An introduction to values and values-based practice for medical students Dr Lucy Fulford-Smith and Prof. Ashok Handa

W HAT ARE VALUES ? 1. Write down three words (or very short phrases) that mean ‘values’ to you … 2. Then compare with your neighbour …

W HAT ARE V ALUES ?  Beliefs  Compassion  Courtesy  Ethics  Equality  Expertise  Genuine care  Health  Honesty  Ideals  Innovation  Integrity  Principles  Trust

I T ’ S YOUR DECISION …  Imagine you have developed early symptoms of a potentially fatal disease  NICE has approved two possible treatments  Treatment A - gives you a guaranteed period of remission but no cure  Treatment B - gives you a 50:50 chance of ‘kill or cure’  Your decision – how long a period of remission would you want from Treatment A to choose that treatment rather than go for the 50:50 ‘kill or cure’ from Treatment B?

I T ’ S YOUR DECISION …  How long a period of remission would you want from treatment A to choose it over treatment B (‘kill or cure’)?  Write down your own answer thinking about your decision from own point of view and in your own particular circumstances  Compare your answer with your neighbours’ answers

C HOOSING TREATMENT A OVER B … Time in years B1-4yrs5-10yrs11-25yrs26-30yrs40yrs50yrs Number of people choosing ? ? ? ? ? ? ? ?

C ASE 1  28 year old female presents with lactational breast abscess. Baby is 2 months old.  Treatment options are:  Admit for oral antibiotics AND incision and drainage under local anaesthetic (may need >1 procedure)  Home on oral antibiotics only  No intervention with explanation of risks  Things to consider:  Breast feeding and antibiotics  Separation from baby if admitted  Risks and benefits of incision and drainage

C ASE 2  19 year old male presents with a 24 hour history of central abdominal pain, now migrated into the right iliac with associated anorexia, nausea and no diarrhoea.  WCC 14.6  Temp  CRP <1  Likely diagnosis = acute appendicitis  His parents are present and want him admitted for an appendicectomy but he is very reluctant - sporting commitments  Your options are:  Admit for antibiotics, analegesia and laparoscopic appendicectomy  Admit for observation, analgesia, repeat bloods +/- imaging tomorrow  Discharge and ask to return for further investigations tomorrow  Things to consider:  Is he clinically stable enough for discharge?  Does he need further investigations before proceeding to surgery?  Are there other reasons (e.g. fear) that make him want to go home?

C ASE 3  63 year old female presents with 48 hours anorexia, severe RUQ pain after eating and ongoing nausea  Mildly elevated LFTs: bilirubin 24, ALT 57, ALP 144, amylase 32. WCC 14.1, CRP 15  Pain subsides with adequate analgesia and patient wants to be discharged, her husband is less certain  Options:  Give oral antibiotics and send home on day leave with USS tomorrow  Admit for antibiotics, ultrasound scan in morning +/- laparoscopic cholecystectomy  Discharge home with oral antibiotics and outpatient USS +/- elective surgery  Things to consider:  Pain – will simple analgesia be enough?  Eating and drinking – often a problem with GB disease, will she need IV fluids?  Emergency v. Elective surgery – does the patient have a preference? Clinical reasons for emergency over elective...  Why is the husband nervous about her being discharged?  Why does she not want admission?

W HAT HAVE YOU LEARNED ?  Consider how your values may differ or be similar to your colleagues, friends and patients  How will this affect your interactions with future patients?

T HE M ONTGOMERY R ULING Montgomery (Appellant) v Lanarkshire Health Board (Respondent), 2015 How will this change our practice?

B ACKGROUND  Mrs Montgomery’s case:  High risk pregnancy (diabetes) under care of Dr McLellan  Baby born with shoulder dystocia  Child left with serious disabilities  The facts:  Mothers with diabetes are more likely to have a large baby  10% risk of shoulder dystocia  Mrs Montgomery had raised concerns about vaginal delivery, but Dr McLellan's policy was not routinely to advise diabetic women about shoulder dystocia

S UPREME C OURT R ULING  Patient should have been told about risk of shoulder dystocia  Judgment as a whole marks shift from ‘prudent clinician’ to ‘prudent patient’ test of consent in health and social care

S UPREME C OURT R ULING  Patient should have been told about risk of shoulder dystocia  Judgment as a whole marks shift from ‘prudent clinician’ to ‘prudent patient’ test of consent in health and social care  This is NOT about: ~ ‘bombard(ing) patients with technical detail’ ~ offering ‘futile’ treatments

S UPREME C OURT R ULING  Patient should have been told about risk of shoulder dystocia  Judgment as a whole marks shift from ‘prudent clinician’ to ‘prudent patient’ test of consent in health and social care  This is NOT about: ~ ‘bombard(ing) patients with technical detail’ ~ offering ‘futile’ treatments  What it IS about: 1. Clinicians engaging in ‘dialogue’ with their patient to the point that 2. they have sufficient understanding of the risks and benefits of the options available to make a choice that 3. takes into account ‘her own values’

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