What is your suggestion/advice if the family member requests firmly not to inform a patient regarding the extent of cancer, with a poor prognosis in particular?
This can be common because of the protective nature of family or for cultural issues. You should ask why and try to unpack fears. Patients have rights and your duty of care is to them and important matters need to be disclosed. The practitioner patient relationship is very much a partnership. The relationship includes respect for the competent adult patient’s right to decide what will happen. The emphasis is very much on patient autonomy. So, if the patient is competent and there are no legal impediments, they need to be advised irrespective of what a family member request. However, information provided by caring family members can assist in providing a valuable insight to a patient personality strengths and weaknesses. Always convey information about serious illness with sensitivity and with awareness of the needs of the patient.
What would you do if a patient requested not to include family or friends on their appointment?
Our response is very similar to that stated above. You would need to be confident of the patient’s competence and that they are legally able to consent. If there is a temporary or permanent lack of capacity to consent for procedures, medical decisions are sometimes made after consulting relatives and or carers. There can be a legal guardian in place or other substitute decision maker so beware of this possibility. In summary, a competent patient can make such a request and you would ultimately accept the request but advise a trusted friend or family member may be of assistance given the circumstances.
Does a child have the right to deny treatment? How do we assess how much a child understands?
Consent of children and teenagers can be a challenging issue. Parents can generally consent to medical procedures for their children provided that the proposed procedure is in the child “best interest”. In general terms, you should not proceed with the procedure without the additional consent of the child where the child is aged 14 or over. To deny treatment it must be demonstrated that the minor is competent, via “achieving a sufficient understanding and intelligence to enable him or her to understand fully what is proposed”. This known as the “Gillick competence” and is used in medical law to decide whether a child (under 16 years of age) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge. Based on the decision of the House of Lords in Gillick v West Norfolk and Wisbech Area Health Authority, binding in Australia. Where the parents are requesting that a procedure be done but a competent child over 14 years old is opposed to the treatment, the refusal of the minor should be respected and independent advice sought. A decision of a court might be ultimately required.
As a palliative registrar, I currently have a 29 year old mother of young baby with metastatic melanoma with brain mets. She and her family have a large social media following and tend to put all the details (accurate or otherwise) online. How does social (or even traditional media) affect your practice?
Social media in health practice is also a challenging issue. There are limitations on what controls you have over your patients, but if you have specific concerns contact MIPS. The big five issues to remember for your involvement in social media are: 1. Confidentiality – ensure a patient or situation cannot be identified 2. Defamation – ensure no comments of a derogatory/defamatory nature are attributable to you. 3. Student/Doctor/patient boundaries – avoid on-line relationships with current/former patients. 4. The destiny of your data – data will live on for years outside your control. 5. Privacy – read and become familiar with each site’s privacy settings The issue of social media is of such importance that the Medical Board in March 2014 issued specific guidelines on Social Media.