Consents in daily practice

Consent in daily practice

Very good article from exam point of view especially tricky EMQ's

• It reviews the best practice for taking written consent for elective procedures.
• Reviews the best practice for taking consent in an emergency situation. It also examines the up-to-date advice from several professional bodies and provides clarity on the legal position.
• It explains what constitutes capacity and the role of the Mental Health Act, the Mental Capacity Act and the Court of Protection?
• It takes into different situations like considerations for capacity and labour.
• It provides valuable guidance in treating the unconscious patient.
• It provides some useful examples of case law relevant to obstetrics and gynaecology that have formed the basis of core legal arguments.

• It is necessary to understand the importance of informed choice and consent.
• It is also of paramount importance to be familiar with the most recent professional advice.

http://onlinelibrary.wiley.com/doi/10.1111/tog.12219/epdf

Breaking Bad News: Glimpses from an Indian Subcontinent Perspective.

Breaking Bad News:  Glimpses from an Indian Subcontinent Perspective.

Bad news is defined as “any information, which adversely and seriously affects an individual’s view of their future.

Breaking bad news (BBN) is never an easy task. Handling bad news in an effective and empathetic manner helps to improve doctor patient relationship.

Methods:

Practicing Obstetrics and Gynecology (OBGYN) doctors and allied personnel (based in India & subcontinent) participated in an online questionnaire. 149 completed responses were analyzed.

Results:

Responders were aged between 25 -60 years with most responses in 31-50 age groups. 95% of responses came from India.

61.1% female and 38.9% male professionals responded.

Amongst these, 128 were OBGYN specialists, 18 were allied specialty doctors and 3 were clinical scientists.

68.5 % responded that they had to BBN on <5 occasions while 25.2 % on 5-10 occasions.

34.9% felt that discussing the diagnosis with patient was difficult & uncomfortable.

26.2% felt that it was difficult to involve family & friends in discussions with patients.

10.7% had doubts about their own skills and competency while BBN.

Shockingly 10.1% were worried about their own safety and the effects of vandalism afterwards.

Though, 90.6% participants never had any formal training in BBN, 47% felt that their skills were fair while 40.3% thought it to be good. Only 10.1% classed their skills as very good.

43% responders thought that their handling of the BBN was neither good nor bad and were not sure how they performed. 40.9% felt that they could have performed better. Only 15.4 % thought they did very well.

85.2% participants had never heard about SPIKES plan to BBN.

57% respondents had no formal plans of structured approach while BBN.

62.4% thought it’s better to talk in consultation rooms with other staff being present while 35% favoured the option of a quiet room and a more private place.

Discussion:

BBN is a very sensitive topic and health care personnel should be trained appropriately. Better support and definitive plans beforehand helps them to boost their confidence thereby avoiding vandalism scenes and thwarting assault by relatives.

Stricter laws against violence with medical personnel and speedy implementation of the same should be stressed.

Conclusion:

BBN should be included in the doctor’s training programmes in India and abroad. Large national and international meetings being held in Indian subcontinent should have dedicated workshops to address this issue. This will immensely benefit both patients and doctors equally.

Abnormal Placenta

Abnormally invasive placenta—prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries


'A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. 

The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. 

The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. 

Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7–10.9). 

Approximately 70% of all cases were not diagnosed antepartum. 

Of these, 39% had prior CS and 33% had placenta praevia.'

• How do you define and diagnose abnormally invasive placenta (AIP)?
• How common is AIP in your practice?
• What are the benefits of prospective registration of rare complications of pregnancy (compared to existing retrospective registration systems based on ICD-10 codes)?
• What are the strengths and pitfalls of amalgamating data from multiple countries?
• What are the major risk factors of AIP identified in this study? How much more likely are women with these risk factors to have AIP?
• Is antenatal suspicion of AIP associated with improved maternal and neonatal outcomes?
• How would the results of this study influence your daily practice?

Thurn L, Lindqvist PG, Jakobsson M, Colmorn LB, Klungsoyr K, Bjarnadóttir RI, Tapper AM, Børdahl PE, Gottvall K, Petersen KB, Krebs L, Gissler M, Langhoff-Roos J, Källen K. Abnormally invasive placenta—prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries. BJOG 2015; DOI: 10.1111/1471-0528.13547.

Consent

'All women aged 18 or over are considered to have capacity to give consent unless there is evidence to the contrary. 

For young women and children under the age of 16, consent can be obtained from a parent or those with parental responsibility. Although parents have the legal right to give consent for treatment, where appropriate it is good practice to involve children and young people as much as possible in decisions about their care, even when they are not able to make decisions on their own. 

In some circumstances a young person under the age of 16 may wish to seek medical treatment without her parent’s knowledge. Mature minors may acquire the right to give their consent, provided that they fulfil certain criteria and are deemed to be Gillick or Fraser competent.

Each case must be judged on its own merit and if there is any uncertainty you should seek advice from an experienced colleague or specialist. Although 16- and 17-year-olds and minors under the age of 16 may have the right to consent to treatment, they do not necessarily have the same right to withhold consent. Refusal of treatment may be overridden by parental consent, or the courts, however each case should be considered individually (see section 6).9 It is important to be aware that Scottish law states that those aged 16 and over are able to give consent and also refuse consent provided that they are considered capable of understanding the nature and consequences of the treatment'

https://www.rcog.org.uk/globalassets/documents/guidelines/clinical-governance-advice/cga6.pdf

UKOSS

UKOSS website figures should always be in your last minute revision especially the leading causes of direct and indirect maternal health

Vaccines in Pregnancy

Vaccines in pregnancy
MCQ's or EMQ's based on this

Vaccines contraindicated

BCG,MMR,Varicella,HPV

Vaccines to be given especially in pregnancy

Pertussis
Influenza & polio (inactivated)
Diptheria & TT

Vaccines in special circumstances

Hep A,B
Puneumococcal
Menningococcal
Typhoid
Yellow fever

D & C is associated with subsequent preterm birth

"This meta-analysis shows that D&C is associated with an increased risk of subsequent preterm birth. The increased risk in association with multiple D&Cs indicates a causal relationship. Despite the fact that confounding cannot be excluded, these data warrant caution in the use of D&C for miscarriage and termination of pregnancy, the more so since less invasive options are available."

http://humrep.oxfordjournals.org/content/31/1/34.full?hwoaspck=true