pneumonia rates.

    However the idea that COPD patients would not be intubated in some ICUs is erroneous. There are simply other more effective therapies for them which are not very useful for others. Although COPD is often compared with asthma, NIV is often found to be pretty poor for asthma rather than COPD.
    thus the threshold for intubating in COPD is much higher than in other respiratory diseases.
    Of course every trust is different. Some have specialist units - called HDUs where NIV is routinely done. Other hospitals rarely do NIV and so rely more on intubating in ICU.

    I might be wrong though. thats what they tought us in GCSE biology..
    We have always been told that if in doubt give oxygen rather than let them become oxygen deprived for too long. However I was suggesting a possible reason for some NHS trusts not incubating (Which I don't think is right). I can only tell you what my Lecturers have told me in a lecture on oxygen therapy (hence the paste from that slide).
    Offline

    1
    ReputationRep:
    Can I be dense and ask what COPD actually is? I'm not a medic (well obvlously, or I'd know, presumably!) but it's interesting to follow the discussions - more interesting if I know what you're talking about though!
    Offline

    0
    ReputationRep:
    Yes doctors have become arrogant, they think they know too much, I hate my doctor she's forever making me get a blood test, it's like getting all my blood sucked out of me.
    Offline

    13
    (Original post by tritogeneia1)
    Can I be dense and ask what COPD actually is?
    Chronic Obstructive Pulmonary Disease - usually brought on by smoking.

    Here's a link to the British Lung Foundation website; we can all educate ourselves now on COPD and speak with some authority.

    http://www.lunguk.org/copd.asp
    Offline

    20
    ReputationRep:
    (Original post by Poison Ivy)
    Yes doctors have become arrogant, they think they know too much, I hate my doctor she's forever making me get a blood test, it's like getting all my blood sucked out of me.
    I am sure that you are given a reason for having you blood tested and surely you would rather go through a little discomfort in the short term than having a condition that could have been detected but those blood tests.
    Offline

    0
    ReputationRep:
    (Original post by yawn)
    Chronic Obstructive Pulmonary Disease - usually brought on by smoking.

    Here's a link to the British Lung Foundation website; we can all educate ourselves now on COPD and speak with some authority.

    http://www.lunguk.org/copd.asp
    or try to speak with authority anyway
 
 
 
Poll
Black Friday: Yay or Nay?
Useful resources

The Student Room, Get Revising and Marked by Teachers are trading names of The Student Room Group Ltd.

Register Number: 04666380 (England and Wales), VAT No. 806 8067 22 Registered Office: International House, Queens Road, Brighton, BN1 3XE

Write a reply...
Reply
Hide
Reputation gems: You get these gems as you gain rep from other members for making good contributions and giving helpful advice.