Medico-Legal Issues
Trauma Care
Rebekah Ley, LLB (Hons), MSc
Innovation and excellence in health and care
Addenbrooke’s Hospital I Rosie Hospital
Introduction
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Challenges of trauma care and trauma units.
The Law – but which ones?
Scenarios.
Ethics.
Shields not swords.
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Challenges
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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 don’t keep things secret patients won’t 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.
– Can’t 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?
– What’s 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?
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 37.8˚C; 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 doesn’t want it. He says
that he has been through this before and recovered. His
friends say that “he doesn’t’ know what he’s saying” and
ask the doctors to treat him.
What should you do?
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 doesn’t 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 patient’s 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.
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
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