GP

Question 1

3 types of consent

Answer 1

1. Informed
2. Expressed
3. Implied

Question 2

Consent forms

Answer 2

1. Competent adults able to consent for themselves where consciousness may be impaired (e.g. general anaesthetic)
2. Adult consenting on behalf of a child where consciousness is impaired
3. For an adult or child where consciousness is not impaired
4. For adults who lack the capacity to provide informed consent

Question 3

Discuss consent in minors

Answer 3

• Young children and older children who are not Gillick competent cannot consent for themselves.
• The patient’s biological mother can always provide consent.
• The child’s father can consent if the parents are married (and the father is the biological father), or if the father is named on the birth certificate (irrespective of marital status).
• If parents are not married and the father is not named on the birth certificate then the father cannot consent.

Question 4

Capacity to consent

Answer 4

1. Understand the information
2. Retain the information
3. Weigh up the information
4. Communicate the decision (doesn’t need to be verbally)
   Patient needs to believe the information to be true

Question 5

General principles of sharing patient information

Answer 5

• Most patients expect that some information will be shared with those who are directly involved in their care. Unless the patient specifically objects, this is considered implied consent.
• If a patient objects to particular personal information being shared, you should not disclose the information. The exceptions are: if it is justified for the public interest (as detailed below) or the patient lacks capacity.
• You should explain to the patient the potential consequences of not allowing personal information to be shared and reach a compromise where possible.
• In cases where a patient cannot be informed about information sharing, such as an emergency setting, you should pass relevant information to those providing the patient’s care

Question 6

Conditions for sharing information

Answer 6

• Must be accessing the information to support the patient’s direct care or be satisfied that it is being shared for this reason
• Patients should be kept informed regarding how their personal information will be used. Should be clear that they have the right to object
• Must have no reason to believe the patient has objected to the information being shared
• Must be satisfied that anyone you disclose the information to understands it is in confidence

Question 7

Discuss confidentiality

Answer 7

• Should not disclose information to a relative, solicitor, or police officer without express consent from patient first
• If the risk is severe enough to break confidentiality, then you should document your judgement and reasons and be prepared to justify this to whoever asks (court, patient, relative)
• Examples of when risk is serious:
  o Disclosure may prevent a serious crime (risk of serious harm/death)
  o A patient who continues to drive against medical advise, there is a duty to inform the DVLA
  o Gunshot or knife crime (don’t need to disclose patient info though)
• If you are unsure, consult BMA or protection organisation and/or seek advice from a senior colleague

Question 8

Define screening

Answer 8

Systematic testing of a population or a sub-group for signs of illness - which may be established disease (pre-symptomatic, e.g. breast cancer) or symptomatic (e.g. unreported hearing loss in the elderly)

Question 9

Modified Wilson criteria for screening

Answer 9

IATROGENIC
I: Condition should be an IMPORTANT one
A: Should be an ACCEPTABLE TREATMENT
T: Diagnostic and TREATMENT facilities should be available
R: A RECOGNISABLE latent period or early symptomatic stage
O: OPINIONS on who to treat as patients must be agreed
G: GUARANTEED safety - high discriminatory power, valid and reproducible
E: The EXAMINATION must be acceptable
N: The untreated NATURAL history of the disease must be known
I: A simple INEXPENSIVE test should be all that is required
C: Screening must be CONTINUOUS (not a one-off affair)

Question 10

Define sensitivity

Answer 10

How reliably is the test POSITIVE in disease?

Calculated:
Positive with disease/Positive with disease + Negative with disease

Question 11

Define specificity

Answer 11

How reliably is the test NEGATIVE in health?

Calculated:
False in health/False in health + Positive in health

Question 12

What is Rees’ rule in screening?

Answer 12

Before offering screening, must inform patients of disadvantages as well as advantages!
E.g. Anxiety whilst waiting for false +ve to be sorted out, or complications of the screening procedure itself (post-biopsy bleeding if +ve cervical screen).
- Must discuss the possibility of false +ve and false -ve

Question 13

Examples of partly effective screening

Answer 13

• Cervical smears (> 25yrs)
• Mammography (post-menopausal)
• Finding smokers (+ quitting advice)
• Faecal occult bloods (colorectal cancer)
• Abdo aortic aneurysm
• Chlamydia screening for <25yrs

Question 14

Examples of unproven/ineffective screening

Answer 14

• Mental test score (dementia)
• Urine dip (diabetes, kidney disease)
• Antenatal procedures
• PSA screening for prostate cancer (detects too many harmless cancers)
• Elderly visiting to detect disease

Question 15

Disadvantages of screening

Answer 15

• Those most at risk often don’t attend - inverse care law!
• The ‘worried well’ overload services by seeking repeat screening
• Services investigating the positives are inadequate
• False positives suffer stress in the meantime
• Negative result may be seen by the patient as a chance to now take risks

Sometimes it’s healthier not to know!!