Ethics Posters 700 – 706

Ethics Posters 700 – 706

700 Antibiotic stewardship in primary care: safeguarding society by ignoring individuals?

Benedict Hayhoe

b.hayhoe@imperial.ac.uk

Background In November 2015, the Lancet announced the emergence of a new mechanism of bacterial resistance, subsequently reported as the dawn of an ‘antibiotic apocalypse.’ Most antibiotics continue to be prescribed in primary care, and this area is a key focus in the battle against antimicrobial resistance (AMR), with antimicrobial stewardship (AMS) strategies seeking to improve ‘appropriate’ use, limiting prescription to where they are of proven benefit.

Aims This paper considers how ethical principles may guide AMS in primary care, and whether these can be integrated into shared decision making with patients.

Discussion There is clear moral value in preserving antibiotics as a finite resource, with AMS programmes aiming to maximize ‘net benefit’. However, it can be hard to judge where antibiotics are ‘appropriate’ in primary care, and withholding treatment for the benefit of future individuals sits uncomfortably with a preeminent view of patient autonomy, especially where there is potential risk of harm.Traditional focus in primary care on individual patients makes balancing their interests with those of wider society particularly difficult, while time constraints, patient satisfaction ratings, monetary incentivisation and threat of regulatory action add further ethical complexity.

Conclusion The catastrophic impact of failure to safeguard the effectiveness of antibiotics makes AMS programmes essential, but these solutions can lead to significant ethical difficulty for clinicians. A ‘communal’ approach, involving collective understanding of public and professionals on acceptable levels of treatment restriction and risk of harm, may allow for patient-centred AMS, with opportunity for expression of autonomy within agreed boundaries.

701 Shared decision-making – a need for intellectual honesty?

Jonathan Ives

andrew.papanikitas@phc.ox.ac.uk

In this poster, we challenge the conceptual honesty of ‘shared decision making’ and argue that whilst it is held up as an ideal decision-making standard, it is used too often to describe (and justify) decision-making practices that are not shared at all. This is problematic because if the legitimacy of a decision relies on it being ‘shared’, but it is not in fact shared, the decision loses legitimacy, or is falsely legitimised by the appearance of being shared. We argue that the realities of clinical practice mean that genuinely shared decision-making is not completely impossible but difficult to achieve in a sincere and just manner.

This leads us onto the horns of a dilemma. We must either accept that the majority of decisions made in clinical practice fall below the required standard and are unethical as a result, or we must acknowledge there is problem with the current standard of shared decision making. Numerous clinical factors make the ideal of a shared decision making untenable, including: The right of veto of either the patient or the clinician on any treatment option.

Genuinely shared decision making is time-consuming and collaborative. In a time limited clinical consultation, there is not sufficient time to engage in the level of collaboration needed to achieve more than simple agreement. Simple agreement is very often good enough, and the level of collaboration required for genuinely shared decision making is only ethically required when substantively important decisions are being made. We argue for more honesty about when shared decision is genuine and when it is not, but make a case for beneficent, honest and reflective agreement possibly being good enough.

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702 Primary care inter-professional ethics: what ought it to be like?

Hilary Engward

andrew.papanikitas@phc.ox.ac.uk

The aim of this poster is to explore what inter professional ethics in the primary care context ought to be like. Inter-professional care is the process in which different professional groups work together to improve the delivery of health care, its underpinning premise being to promote the well being of the patient. Inter professional working therefore involves aspects that arise from differing professional working together, and literature indicates that inter professional working as detrimental to patient care, with issues such as problematic power dynamics, poor communication, lack of understanding of own and others roles and responsibilities, and conflicts due to various approaches to patient care.

These can bring about ethical conflict in inter professional working in the primary care context. Our approach is two fold: firstly, we consider how we might better understand ethics in primary care inter professional working, and secondly, we consider what ethics in inter professional primary care ought to look like. To do this, we argue that inter professional ethics ought to be considered at the team and organisational levels.

Globally primary healthcare comprises many kinds of interacting multi- and inter professional teams that nonetheless can be remote from each other in terms of geography and work schedules as well as ethic and ethos. Organisational and professional aspects that impact on inter professional decision making and practice may in themselves bring about ethical conflict within inter professional working in the primary care setting. Using examples, we discuss inter professional/disciplinary.organisational differences between how ethics can be understood and even celebrated. We conclude by suggesting means of developing ethics in primary inter professional care.

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703 What is primary care ethics?

Andrew Papanikitas

andrew.papanikitas@phc.ox.ac.uk

In this poster we discuss a notional field of primary care ethics and ways that it may be usefully defined within the bioethics literature. We will discuss: Whom does it concern? What disciplinary approaches might inform the field? And what might such a field offer? Primary care ethics has predominantly been a guise of general practice ethics – the study of moral issues arising in general practice (or its equivalents outside the UK context) and population or public health ethics.

The definition of the field so far is largely in terms of context, for example the family practice consultation and out of hospital population-based healthcare. We suggest however that primary care ethics overlaps with public health ethics rather than encompassing it. And further, that it overlaps with many other fields, including the emerging field of inter-professional ethics. This is because it examines the individual practitioner, the team and the organisation, as well as national and international policy decisions at the interface between healthcare worker, organisation, patient and society.

Furthermore we suggest that the emerging field of primary care ethics is strengthened by academic inter-disciplinarity: biomedicine, healthcare, business and management can learn from each other, as can philosophical ethics, history, theology, law and other humanities disciplines. By focussing on the consultation, the back-office, the population and society simultaneously – the field of primary care ethics can enrich medical education and public policy, and ground the practice of primary care in a conscious morality as yet undeveloped.

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704 Self-care, sustainability and the ‘extra mile’ in general practice

Emma McKenzie-Edwards

emck-edwards@doctors.org.uk

Medicine has a special place in the overwork and efficiency culture of the day. This cultural debate is about success, achievement, the limits of efficiency and what it is to be human. Culturally medicine and its allied professions have a tendency to value perfectionism and excellence in the workplace. Health care workers learn that good enough is not excellent and that anything less than excellent is not good enough. Induction into the medical world can distort understanding of what duty means and instil the idea that ‘going the extra mile’ is normal practice. Raising the bar by constantly making more effort than is expected of you raises the expectations of other stakeholders in medical services. In a perfectionist framework there is no distinction between what is required and what is beyond requirement and optional.

Discussion about the enlarging ‘credibility gap’ between rhetoric and reality in clinical care provision leads us to acknowledge the potentially limitless need and demand for healthcare provision in the primary care setting. The unsustainable option of going beyond the call of duty cannot be the ethical norm in the long term. How can we recreate balance in the healthcare work environment? In this poster I explore the concept of ‘going the extra mile’ in the context of good medical practice and the continuing formative development of the healthcare worker. I consider possible ways of continuing to strive for excellence in a new culture of ethical self-care.

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705 Ethics and values at the 2015 RCGP Annual Conference

Andrew Papanikitas

andrew.papanikitas@phc.ox.ac.uk

We report on the ways in which the ethics and values conference stream manifested at the 2015 RCGP Annual Primary care Conference in Glasgow. The call for posters elicited contributions including: empirical work on patient choice regarding place of death (the winning poster in the category), the ethical puzzle of clinician self-care, issues arising from ethnic diversity, and GMC standards displayed by the doctors in the television programme Star Trek.

Plenary sessions had a strong moral flavour: These included Shami Chakrabarti discussing human rights, and Samuel Shem discussing human disconnection and the moral and political agency of the healthcare workforce. Three breakout sessions (a debate, a workshop organised by the RCGP Ethics committee and a session on ‘The flourishing practitioner’ by Dr Peter Toon) were well attended. The debate asked ‘Who knows best – the patient or the clinician?’ This highlighted difficulties in defining honest and meaningful patient-centred choice.

The “Inside GP ethics” workshop began with brief presentations form the Chair of the ethics committee, a senior educator involved in teaching ethics, and a GP-philosopher. The discussion included issues such as ethical aspects of the trainee in difficulty and broader discussion about the place of philosophy in clinical thinking. Unfortunately the debate and the session on flourishing were concurrent, forcing the delegates to choose.

We conclude that there is appetite for ethical discussion and debate at the RCGP conference. This has the potential to improve clinician welfare and decision-making though making resources available when clinicians face a dilemma. The RCGP Conference offers a protected space where issues can be considered at a remove from clinical pressures, with the luxuries of time and available expertise.

706 ‘An enlightened discussion’: raising awareness of the virtues and vices of complementary and alternative medicine in oncological primary care

Laura Chapman

laura_chapman_@hotmail.com

Aims/Objectives To raise awareness of Complementary and Alternative Medicine (CAM) in cancer patients in primary care. To also promote discussion of CAM in primary care consultations. To finally discuss the ethics around CAM, in order to facilitate fully informed decision making.

Content of Presentation We present a review of key studies on CAM for cancer patients based on literature relating to Primary Care Oncology in the UK, with lessons for all practitioners managing the global burden of malignancy. We then expand on this topic by highlighting some ethical issues that are seldom discussed with regards to CAM.

Relevance/Impact With an ageing population and modern diagnostic techniques, cancer is an increasing bio-psycho-social morbidity in primary care populations. For alleviation of this burden, patients are increasingly turning to CAM. With mainstream acceptance and easier access, it is important to familiarise oneself with this growing field. In addition, there are a number of ethical issues in terms of accessibility and informed consent that often goes unrecognised by clinicians.

Outcomes We highlight the core principles, therapies, popularity in different malignancies, advantages, disadvantages and some general guidance for the conscientious and proactive discussion of CAM in Primary Care Oncology. We then discuss the inequity of access to CAM and the how the stages of acceptance are important in the process of informed consent.

Discussion With limited objective evidence but growing subjective benefits, primary care practitioners should be more aware of CAMs. This poster supports an informed, ethical and sensitive approach to this increasingly popular field.