Please select 1 option

You are asked to see a young man with a severe laceration to his arm.

Before you suture the wound, the patient tells you that he is HIV positive but asks you not to write it in his notes.

He tells you later in the conversation that he is a theatre nurse in a neighbouring hospital. He says that he has not told his employer about his HIV status as it does not impact on his work, and tells you that if you tell anybody he will "get you" for discrimination.

Which of the following is the most appropriate action that should be taken in this case?

(Please select 1 option)

Doctors should never inform a third party that a patient is HIV positive without the express consent of the patient.

You should arrange for the patient to have an HIV test and confirm the diagnosis before considering breaching his confidentiality.

You should discuss with your consultant and, if you feel the patient is practising in a way that places patients at risk, inform the occupational health department at his employing hospital, having informed the patient that you intend to do so. Correct

You should tell the hospital infectious diseases consultant in order that the patient can be offered ongoing treatment for HIV

You should tell the patient that in your opinion he should inform his employer, but take no action yourself.

You should discuss this with your consultant.

You have a duty as a doctor to protect all patients, not only your own, and this duty must be weighed against your duty of confidentiality to this patient.

The GMC expect doctors to breach confidentiality in certain circumstances where failing to do so may expose the patient or others to risk of death or serious harm, for example where a healthcare worker is practising in a way that places patients at risk.

As a doctor you may be called upon to justify your decision to disclose (or indeed to not disclose), and it would certainly be helpful to take senior advice.

If you decide to disclose information without consent, you should disclose the minimum necessary information to the minimum number of people for purpose.

In this case you may consider disclosing to the occupational health physician in the hospital where the patient works, although you may also consider disclosing the information to the nurses' regulatory body, the Nursing and Midwifery Council

A 22-year-old female is admitted following severe injuries sustained in a road traffic accident. She is communicative but in shock with low blood pressure and tachycardia. You realise that without a transfusion she will die but she informs you that she has recently become a Jehovah's Witness and that she adamantly refuses transfusion despite knowledge that she could die. Her distraught parents tell you that she has only recently joined the Jehovah's Witnesses and implore you to transfuse her, as they insist that she does not know her own mind. Together with other

intervention which she permits, what is the most appropriate action regarding possible transfusion?


Declare her incompetent and transfuse.

Do not transfuse even if it means that she will die. This is the correct answer

Get immediate psychiatric intervention to section her and then transfuse.

Transfuse immediately, irrespective of the patient's wishes. Incorrect answer selected

Wait until she becomes unconscious and then get consent from her parents to transfuse.

The patient appears competent and has elected to refuse the transfusion. Despite the parents protestation, you must respect the patient's wishes if, as seems likely here, she is making a reasoned judgement. If the patient refuses the transfusion then even if she slips into unconsciousness you are not permitted to treat with transfusion, even if it is in her best interests

An 18-year-old man develops thirst, weight loss and polyuria. Investigations confirm that he has type 1 diabetes and is treated with basal bolus insulin. He is keen to know what limitations this diagnosis imposes on career opportunities. Which of the following professions would he not be able to pursue?


Ambulance control centre worker

Civil engineer

Milkman

Physical Education instructor

Policeman Correct

The armed forces, working offshore or aboard ships, air pilot, HGV/PSV licence, Police, Fire or driving in the post office are career paths closed to subjects with insulin dependent diabetes .

Some local authorities do permit licences to taxi drivers with insulin treated diabetes whilst others do not

You intend to undertake a study of patients who have undergone excision of minor lumps and bumps over the last 5 years. Specifically you wish to compare post-operative infection rates and also whether there are any differences between the clinical diagnosis and the histological diagnosis between the differing grades of practitioner performing the procedure.

Which of the following statements are correct concerning this study?


Approval for the study must be obtained from the local ethics committee. This is the

correct answer

If a study had already published with exactly the same concept then this constitutes plagiarism.

If such a study has already been published then the investigators must obtain consent from the original authors to replicate their work.

This is an audit and does not require ethical committee approval. Incorrect answer

selected

The study is flawed in its design and should not be performed.

This is not an audit. There is no information provided to indicate that there are either any local or national guidelines relating to such a study. Furthermore, there is no information provided to indicate that there is a specific clinical problem to which an audit should be addressed.

Consequently, this is a research study and is a retrospective study. As such, it requires local ethical committee approval. The study itself seems very reasonable and even if it were published elsewhere it would still be reasonable to perform in the investigators' practice as the outcomes may be completely different. Using the same methods as another study is perfecly justifiable, if only to prove the veracity of the original publication. No consent is required from the original authors if a similar study has already been published.

A 63-year-old smoker has been investigated for a cough and chest pain and a diagnosis of bronchial carcinoma is made on a plain chest x ray examination.

Before a tissue diagnosis can be made, he dies in hospital of a large and unexpected haemoptysis and a post mortem examination is carried out with the consent of the relatives. At this examination, the correct diagnosis is shown to be tuberculosis and there is no carcinoma.

In this circumstance, it is mandatory to make a report to a particular authority.

Which authority?


Consultant in Communicable Diseases Control Correct

Coroner

General Medical Council

Health and Safety Executive

Strategic Health Authority

There are a number of notifiable infectious diseases that it is mandatory to report to the

Consultant in Communicable Diseases Control. They include:

 tuberculosis

 malaria

 meningitis

 meningococcal sepsis

A 52-year-old female asks you for copies of her medical records. Within the records are several letters from hospital specialists, one of which refers to the patient in very unflattering terms. There is also a note in the records of a call that was made to the surgery by a neighbour of the patient who reported hearing noises through the wall and expressed concern that the patient may be suffering domestic violence.


Under the Data Protection Act 1998 you are allowed to withhold the note of the telephone call from the neighbour. This is the correct answer

Under the Data Protection Act 1998 you are obliged to disclose the record in its entirety

You may withhold access to any references to third parties, including hospital specialists.

You must seek the consent of the hospital specialists before disclosing their letters

You must withhold access to any references to third parties, including hospital

specialists Incorrect answer selected

Under data protection etc. The legislative framework for the disclosure of medical records is the

Data Protection Act 1998. Under the Act, you may withhold access to any part of the record if you consider that disclosure would cause serious mental or physical harm to the patient or another person. You may also withhold access to part of the record that in effect discloses information about an identifiable third party, unless you have the consent of the third party to make the disclosure or it is reasonable in all the circumstances to make the disclosure without seeking consent. Information in a health record made by a healthcare professional involved in the care of the patients does not count as third party information for this purpose; where, as in this case, disclosure of a hospital letter is likely to generate a complaint, you may choose to inform the author that the disclosure has been made but are not obliged to do so. If information is likely

You are intending to publish a case report as a fascinoma of the month within a national medical journal. As part of the publication you provide an image from the MRI film of the abdomen.

Medical illustration have transferred the film to electronic format and have removed all patient identification markings. The case report itself is otherwise completely anonymous.

Which of the following concerning consent is correct?


Consent for publication may not be required depending on the journal to which the manuscript is submitted

Consent for publication of the image must be obtained from the radiologist

Consent for publication must be sought from the local ethics committee

Incorrect answer selected

Patient consent for publication is not required

Patient consent must be provided for publication This is the correct answer

There is much controversy concerning case reports and consent, but without question, prior to publication, and particularly as you are using images, consent for publication must be obtained from the patient for use of both images and for the publication of the case report. This consent must also be appropriately informed.

All UK journals expect this prior to publication despite the anonymity of the subject matter. This is not an issue for which medical ethics committees are involved.

This is a complex area and there is flexibility around publication of images. However, there have been incidences of x rays being published which have been deemed to have been an invasion of privacy

A 23-year-old female attends clinic for a routine appointment regarding a six month history of occasional fits. She has seen the neurologists who have diagnosed idiopathic epilepsy and have prescribed lamotrigine. She informs you that she is doing well with this medication and has not had a fit for two months. She has been told that she must stop driving but you have seen that she drove to attend the clinic. You discuss this with her and insist that she stops driving to which she informs you that she had stopped driving but since she is fit free she must continue to drive because of her employment. Which of the following is the most appropriate action to take in these circumstances?


Inform patient that you will notify the DVLA Correct

Inform patient that you will notify the police

Inform the epilepsy clinic that she is still driving and allow them to deal with this issue.

Your only action is to write in the notes that the patient has been repeatedly warned but chose to ignore advice as she presents no serious risk in view of her epilepsy control.

You cannot inform any external body due to patient confidentiality.

The law is quite clear on such issues regarding epilepsy and the ability to drive. If the diagnosis is confirmed the patient must stop driving and inform the DVLA regarding the diagnosis. If the patient continues to drive despite advice to the contrary then the doctor has a duty of care to society overriding confidentiality to the patient and may inform the DVLA

Question: 9 of 10 / Overall score: 56%

20248

A 78-year-old male dies and is found by his children the following morning (after having seen him alive the night before). His GP attends to certify him dead. The patient had a known history of ischaemic heart disease and was treated in the local hospital where angiography performed 9 months previously for angina had revealed some insignificant coronary artery disease of two vessels for which medical therapy was deemed most appropriate. He had also been diagnosed eight years previously with diabetes mellitus for which he took metformin and gliclazide.

He had seen the practice nurse two weeks ago for review of his diabetes. One month ago he had seen the diabetologists for his annual review and had seen the cardiologists approximately 6 months ago. He had last seen a partner in the practice 6 weeks ago for advice concerning driving licence registration.

The family are keen to have a death certificate issued and proceed to cremation. They do not want any post mortem examination.

Which of the following is true concerning the issuing of a death certificate?


The partner in the practice may issue a death certificate

The death needs to be referred to the coroner Correct

The certifying doctor may issue a death certificate

The practice nurse can certify the death

The diabetologist can certify the death.

Death certification is becoming a hot area post Shipman. A death certificate may be completed if the practitioner has seen the deceased within 14 days of the death (28 days in NI). In this case the patient had been seen 6 weeks previously by the partner. Consequently and in view of the sudden death the coroner should be informed although may decide that under the circumstances reported, the doctor may be able to issue a death certificate stating ischaemic heart disease if he deems appropriate and on the balance of advice given to him

A 54-year-old male who is a HGV driver and has a 10 year history of type 2 diabetes is seen on annual review.

His glycaemic control is poor with a HBA1c of 10.5% on maximal oral hypoglycaemic therapy (3.8-

6.4).

You suggest switching to insulin but he refuses to do this as he would lose his HGV licence. He also refuses to inform the DVLA himself.

What is the most appropriate action in this case?


Continue to review patient in clinic and accept that he continues to drive Correct

Discharge him from clinic as there is nothing more that you can do

Inform his employer that he must stop driving and suggest administrative work

Inform the DVLA even if the patient withholds his consent

Tell his next of kin that they should inform the DVLA that he is nol onger fit to drive

In this particular case, the patient has poor glycaemic control, but otherwise has no features whatsoever that preclude him from driving such as retinopathy, neuropathy or hypoglycaemic episodes.

You cannot therefore force this patient to switch to insulin and neither can you stop him driving.

He will continue to need a regular medical every three years for his continued HGV licence

Lesions of the frontal lobe include difficulties with task sequencing and executive skills.

Other symptoms include:

- expressive aphasia (receptive aphasias are due to a temporal lobe lesion)

- primitive reflexes

-perseveration (repeatedly asking the same question or performing the same task)

- anosmia and

- changes in personality.

Lesions of the parietal lobe include:

- apraxias

- neglect

- astereognosis (unable to recognise an object by feeling it) and

- visual field defects (typically homonymous inferior quadrantanopia).

They may also cause alcalculia (inability to perform mental arithmetic).

Lesions of the temporal lobe cause:

- visual field defects (typically homonymous superior quadrantanopia)

- Wernicke's (receptive) aphasia

- auditory agnosia, and

- memory impairment.

Occipital lobe lesions include:

- cortical blindness (blindness due to damage to the visual cortex and may present as Anton syndrome where there is blindness but the patient is unaware or denies blindness)

- homonymous hemianopia and

- visual agnosia (seeing but not percieving objects - it is different to neglect since in agnosia the objects are seen and followed but cannot be named).

Informed consent is best described as:


Following the doctor's advice.

A process of shared decision making based on mutual respect and participation. Correct

A process of communication that is essential only to treatment for a life-threatening illness.

Obtaining a second opinion prior to starting treatment.

Putting the best interests of the patient first

Informed consent is a process of informing the patient fully of the benefits and risks of a course of action and under those circumstances obtaining the patient's permission to proceed. Putting the best interests of the patient first is a process to which every doctor subscribes but is not part of consent.

Obtaining a second opinion is not essential to informed consent

In which of the following cases is the individual's right to autonomy violated?


An athlete who seeks a second opinion

An infant whose parents elect for surgery to correct a congenital heart defect

An older man whose physician and family coerce him into having foot surgery Correct

An older woman who refuses to undergo back surgery

A patient with marked Alzheimer's disease whose relatives consent for him to have an endoscopy

Autonomy refers to an individual's right to be self-governing. Although the procedures may be in the best interests of the patient, if the patient refuses and this refusal is informed, then the doctor or relatives cannot coerce that person into having the procedure.

In the case of the patient with Alzheimer's, informed consent may be impaired and therefore the doctor or the next of kin could agree for that person to have the procedure, so long as it is in the patient's best interests

Withholding or withdrawing treatment is best described as:


Acting in the best interests of a gravely ill patient

Refusal to treat

Assisted suicide

Letting nature take its course. This is the correct answer

Passive euthanasia Incorrect answer selected

Assisted suicide refers to providing someone with the means to hasten his or her death. Passive euthanasia implies the introduction of a medication that will control symptoms but may expediate the patient's demise. Letting nature takes it course infers the process of allowing the patient to die from his illness as there is no prospect of recovery from the illness.

(Editor's comments:Although this question may seem rather trite, this sort of ethical question is appearing with increasing frequency at examination. Apologies if you think that its daft but we are trying to prepare you for all eventualities)

The most important factor in determining if someone is a suitable candidate for an organ transplant is


Emotional stability.

Someone for whom a transplant offers a reasonable likelihood of recovery. Correct

Ability to deal with stress.

age.

Knowledge of the aetiology of the underlying condition

The most important factor in determining the suitability of transplant is that the condition may be cured by a transplant.

Age is sometimes a factor in transplant but physical health is probably the more important as it depends also on what is being transplanted. Having emotional stability, or an ability to deal with emotional stress does increase the chances of a successful outcome, but it is not the most important.

Knowledge of the underlying condition is important but not essential e.g cardiomyopathy. The aetiology is usually unknown but it does not preclude transplantation

Which of the following statements is the principle argument made by proponents of making commerce in human organs for legal use?


Shortages or surpluses would be eliminated. This is the correct answer

Commercialization is not ethically preferable to the gift model of organ donation.

A person's heirs have the right to earn money by selling the deceased's organs.

Incorrect answer selected

There is already an active "black market" in transplantable organs.

It is an ethical trade in a capitalistic society

Although particularly controversial the arguments for commercial organ donation suggest that surpluses or deficits in organs would be eliminated and that the current black market in this resource associated with the inherent exploitation of the poor would be resolved. However, it is unethical to exploit live donors in impoverished countries as may happen currently.

The need for new methods of defining and determining death was created by what medical procedure?


Artificial resuscitation

Brain surgery

Open heart surgery

Organ transplantation This is the correct answer

ITU ventilation Incorrect answer selected

The conventional criteria previously established for clinical death was based upon cardiac standstill .

Due to the development of organ transplantation, that criteria needed revision such that it is now based upon brain stem death .

A placebo is defined as:


A standard treatment against which a newer treatment is compared

A substance given as a treatment for a disorder.

A way to deceive a patient into taking a medication. Incorrect answer selected

An inert substance given as a medicine in an assessment of its suggestive effect. This is

the correct answer

The medication given to a patient for a specific type of ailment.

Placebos typically produce mainly a psychological effect

You are the general practitioner of a 76-year-old man who has been suffering from bronchial carcinoma for the past one and a half years. He is requiring increasing amounts of morphine to cope with his pain, and he dies in his sleep.

You certify the cause of death as bronchial carcinoma.

His wife who requests cremation asks to see form 4.

Which of the following is true with respect to her viewing the form?


She is not allowed to view it under any circumstances

The form should be typewritten if possible

The name of the completing doctor must be obscured

You can apply for certain information not to be disclosed by discussing this with the referee Correct

You cannot prevent her from reviewing all aspects of the form

The recent cremation regulations detail that the cremation applicant can view the form.

There may be circumstances though when you wish for certain information not to be disclosed, that the patient may have told you in confidence. In this case you can write to the cremation referee requesting that certain pieces of information are withheld.

When you complete the form it is important that you remember the information may be seen by a relative; also make sure that your handwriting is as legible as possible.

Withholding the truth about a patient's illness is a violation of:


Autonomy This is the correct answer

Beneficence

Informed consent

Infringement of the Human Rights Act

The Bolam principle Incorrect answer selected

By not informing the patient about all the aspects of their illness we are removing their ability to make decisions for themselves. In effect we, and their relatives, are making the decisions for them.

This is the removal of their autonomy.

Informed consent relies upon the patient being provided with the information that is generated from the investigations to which he has consented. Justice implies going beyond one's own feelings, prejudices, and desires to find an appropriate balance among conflicting interests.

The Bolam principle is the basis upon which a doctors actions are judged such that they would be considered appropriate and reasonable to those actions that would be performed by a responsible body of their peers in similar circumstances.

A patient of yours suffers a myocardial infarction and dies in Spain. His relatives arrange for his body to be repatriated and plan for him to be cremated.

You last saw him alive seven days before his death.

Which of the following is true with respect to completion of cremation forms?


A colleague should complete form 4

A cremation may only take place if a coroner rules that no inquest or post mortem is needed This is the correct answer

The Spanish doctor who originally treated him should complete form 4

You are allowed to complete form 5

You are allowed to complete forms 4 and 5 Incorrect answer selected

Where deaths abroad are concerned, a cremation may only take place if the coroner is satisfied that a post mortem or inquest is not necessary.

It is highly unlikely that you will be in a position to complete forms 4 and 5, and it is not appropriate for form 4 to be completed by the Spanish doctor who originally treated the patient.

A 30-year-old male is unconscious on admission following a road traffic accident. He was the driver of the car and there is the suspicion that he was responsible for the accident in which a passenger of another car died. In attendance with the patient is his wife who was uninjured in the accident.

The police are keen to obtain a blood sample for alcohol measurement but the patient is incapable of giving consent for this procedure.

What is the most appropriate action in these circumstances?


Draw a blood sample for later analysis when the patient is competent to consent. This is

the correct answer

Draw a blood sample which can be analysed immediately. Incorrect answer selected

Inform the police that you may only take blood samples on medical grounds.

Obtain consent from his wife, as next of kin, to draw the blood sample.

Refuse to obtain a blood sample until the patient is competent to provide consent.

There is clear guidance published on such a situation by the BMA.

Following the Police Reform Act, it is no longer necessary to obtain consent from unconscious or incapacitated drivers.

However, the sample is not tested until the person regains competence and gives valid consent to it being tested.

A competent person who refuses to allow his or her sample to be tested might be liable to prosecution.

Similarly, the new law recognises the duty to justice.

An 85-year-old lady with advanced Alzheimer's dementia has inhaled her hearing aid. The respiratory rate is 35. A bronchoscopy is proposed.

Which of the following apply with regard to obtaining consent for the procedure?


If the mini mental score is above 20/30, consent can be taken from patient

Psychogeriatric opinion is needed before consent can be obtained

Relatives/next of kin will have to consent for the patient Incorrect answer selected

The doctor will be able to consent for the patient

The procedure does not require a written consent This is the correct answer

In this case, which is an emergency, informed written consent is not essential as the procedure is potentially life-saving and the doctor would be seen to be acting in the patient's best interest.

The process of consent for a procedure relies upon written and informed consent which the patient has to understand.

When a patient has impaired mental capacity, the doctor may be uncertain whether the patient is competent to give informed consent. Under English law no other person can consent to treatment on behalf of an adult, though it is desirable that next of kin are consulted before treating an adult without consent.

Recent legislation gives legal authority to people appointed by the patient, or by the state, or a relative or carer, to consent (or refuse) on behalf of the patient.

A mini-mental score may not adequately identify those unable to give consent.

The following link diverts you to the DoH site which guides doctors and lawyers with respect to consent and is very informative: http://www.dh.gov.uk

Most deaths are determined by:


Brain stem tests

Absent pulse

Loss os pupilaary reflex

The absence of vital signs. Correct

The coroner.

The absence of vital signs is the commonest mode of diagnosing death and entails absent pulse, absent heart sounds, respiratory arrest and loss of pupillary light reflex. Brain stem tests are generally reserved for ventilated cases where organ transplantation may be required. Doctors most commonly diagnose death not the coroner who provides a verdict on the cause of death

You are completing a list of cremation form 5s for patients in the hospital where you work.

You examine one form where the junior doctor has completed the cause of death as stroke, but the patient appears to have fallen at home. The husband wants to arrange cremation as soon as possible.

Apparently the junior doctor is working nights and has gone home, so you cannot easily get hold of him to question him further.

Which of the following is true with respect to completion of the form?


Completion of form 5 to show that examination of the case has been "adequate" would be acceptable

It is acceptable in this case not to question the doctor

Medical referees will not mind if you have not contacted the doctor

When completing form 5 you must only be reasonably sure that the patient suffered a stroke

You should wait to complete the form until the doctor is available to answer questions

Correct

Doctors are now instructed that form 5 should always be completed after questioning the doctor who completed form 4 except under exceptional circumstances, that is, only if the doctor is seriously ill.

Unavailability of the doctor is not an appropriate excuse, so quite clearly in this case you should wait to complete the form.

The other major principle with respect to completion of form 5 is that you must be absolutely sure that the cause of death is correct.

A female patient of yours unfortunately goes into premature labour at 23 weeks. The fetus is not viable. She wishes to have the fetal remains cremated.

Which of the following is true with respect to legal aspects of this case?


Cremation of the remains is not subject to the Cremation Act Correct

Only a pathologist is allowed to complete form 4

Only form 4 need be completed

Only form 5 need be completed

The case must be discussed with the coroner

Cremation of fetal remains under 24 weeks is not subject to the Cremation Act.

As such, forms 4 and 5 should not be completed.

In spite of this, most crematoria are happy to make arrangements to cremate fetal remains.

Where body parts are removed at post mortem, arrangements for cremation of these are normally made by the pathology service

Ethics is defined as:


Codes and statements of professional organisations of physicians about

appropriate conduct Incorrect answer selected

Prescriptions found in Scripture

Obedience to the law

The study of morality This is the correct answer

The study of the human conscience

Ethics is defined as the study of morality/the philosophical study of moral values and rules.

Integrity refers to a virtue that requires the physician to:


Risk health and life in the care of patients

Acknowledge and respond to the suffering of patients

Ignore irrelevant differences between the physician and the patient

Practice medicine according to intellectual and moral standards of excellence Correct

Treat in the best interests of the patient

Integrity refers to the practice of medicine according to appropriate ethical standards and excellence

Which one of the following deaths should be reported to the coroner?


A 73-year-old female who had undergone a hip replacement two months previously presents with severe chest pain and breathlessness. She is diagnosed with pulmonary

embolism but dies. Incorrect answer selected

A 72-year-old male is admitted with a myocardial infarction and dies 48 hours following admission.

A 69-year-old male with pneumoconiosis is admitted with fever and breathlessness. He dies two days later from pneumonia. This is the correct answer

A 62-year-old male with a two year history of severe dementia is admitted from a nursing home with fever and breathlessness. He dies three days later with pneumonia.

A 52-year-old male with a long history of alcohol abuse is admitted with confusion. He dies two days later with hepatic failure.

Increasingly emphasis is placed on the appropriate reporting of deaths particularly from the enquiries into Shipman and the Coroners' Reform Bill. In fact, it is the duty of the Registrar of Births,

Deaths and Marriages to report a death to the coroner but doctors need to be aware of the circumstances in which a death should be reported.

These include:

 The cause of death is unknown

 The deceased was not seen by the certifying doctor either after death or within 14 days before death

 The death was violent or unnatural

 The death may be due to an accident

 The death may be due to self neglect or neglect by others

 The death may be the result of industrial illness or due to the person's employment (as in D pneumoconiosis being an industrial disease)

 The death may be due to an abortion

 The death occurred during an operation or before recovery from anaesthesia

 The death may be suicide

 The death occurred during or shortly after being taken into police custody.

The MDU have published a guide to Coroners Inquiries which is free to members: www.the-mdu.com

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