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An introduction to values and values-based practice for medical students Dr Lucy Fulford-Smith and Prof. Ashok Handa
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W HAT ARE VALUES ? 1. Write down three words (or very short phrases) that mean ‘values’ to you … 2. Then compare with your neighbour …
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W HAT ARE V ALUES ? Beliefs Compassion Courtesy Ethics Equality Expertise Genuine care Health Honesty Ideals Innovation Integrity Principles Trust
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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?
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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
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C HOOSING TREATMENT A OVER B … Time in years B1-4yrs5-10yrs11-25yrs26-30yrs40yrs50yrs Number of people choosing 4062111 ? ? ? ? ? ? ? ?
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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
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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. 37.8 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?
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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?
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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?
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T HE M ONTGOMERY R ULING Montgomery (Appellant) v Lanarkshire Health Board (Respondent), 2015 How will this change our practice?
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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
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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
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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
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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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Thank you for attending Please complete the feedback before leaving You can learn more about the Collaborating Centre at: valuesbasedpractice.org If you would like to take part in future projects in values-based practice, please get in touch! lucy.fulford-smith@nds.ox.ac.uk
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