Medico-Legal Issues

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Medico-Legal Issues Trauma Care Rebekah Ley,
LLB (Hons), MSc
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Introduction

• Challenges of trauma care and trauma units.
• The Law but which ones?
• Scenarios.
• Ethics.
• Shields not swords.

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Challenges

• What makes trauma care (the emergency
  department) different?
• What do you know about your patient?
• How many patients need to be seen?
• How quickly must you make a decision?
• Quality indicators.
• Legal and ethical interface.

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The Law but which ones?

• Privacy and confidentiality.
• Viewed as a basic human right.
• If you dont keep things secret patients wont
  share important information to enable diagnosis
  and treatment.
• However sometimes disclosure is compulsory and
  permissible
• Data Protection Act.
• Public Health.
• Professional codes of conduct.

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The Law but which ones?

• Capacity
• Mental Capacity Act.
• Cant simply explain the risks and then ask a
  patient to agree.
• Quick screen, ask the patient
• What is wrong with you?
• Do you know what your options are?
• Whats likely to happen if you accept the
  treatment or refuse it?
• What is your choice?
• Why have you made this choice?

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The Law but which ones?

• Advance Directives
• Basis is the concept of autonomy.
• Mental Capacity Act.
• Prior the Mental Capacity Act.
• The directive may
• Be a statement a competent individual has made
  about desired future care.
• Be more formal and rarely appoint a person to
  make decisions for them.
• Consider intention not just the specifics
  consult.

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The Law but which ones?

• Criminal behaviour
• Investigation and prevention of crime.
• Road traffic offences.
• Judicial or other statutory proceedings.
• Safeguarding.

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Scenarios Privacy and Confidentiality

• 15 year old girl admitted following RTA her
  boyfriend was driving the car. She admits to
  being pregnant. She tells you that she does not
  want her parents to know. What should you do?

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Scenarios Privacy and Confidentiality

• Consider
• Normally only share with express consent.
• Competence.
• GMC Guidance.
• Safeguarding issues?

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Scenarios - Capacity

• 27 year old male brought to the Trauma Centre by
  friends after consuming an unspecified amount of
  cocaine. He is unkempt and shivering. His
  observations are pulse 172 bpm BP 196/30 mm Hg
  RR 36 breaths/min temp 37.8C Sp02 100 on room
  air. He is connected to a cardiac monitor, given
  oxygen and an intravenous catheter inserted.

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Scenarios - Capacity

• The doctor asks for the patient to be given 10mg
  of diazepam. The patient says he doesnt want
  it. He says that he has been through this before
  and recovered. His friends say that he doesnt
  know what hes saying and ask the doctors to
  treat him.
• What should you do?

to treat him. What should you do?
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Scenarios - Capacity

• The consequences of refusing emergency care may
  be serious and permanent.
• Sudden cardiac arrest?
• Intoxicants, hypoxia, brain injury, mental
  illness and dementia are common problems that can
  impair decision making but just because they are
  present doesnt mean the patient lacks capacity.
• Be sure to assess carefully you can use the quick
  screen.
• Can you defer the decision while the patient
  improves?
• Document the decision

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Scenarios Advance Directives

• A 75 year old male has been airlifted to
  hospital after falling 10ft from a roof. He was
  initially unconscious but when paramedics arrived
  he was awake but confused. His GCS was 14. He
  was immobilised with a C-collar and backboard.
  During transfer to the trauma centre his GCS
  dropped from 14 to 10. On assessment significant
  head injury was suspected and arrangements being
  made to transfer the patient to CT when the
  patients wife and son arrive.

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Scenarios Advance Directives

• The patient suddenly deteriorates dropping his
  GCS to 8. Clinicians prepare to intubate but the
  wife becomes very upset saying that her husband
  has a living will that says if he is critically
  ill he does not want any interventions including
  intubation.

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Scenarios Advance Directives

• Advance Directives/living wills can have limited
  application.
• Context.
• Would the patient have wanted the directive to
  apply to this particular circumstance e.g., did
  he write it contemplating something irreversible
  or this situation?
• What will you do?

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Ethics

• Understanding and acknowledging your own views.
• Dissecting common problems and common themes.
• Remember
• Ethics and the law are not the same following
  the law does not necessarily result in ethical
  behaviour and ethical behaviour might not be
  covered by the law.
• Difficult to disentangle these concepts in trauma
  care.
• While legal and ethical conclusions may be
  similar, ethical and legal analysis are often
  very different.

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Shields not swords

• Having worked in the NHS for twenty years I have
  seen most things.
• The best advice I can give anybody here today is
  simple (you should be doing it anyway) but just
  in case
• I call it 3Cs -
• Casenotes
• Communication
• Competence