CEO of Medisec Ms Ruth Shipsey answers questions from Catherine Reilly on how the pandemic is impacting GPs from a medico-legal perspective
What are the main types of medico-legal queries Medisec has been receiving during the pandemic?
Medisec has been working closely with its members and has witnessed first-hand the remarkable response and rapid evolution of general practice in recent weeks, as GPs adapt virtually every aspect of their practice to current realities. Our focus has always been on supporting and protecting members, so that they have peace of mind while looking after their patients. Now, more than ever, we’re encouraging our members to let us know how we can help and in recent weeks, we have advised on many novel Covid-19 related queries, including:
Fitness to work certification: The fundamental principles remain unchanged and if a GP is happy to do so, they can issue a limited certificate to allow a patient to return to work following a period of self-isolation. However, in order to avoid any suggestion of the GP giving a ‘blanket’ opinion regarding a patient’s fitness to work, we recommend:
Limiting your opinion on fitness to work to those symptoms reported, if any;
Referring to the relevant public health/HSE guidelines on which you are relying;
Stating the date the symptoms were reported to have commenced and the date they were reported to have resolved;
Specifying the means by which you spoke with the patient and clarify that you have not examined the patient (if that is the case);
Framing the certificate in negative terms, ie, ‘there is no current medical reason why they cannot return to work’; and
Confirming it is a matter for the employer as to whether the patient should be asked to agree to be monitored on an ongoing basis.
Death pronouncement and certification: The Coroners Society of Ireland has issued updated guidance and GPs should monitor the coroners.ie website for any further updates. We had numerous enquiries as to whether an assessment by video would be sufficient to pronounce death and the position is that a video assessment is not acceptable. It has been confirmed that a competent, trained person can pronounce death if a doctor is unavailable and this may include, for example, senior nurses, palliative care nurses or paramedics in the community setting.
The legalities of DNAR (do not attempt resuscitation) orders and any ethical requirement to commence CPR (cardiopulmonary resuscitation): A key message is that in reality, every situation differs and the guidance we would give to our members would be to approach each scenario on a case-by-case basis, taking into account what is in the best interests of the patient and bearing in mind the fact that cardiopulmonary resuscitation is an aerosol-generating procedure, which would call for full personal protective equipment (PPE). It would not be appropriate to discuss DNAR orders with, for example, all residents of a nursing home simply by virtue of their being residents there, almost as a ‘tick-box’ exercise. These conversations are, by their nature, emotive and potentially distressing and it would be preferable for the patient to have the support and presence of a family member, which is currently a difficulty when there are no visitors allowed. A change in the patient’s health status can sometimes mean that it is appropriate to revisit an earlier conversation regarding a DNAR order. As always, careful records should be kept of all discussions.
Finally, the Medical Council guidance makes it clear that a doctor is not required to put himself/herself or others at risk. In any given situation, a doctor is entitled to have regard to the risk to their personal safety and to the possibility that commencing CPR will cause more harm than benefit and/or be unsuccessful. Again, any decision not to commence CPR should be carefully documented, including the reasoning for it.
Separated parents and access arrangements: Our primary concern is ensuring that our members avoid becoming entangled in any family disputes and the Law Society Family Law Committee has issued very practical guidance on facilitating custody and access arrangements during Covid-19. Some of our members have been asked to certify or confirm that it would be inadvisable or unsafe for a child to travel between households for access purpose. The position is that orders of the Courts must continue to be observed and respected to the greatest extent possible and children are permitted to move between their parents’ homes. GPs should, in our view, be careful not to become embroiled in any family disputes.
What is the key advice for GPs?
Our five top tips would be:
Stay abreast of the changing HSE guidance and algorithms.
Plan ahead by considering what contingency plans you would put in place in the practice in the event of you or a staff member testing positive for Covid-19. It is essential for there to be some means of monitoring incoming communications and test results in the interests of patient safety.
Don’t compromise your standard of record-keeping. The donning and doffing of PPE makes record-keeping more challenging and it will often be necessary to wait until the conclusion of a clinic before entering a series of notes at once. Be vigilant and try to capture the same degree of detail that you usually would.
Ensure that you follow-up test results and referrals as you would under normal circumstances. There is added potential for something to slip through the cracks at the moment, with so many competing demands on time and resources in general practice. Also, the public health advice is that vaccination programmes should continue as normal and not all patients may be aware of this.
All testing in Ireland must be aligned with the national approach under the direction of the national public health emergency team (NPHET) to ensure monitoring and surveillance. Beware of potentially counterfeit tests for detection of Covid-19 antibodies, which may provide incorrect results.
What particular challenges for GPs have been posed by the pandemic, including establishment of new structures like community assessment hubs?
The secondment of GP registrars on either a full-time or part-time basis, depending on their training scheme, is obviously challenging on these young doctors who have shown such commendable adaptability and camaraderie.
We are aware anecdotally from members of concerns regarding the adequacy and availability of PPE. We know that the HSE has been effective in procuring PPE at a time when it is in worldwide demand and we hope that supplies will remain available and will be enhanced where possible.
The Department of Health has issued an ethical framework for decision-making in a pandemic. Its detailed guidance warrants careful review and consideration and ideally, discussion and training for team preparedness, particularly in the context of community assessment hubs and secondary care.
What are the main queries emerging in terms of telemedicine (ie, remote prescribing)?
Remote consulting via telephone or video has, in a matter of weeks, become a norm of GP practice rather than a relative rarity. This presents real challenges in terms of patient triage, clinical assessment, prescribing, follow-up and confidentiality.
Ensuring patient confidentiality and data security when engaging in telemedicine is an obvious concern in the post-GDPR era and it is one that many GPs, who did not previously use telemedicine, have had to grapple with quickly. The Data Protection Commissioner has issued helpful guidance and the ICGP GPIT Committee has been very helpful to GPs by demystifying many of the available options.
The logistics of scheduling and co-ordinating consultations via telemedicine can be time-consuming and many clinical presentations cannot be dealt with appropriately via telemedicine. The reported decline in patient numbers attending hospitals following a stroke or cardiac event is very concerning. It is crucial for GPs to retain appropriate triaging practices so as to identify patients who need to proceed straight to emergency departments.
Not every patient will be capable of engaging with online telemedicine and we have seen our GP members doing a wonderful job of proactively reaching out to their older and more vulnerable patients by telephone, to check that their needs are looked after.
The Minister for Health moved quickly to amend the prescribing regulations to allow some flexibility during Covid-19 and the transmission of electronic prescriptions directly to pharmacies is a welcome innovation.
We are often asked whether doctors are under a legal or ethical obligation to review a patient each and every time they issue a prescription. Whilst the short answer is ‘no’, we advise our members to aim to take protected time for repeat prescribing so that they can consider where the patient’s best interests lie and whether clinical review is indicated prior to prescribing. We are particularly encouraging our members to remain vigilant about continuing to monitor patients on long-term and toxic medications appropriately.
Are there any concerns about GPs’ ability to undertake CME (continuing medical education) during this time, and could this present a medico-legal issue?
We believe the Medical Council’s decision not to monitor CPD compliance for the year 2019/2020 was practical, given the disruption caused by social distancing requirements and curtailed travel capacity. It was also a welcome acknowledgement that doctors are working incredibly hard, under enormous pressure, to care for their patients.
The Medical Council has advised any doctor who has not completed their CPD requirement for the year ending 2019/2020 to inform their professional competence scheme and disclose this on their annual retention form. The Medical Council has said that it will take an individual doctor’s CPD compliance in previous years and extenuating Covid-19-related circumstances into account in monitoring compliance. CPD compliance is routinely checked in the context of any Medical Council complaints against doctors, so it is important for doctors to follow the advice correctly.
Medisec was proud to support the ICGP’s virtual Covid-19 conference and 1,800 or so doctors logged-in online. That level of attendance is truly remarkable and most encouraging. Our sense is that logging completed CPD has understandably not been a priority, but that doctors are being very proactive when it comes to amassing and disseminating new knowledge.
From a medico-legal perspective, it is essential for doctors to keep abreast of the clinical algorithms and HSE guidelines as they are updated. In Medisec, we are tracking the guidance so that if a member is sued as a consequence of care provided during the pandemic, it will be possible to identify the standard of care which applied at the relevant time.
Finally, the Medisec team would like to express our admiration for all GPs and indeed all healthcare professionals who are battling through these challenging times and continuing to provide a first-class service to patients. We have seen at first-hand their commitment to patient care and resilience over the last number of weeks. There has also been excellent leadership shown by the ICGP, IMO, Irish Medical Council and HSE throughout this crisis.
Medisec has recently entered a new business arrangement with MedPro as the underwriter for Medisec’s GP medical indemnity insurance programmes. According to Ms Shipsey, this will enable the not-for-profit organisation “to offer enhanced services to its current membership and to expand into other healthcare specialties, leveraging their expertise to offer the same great legal and clinical risk advice service, assistance with claims and regulatory issues, education and risk programmes to the wider medical industry. The first step on this journey will be offering membership services and arranging occurrence professional indemnity insurance for consultant doctors and new GP members from 1 July 2020.”Links to recent Medzines for additional information:
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