Escolar Documentos
Profissional Documentos
Cultura Documentos
Contents
1.1 Communication with patients and
confidentiality 2
1.2 Consent and chaperones 4
1.3 Teamwork 6
1.4 Keeping up to date 8
1.5 Clinical governance 10
1.6 Risk management 12
1.7 Confidential Enquiry into Maternal
Death 14
1
1.8 Bereavement 16
1.9 Domestic violence 18
1.10 When things go wrong 20
1.11 Legal issues in obstetrics and
gynaecology 22
1.12 Ethics in obstetrics and gynaecology 24
Covered elsewhere
• Breaking bad news (see Section 15.1)
CHAPTER 1
Be careful facilitate follow-up of both mother and baby
• Do not leave notes open on the reception desk or the trolley
while you go into a room or answer a bleep (see Figure 1.1)
• Ensure your phone conversations cannot be overheard
• Do not discuss patients in public areas (e.g. lifts)
Disclosure
Confidential information may sometimes be needed. In such cases, 3
conflicting interests must be balanced. This is usually done by public
consultation or the courts.
Should you find yourself in a dilemma, seek advice from a senior
consultant and your defence organization. You must usually warn
your patient if you intend to disclose, and give her a chance to do so
herself.
HIV-positive women
The UK Department of Health initiated a policy consultation on the
confidentiality of HIV and sexual health records because:
• Since 2003 nine people were imprisoned for reckless transmis-
sion of HIV
• An underlying principle in the care of people with HIV is the
need for a secure and confidential environment in which sensi-
tive issues can be fully discussed
• GMC guidance to doctors on Serious Communicable Diseases
states: ‘you may disclose information to a known sexual contact
where you have reason to believe that the patient has not
informed that person and cannot be persuaded to do so. In such
circumstances you should tell the patient before you make the
disclosure’
• Also, ‘confidential medical information may be disclosed to other
health workers if failure to disclose would put them at serious
risk of infection’
Fig. 1.1 Who can see or overhear? Most breaches of confidentiality
In HIV pregnancy the situation differs somewhat because: are inadvertent. Always ensure that you do not leave notes around.
• By law the duty of care is to the woman not her partner
• The unborn child has no legal rights
• Women come for care and support and advice on reducing the
transmission to the baby Further reading
• It is crucial that confidentiality be guaranteed www.bhiva.org for guidelines about management of HIV-positive
• Confidentiality helps compliance with medication and fetal sur- pregnant women.
veillance because the woman feels safe www.gmc-uk.org for guidance about confidentiality, disclosures,
• Women are often dependent on their partners serious communicable disorders.
CHAPTER 1
problems. • If you feel the criticism is unfair, check with your educational
• Check who is on call supervisor or a senior colleague
• See the patient • Severe, repeated or persistent criticism may amount to bullying
• Never rely solely on what you were told and harassment. Take advice from the people above, your trade
• Start the investigations and primary measures necessary union or defence organization
• Have all the facts (and notes) at hand • Do not be overwhelmed by the negative. See it as the opportunity
to improve
• Give the consultant a few pointers regarding the patient as they
may already be aware of the case Do not complain about or criticize colleagues or other departments 7
• Be clear about the need for the consultant to come in in public. ‘The place is going downhill’ does not inspire the trust of
patients or relatives who are seeking help. There are more profes-
• Treat night and day the same—if you’d ask in the day for help
sional routes by which to express concerns (see Section 1.6).
with this problem, then ring at night
• Do not leave messages with patient details; say ‘please call/bleep
ASAP’ Further reading
Griffiths M. Communicating with colleagues. BMJ Careers 2005;
Criticism 331:110.
In day-to-day work, problems arise and bad outcomes, mistakes or Srivastava D. Communicating with the on-call consultant. BMJ Careers
errors of judgement occur. From time to time there will be criticism: 2006; 332:189–90.
from within, from patients or colleagues. www.kingsfund.org,uk Safe births: everybody’s business 2008. Most
• Learn to deal with criticism and the emotions that go with bad recent enquiry into teams and systematic approach required to
outcomes (guilt, denial, and blame) maintain safety.
• Be open—if people have made the effort to talk to you, assume www.popan.org.uk Prevention of professional abuse network (or
it is because they care WITNESS), a UK charity concerned with breaches of trust in pro-
• Take time out and think things through fessional relationships. They work with organizations to improve
public protection and support people whose trust has been
• If it is a communication failure with a patient or colleague,
broken. WITNESS runs a helpline, support, and advocacy serv-
apologize and talk to them to clarify the issue
ices, provides professional boundaries training, and undertakes
• If your management has deviated from normal, look up the research and policy work.
guideline or the evidence
CHAPTER 1
may not reach statistical significance. On the other hand, tiny but www.ncbi.nlm.nih.gov National Center for Biotechnology
statistically significant differences from huge trials may not be Information with medical literature databases.
useful in clinical practice
www.jameslindlibrary.org A website about the history of fair tests in
• Absolute and relative risks are different for individual healthcare.
patients: common sense must inform us. In clinical practice the
CHAPTER 1
• Set a deadline
Collect the data
Further reading
• If your audit is retrospective, you will need the medical notes or Gibbons A, Dhariwal D. Audit for doctors: how to do it. BMJ 2003;
information stored on the computer. This is an area where you 327:51–2.
can and should get help from medical records, the audit office, or Greenhalgh T. Is my practice evidence-based? BMJ 1996; 313:957–8.
IT support. Sackett DL et al. Evidence based medicine: what it is and what it isn’t.
• If the audit is prospective, make sure you have disseminated the BMJ 1996; 312:71–2.
proforma and made your colleagues aware it exists (e.g. ask the
clinic clerk to attach it to every set of notes, or intercalate it with C
w Box.1.1 The seven pillars of clinical governance
11
the consent forms if you are auditing emergency CS)
• Clinical effectiveness, in which clinicians use an evidence-
Results based approach, benchmark their practice against others, and
• Analyse the data collected make use of recent evidence and guidelines
• Draw the conclusions—does the practice measure up to the • Clinical audit, which aims to evaluate how current practice
standards? conforms to the guidelines and what the effect of the practice
• Make recommendations is on the outcomes
• Present your audit at a departmental meeting (the audit office • Patient and public involvement: services and care are aimed
can be a great asset in analysing the data, help with statistics and at patients. Their experience and involvement is essential to
graphs for the presentation). Make sure your presentation is well improvement, and patient satisfaction is an important measure
prepared as this is a time to show your ability of outcome
Tips for involvement • Risk management systems monitor adverse events and aim
• Aim for one quality audit a year, rather than a poor one every to prevent them by undertaking risk assessment and learning
6 months from adverse events
• In your first year, try to join a senior, or a team of senior trainees • Staff management, including appropriate organizational
who are running an interesting audit. This way, in return for your culture for the appraisal and development of staff and the
work, you will learn how it is done well and may even get handling of poor performance
published. It is also a great opportunity to show a senior (who • Training, including continuous professional development
may be your future consultant) that you are committed and • Resource management (funds, equipment, buildings):
hardworking and to establish contacts information (and information systems) to support delivery
of healthcare
CHAPTER 1
record-keeping—this will include secure storage of CTGs, legible,
• Clinical Negligence Scheme for Trusts (CNST)—a system of set signed, chronological record-keeping and evidence of improve-
standards to prevent and reduce clinical risk and litigation in all ment of the record-keeping by audit at least every 12 months
acute care
• Standard 7: a clinical risk management system is in place and
• The Confidential Enquiry into Maternal Deaths (CEMD), a operational—this has to start with risk assessment and continue
national ‘audit’ investigating the causes with a view to collective with evidence of progression and achievement of action points
learning from the most serious outcomes
• Standard 8: staffing levels—it is necessary to have clear arrange-
ments for the statutory supervision of midwives, dedicated
Clinical Negligence Scheme for Trusts obstetric anaesthetic services in all consultant units, sufficient 13
Administered by the NHS Litigation Authority, CNST provides an medical leadership and experience to provide a reasonable
indemnity to members and their employees in respect to clinical neg- standard of care
ligence events that occurred after April 1995. It is funded by contribu- The role of the trainee
tions paid by member trusts and provides means for the NHS trusts Make sure you:
to fund the cost of medical negligence litigation. The aim is to minimize
• Report incidents promptly
the overall cost to the NHS and thus maximize the resources available
for patient care by defending unjustified actions robustly and settling • Take part in clinical risk meetings
justified actions efficiently. • Know the guidelines
CNST has set safety standards for each area of care. There are • Participate in clinical audit
standards specific to maternity (see below). Each trust will pay a set • Have a high standard of record-keeping
amount of monetary contributions into the Scheme. However, a • Are up to date with ‘skills and drills’ training
discount is available based on attainment of the standards: • Produce statements promptly
• Compliance at level 1 10% CNST understands that the role of the clinician is crucial when
• Compliance at level 2 20% investigating a negligence claim. The panel of solicitors need to know
• Compliance at level 3 30% what would happen at a trial to work out the chances of success.
An assessment is made by a body of assessors every 2 years for level They need to know:
1 and every 3 years for levels 2 and 3. • The facts (what you did)
The CNST Maternity Standards fall into eight areas: • The reasoning behind the decisions you made
• Standard 1: organization—meaning clearly defined local arrange- • What the notes say
ments and accountability for implementing clinical risk manage- Most claims are settled out of court, but when investigated, the
ment. This will include the existence of a written maternity most important aspects of your care will be scrutinized. The two
services risk management strategy, a nominated lead professional most important aspects are contemporaneous record-keeping and
for clinical risk management, clear lines of communication and compliance with guidelines.
accountability, a lead consultant, and midwifery manager for
labour ward
• Standard 2: learning from experience—i.e. the maternity services Further reading
proactively use internal and external information to improve www.dh.gov.uk An organization with a memory. June 2000.
clinical care. In practical terms, this relates to the reporting www.kingsfund.org,uk Safe births: everybody’s business 2008. Most
of adverse incidents and near misses, review of summarized recent enquiry into teams and systematic approach required to
incident reports, applications of recommendation from national maintain safety.
Confidential Enquiries, and evidence of lessons learned from www.rcog.org.uk Improving patient safety: risk management for
incidents, i.e. implemented changes maternity and gynaecology.
• Standard 3: communication—refers to the expectations that
women are informed by competent professionals of all aspects
CHAPTER 1
• Obesity: more than half of all women who died were obese, and staff learn from any critical events and serious untoward incidents
15% were morbidly obese and document this
• Domestic violence: 14% of the women who died self-declared 8) Clinical staff must undertake regular, written, documented and
that they were subject to violence in the home audited training
• Child protection: 10% lived in families known to child protection 9) Routine use of a national obstetric early warning chart will help in
services the timely recognition, treatment, and referral of women who have,
• Substance abuse: 11% of the women had problems with sub- or are developing, a critical illness (in O&G, emergency, and critical
stance misuse (of whom 60% were registered addicts) care settings) 15
• Substandard care was identified in 64% and 40% of direct and 10) Guidelines for the management of obesity, sepsis, and early
indirect deaths, respectively. A number of healthcare professionals pregnancy pain and bleeding
failed to identify and manage common medical conditions or
potential emergencies outside their immediate area of expertise.
Resuscitation skills were also considered poor in some cases Further reading
• Lack of cross-disciplinary or cross-agency working or com- The full report is available at www.cemach.org or as hard copy from
munication: this included poor or non-existent team working, the RCOG bookshop.
poor interpersonal skills, inappropriate or too short consulta-
tions by phone, the lack of sharing of relevant information
between health professionals, including between GPs and the
maternity team. The lack of sharing of significant information Improved case Improved case ascertainment
ascertainment by ONS by CEMACH
regarding a risk of self-harm and child safety between health and 16
social services was particularly noted.
14
Recommendations for local maternity services
Rate per 100,000 maternities
12
2003–2005
• Maternity services should be approachable and flexible 10
• Asylum seekers and refugees are particularly vulnerable
8
• Women should be educated on the importance of seeking
antenatal care early 6
• Professional interpreters should be used for women who do not 4
speak English (not family members)
• Coordinated multidisciplinary and multi-agency care should be 2
available for women with complex problems, bearing in mind
0
that one midwife should stay closely in contact to 1985-1987 1988-1990 1991-1993 1994-1996 1997-1999 2000-2002 2003-2005
support the woman Overall maternal mortality rates
• Women at risk of developing clinical problems should not be Direct maternal mortality rates
delivered in isolated units Indirect maternal mortality rates
• Dedicated obstetric anaesthesia should be available in all Fig. 1.2 Maternal mortality rates per 100 000 maternities and the
consultant obstetric units dates of improved systems for case ascertainment, United Kingdom
1985–2005. ONS, Office for National Statistics. (Reproduced from
Gwyneth Lewis, Summary and overall findings, p. 5, 2007, with the
Top 10 recommendations 2003–2005 permission of the Confidential Enquiry into Maternal and Child
Many lessons from previous reports were repeated (see above), but Health.)
specific auditable recommendations were made.
1) Pre-conception counselling, both opportunistic and planned, should be
provided for women with pre-existing serious medical or mental health
conditions which may be aggravated by pregnancy. This includes obesity
and especially prior to fertility treatment
Termination of pregnancy
(see Section 5.9)
Termination requires a special mention as a bereavement. This is a
complex issue. The legal right for women to choose not to continue
with pregnancy was hard won. There is a wide range of firmly held
beliefs amongst women and professionals alike whether abortion is
morally right or wrong. Doctors choosing gynaecology and obstet-
CHAPTER 1
rics have to think about it continually. Women do not make deci-
sions to terminate a pregnancy lightly and are entitled to grieve.
There needs to be an understanding of the difficult circumstances in
which women find themselves. The decision includes several dimen-
sions: reason for being pregnant, making the decision, the pressure
of time, the procedure, and the aftermath with (usually) lack of
follow-up care. Doctors and nurses may conscientiously object to
being directly involved in the termination. They have a right to be
supported by their colleagues in this, but still have a duty of care to 17
women (see Section 1.12).
CHAPTER 1
• Educating young people at school
• She will be in more danger, as the greatest risk of homicide is at,
• Domestic Violence, Crime and Victims Act 2004
or after, the point of separation
• Police guidelines on investigating DV. Arrest and prosecution no
• Of women who leave their partners, 76% report post-separation
longer rely on a victim’s statement
violence
• Training for magistrates and policies on DV within the CPS
• Perpetrator programmes within the Probation Service and, since
Good practice to support women 2004, a phone line for perpetrators who seek help
• Waiting rooms with messages or posters about DV encourage • Specialist DV courts since 2004—currently seven running 19
women to feel safe to tell their stories • National phone line for the lesbian, gay, bisexual, and
• Detailed information about local DV services, Women’s Aid or transgender communities
Refuge can be kept in areas entered only by women (e.g. toilets)
Useful contacts
• DV specialists can help with refuge accommodation, childcare,
advice about solicitors, etc. • English National DV Helpline 0808 2000 247
• Talk to the woman alone • Northern Ireland Women’s Aid 24-hr DV Helpline 028 9033 1818
• Never ask about relationships or abuse in front of the partner, • Scottish Domestic Abuse Helpline 0800 027 1234
friends, family or even small children • Wales Domestic Abuse Helpline 0808 80 10 800
• Use an interpreter (e.g. phone) for non–English-speakers • Male Advice and Enquiry Line 0845 064 6800
• Refugees are especially vulnerable as they may have no secure • The Dyn Wales/Dyn Cymru Helpline 0808 801 0321
residency, money or entitlement to public funds even to enter • The Samaritans 08457 909090
safe refuges • Parentline 0808 800 2222
• Ask direct questions: ‘are there any stresses at home?’, ‘is anyone
frightening you?’, ‘were you hit or hurt?’, ‘who by?’ This will show
the woman that you are able to handle disclosure
• Be gentle, sympathetic, listen, and do not judge
• Do not feel that you need to give good advice or solve her
problem—it is complex. You can facilitate by putting her in
contact with the support agencies
• If a woman discloses DV, assess her safety. Is she safe to go
home? Has the partner threatened her or worse?
• Ask particularly about the use of weapons, sexual assault, and
threats to kill as these are associated with severe violence and
death Fig. 1.3 Injuries from an assault by the partner that led to stillbirth.
• Offer a phone in a private room where she will not be disturbed
or heard. Let her ring the support agency and allow her to make
plans. Pop back to offer support, but do not influence her decision Further reading
• Keep a clear concise account
Bewley S, Friend J, Mezey G (eds.) Violence Against Women. RCOG
• If there is fighting on the ward, call security. Diffuse the situation
Press, 1997.
if you can but stay safe
• Do not intervene. Do not tackle the partner, even if the woman www.dh.gov.uk DH 4126161. Responding to domestic violence.
A handbook for health professionals. December 2005
asks you, as he may become aggressive. Instead, refer to the
agencies mentioned below www.homeoffice.gov.uk (guidance for practitioners).
• The process of change has to come from the woman www.victimsupport.org.uk
• We have a duty of care to the woman, to act in her interest, and www.refuge.org.uk and www.womensaid.org.uk can be viewed by
advise her but we cannot act for her women in confidence and are not traceable on computers.
• Refer child protection concerns to relevant agencies www.cemach.org Why mothers die 2000–2002 and Saving mothers
• Intervention is only part of the solution lives 2003–2005.
CHAPTER 1
or patients’ organizations • Remember that you may be physically threatened, position your-
The majority of complaints start informally. Patients express their self nearer the door so that you can leave quickly if need be
dissatisfaction with staff at the time of their visit or admission. This is • Use simple techniques, such as repetition (‘the broken record’)
by far the best time to address them. to express yourself calmly and persistently
A complaint is not a medicolegal claim (yet). It is important that it is • You can take some wind out of the angry complainant’s sails by
handled well. Do not underestimate your role as a junior doctor in acknowledging the truth in what they are saying ‘I can see that’,
handling complaints. Remember we all become involved at some ‘that would be disappointing/distressing’
point in our careers. Patients and relatives are usually understanding • Ask ‘Is there anything that you would like me to do?’ 21
and forgiving as long as they feel the truth is not being concealed.
• Find out what happened
• Offer an explanation promptly
Further reading
• Deal with the situation sympathetically Wu AW. Medical error: the second victim. The doctor who makes
the mistake needs help too. BMJ 2000; 320:726–7.
• Offer a carefully phrased apology. This is not an admission of liability
• Do not say ‘I’m sorry you feel like that’; say ‘I’m sorry for the wait, Wu AW. Doctors are obliged to be honest with their patients. BMJ
2001; 322:1238–9.
for what happened...’ or ‘It was not our intention to upset you’
Denial
Guilt
Blame
We did every-
thing we could….
Grief
Why didn’t
you stop it?
Fig. 1.4 The main emotions for both patient and doctor when things go wrong.
CHAPTER 1
Authority, which has powers to license and control any unit or http://www.hfea.gov Code of Practice
person carrying out: www.veradrake.com Award winning film directed by Mike Leigh,
• The creation and keeping of an embryo 2004.
• The storage of gametes
• The placing of sperm or eggs in a woman
• Research on embryos
23