Best practice & research. Clinical anaesthesiology
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This chapter discusses a framework for and process of ethical decision making in the context of the discipline, theories, and principles of ethics. Daily decision making within the Hospital Ethics Committee is considered and some of the emerging ethical issues in anaesthesia are discussed.
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This chapter deals with the obligations of trainers and trainees to each other, the responsibilities of the programme and the conflicts of providing a service while training. Management of trainees with differing needs, such as those working part-time or returning to training after sickness, is reviewed. Assessment of performance and the obligation of consultants to identify, manage and support struggling trainees are discussed. ⋯ For the patient, there are advantages and disadvantages to receiving care in an educational setting. A 'teaching environment' tends to encourage and maintain high standards of practice from senior clinicians, but it also exposes patients to new learners, who are less efficient and polished and perhaps more prone to make errors. Learning has to fit round and complement the clinical and emotional needs of patients.
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Public expectations of healthcare have changed dramatically over the last 10-20 years, particularly in relation to the involvement of patients in determining treatment options and the selection of the most appropriate treatment plan. Paternalistic actions of doctors, which involved telling the patient what treatment they were going to receive, without discussing risks and benefits of various options, are no longer acceptable. This has been reflected in decisions reached by the courts in cases in which patients have entered litigation on the basis that inadequate information was given to them before treatment, and that they were unaware of risks of complications which subsequently materialised. ⋯ Complaints about lack of information or inadequate consent can also result in a doctor being reported to regulatory authorities. It is therefore necessary for anaesthetists to be aware of current issues surrounding provision of information and obtaining consent for anaesthesia in various categories of patient. This article summarises these issues.
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It is not possible to generalise about the way in which increasing years affect the performance of an individual anaesthetist. Physical and mental deterioration occurs as we age; most anaesthetists will be able to reach the normal retirement age of 65 years without that deterioration affecting their clinical practice. In some, however, decreasing competence and an unwillingness to embrace a continuing education regime may offer a direct threat to patient safety. ⋯ Continuing involvement in the on-call rota is a potent stressor. Airline pilots are required to retire at 60 years; the feasibility and desirability of applying this process to anaesthetists are discussed. Employers have a duty to provide employees with adequate and achievable demands in relation to their agreed hours of work and to have in place policies and procedures to offer adequate support.
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Society and the culture of health care delivery have radically changed over the last thirty years, the rate of change increasing exponentially towards the present time. Maternity care has been part of that change. Previously paternalistic obstetricians told women whether they should or should not become pregnant, advised hospital confinements, kept women in hospital for days after their confinements, and discussed little of their management with the women themselves. ⋯ This was, and to a certain extent still is, threatening to obstetricians. But there are also genuine concerns as to whether these changes will adversely influence the morbidity and mortality of mother and child. This chapter deals with issues of maternal choice from pre conception through to the post natal period, looking at how the exercise of maternal choice may conflict with the advice of the medical profession, potentially leaving accountability and responsibility a very grey area and how all this impinges on the anaesthetist.