Coronavirus: Your frequently asked questions

Vaccines

We’re not directly involved in developing or regulating vaccines. But we understand that doctors and patients could have questions about the rollout of the coronavirus (COVID-19) vaccines, and how this will impact them. 

We answer some of those common questions below.

As a doctor, should I be vaccinated against COVID-19?

In our guidance Good medical practice (2013), we say that doctors should be immunised against common serious communicable diseases unless doing so is contraindicated.

In our view, the potential risk to a doctors’ own health as well as the risk of inadvertently spreading COVID-19 to vulnerable patients weighs in favour of doctors being vaccinated. And reducing the number of staff who are sick or in self-isolation due to COVID-19 infection has a positive impact on workforce capacity to respond to patient need and wider health service demands. 

However we recognise that vaccination is not possible in all cases. If you are not vaccinated, you need to be confident that there are measures in place where you work to manage any risk to patients and colleagues. You will need to take appropriate steps to reduce risks and prioritise patient safety.

Together with the Academy of Medical Royal Colleges we have set out our position on vaccination against COVID-19 as a condition of deployment for health and social workings in England. 

Can a child or young person consent to the vaccine without the agreement from a parent or guardian? 

In 0-18 years: guidance for all doctors, we set out that young people aged 16 or over can consent to their own treatment and are presumed to have capacity to do so unless there is evidence to the contrary. 

Children under the age of 16 can consent to treatment if they have the maturity to fully understand its nature, purpose, and possible consequences. This is also known as ‘Gillick competence’ after the legal case that established the concept in law. 

Doctors should encourage children and young people to involve their parents in important decisions about their care but should usually abide by any decision the child or young person has the capacity to make themselves. 

Doctors should take account of our Decision making and consent guidance when discussing treatment options, their risks, benefits, and potential outcomes. 

What’s the best way to explain the risks and benefits of the vaccine to a child or young person?

It may be challenging to explain the risks and benefits of a vaccine in child-friendly terms especially if you work in a time-pressured environment.  Support for this is available from Public Health England, Public Health Scotland, Public Health Wales and Public Health Agency who have produced a range of leaflets and information for children and young people, including simple text versions.

We suggest doctors use these resources to help children and young people understand the benefits and risks of the vaccine. They can then assess whether the young person has the maturity and understanding to make the decision about whether to receive the vaccine. 

How should doctors seek an adult patient’s consent for the vaccine? 

Doctors must be satisfied they have consent or other valid authority before they provide treatment to patients (paragraph 17 in Good medical practice). Our expectations are the same for doctors before they administer vaccines.

As part of this process, registered healthcare professionals, including doctors, nurses, pharmacists and many other professionals, will be responsible for speaking with patients to find out about allergies, their medical history and any contraindications.

The National Protocols for the approved vaccines include information on obtaining patient consent. You can find further information, resources and template consent forms for your area: 

• England 
• Northern Ireland
• Scotland
• Wales

In all cases, doctors should familiarise themselves with our Decision making and consent guidance, in particular the seven principles and paragraphs 21-26 on discussing benefits and harms and uncertainties with their patients.

For adult patients who lack capacity, paragraphs 87-93 of our Decision making and consent guidance explains the ethical basis and process for treatment decisions.

What information is available about the safety of the vaccine?

For a vaccine to be approved for use in the UK, the Medicines and Healthcare products Regulatory Agency (MHRA) has said that robust standards of quality, safety, and effectiveness must be met.  

NHS England publishes National Protocols for each vaccine as they are approved and become available. Protocols contain the safety information relevant to that vaccine. Information has also been published for:

• Northern Ireland
• Scotland
• Wales

This information will help doctors to give clear, accurate and up-to-date information to their patients so they can make informed decisions about vaccination. Our Decision making and consent guidance will support you to have these conversations with patients.

Your health and wellbeing

What should I do if I feel exhausted?

This has been, and continues to be, a hugely stressful time and many staff will be working long hours to provide care for patients.

Simple steps such as staying hydrated and well-fed and getting the rest you need can help.   There are some really useful resources from the Association of Anaesthetists on fighting fatigue and there's a helpful poster about self-care for NHS staff. 

But if you need more support it’s important to speak up and tell your employer how your feeling so they can take the steps needed to help you.

What can I do if I feel overwhelmed?

We know this is a stressful, challenging time for all healthcare workers, and you might feel like your own wellbeing isn’t a priority at the moment.

But it’s important to look after yourself and support is available if you need it. To help, we’ve created a list of useful resources and links to organisations that can support both you and your colleagues. 

Should I attend work if I have symptoms of coronavirus?

If you know or suspect you are infected with coronavirus, you should follow the current UK government public health advice. If your symptoms worsen, seek medical attention. Be aware that when unwell, your judgement is likely to be clouded, so don’t simply continue to self-treat if your condition worsens.  

Paragraph 28 of Good medical practice says that if you suspect you have a serious condition that could be passed on to patients, you must consult a suitably qualified colleague and follow their advice about any changes to your practice they consider necessary. 

I have a long-term health condition. What should I do?

If you have a pre-existing health condition that places you at increased risk, you should discuss working arrangements with your employer. It may be appropriate to ask another suitably qualified clinician to take over the care of patients who are suspected to have, or have been diagnosed as having, coronavirus.

How can I help my colleagues?

The pandemic continues to affect people in a variety of different ways and it’s important to still remember to look out for each other’s wellbeing.   

Regularly check in with your team members to see how they’re feeling and let them know they have your support. Setting up a buddy system on shifts and carrying our regular team debriefs can help provide a wellbeing safety net and help people to keep an eye on each other. 

If you think a colleague is too tired to drive home after a shift, make sure you discuss your concerns with them before they leave – there may be an alternative, safer way for them travel or on-site accommodation available. 

You can find resources on how you can support colleagues on our wellbeing page. 

What can I do if my employer asks me to cancel my annual leave? 

This is a matter for employers and isn’t covered by professional standards for doctors. However, our Leadership and management guidance says that doctors in leadership positions must promote the health and wellbeing of staff they manage (paragraph 73). 

Working safely

Do you set guidance on what level of PPE is appropriate while working in the pandemic?

Doctors should use PPE in line with the most up to date guidance issued by the four UK health departments. Employers and contracting bodies should take all necessary steps to make sure staff are suitably equipped for their clinical setting in line with that guidance.

How should doctors approach treatment of patients if they think their PPE is inadequate?

If the recommended level of PPE isn’t immediately available, difficult decisions may need to be made quickly about the safest and best course of action, taking account of the clinical situation.

We know that a doctor’s priority will be the welfare of their patients, alongside their own wellbeing and that of the healthcare team in which they work. 

We do not expect doctors to leave patients without treatment, but we also don’t expect them to provide care without regard to the risks to themselves or others. This pandemic is an unprecedented challenge in which clinicians are understandably balancing the imperative to provide care with their own fears. 

We understand that this may lead to doctors having to make very difficult decisions where they have to use their professional judgement.

Doctors will need to consider:

• whether treatment can be delayed, or provided by another team
• what course of action is likely to result in the least harm in the circumstances
• whether alternative actions or additional steps can be taken to minimise the risk of transmission
• whether any doctors or other healthcare professionals are at a higher risk from infection than other colleagues.

You should try to work with colleagues to find the best way forward in the circumstances. Our expectation is that doctors will do their best in the circumstances they face, considering the welfare of the patient and the risk to their own or others’ health to make these difficult decisions. 

How does that sit with your core guidance, Good medical practice, which says that you must not deny treatment to patients because their medical condition may put you at risk?

The advice on our ethical hub on working safely during the pandemic explains how Good medical practice applies to these specific circumstances. Good medical practice (para 58) is clear that if a patient poses a risk to your health or safety, you should take all available steps to minimise the risk before providing treatment or making other suitable alternative arrangements for providing treatment. That’s important because we recognise that it’s not just patients who need protection.

The fundamental duty of a doctor is to make the care of your patient your first concern. We understand that, particularly in these unprecedented and stressful times, doctors may also have significant concerns for their health and that of their families. All our guidance requires professional judgment and the application of principles to the context doctors face. 

What else should I do if my personal protective equipment (PPE) is inadequate?

If you and other healthcare staff may be put at risk by PPE which is below the standard set out in the most up to date guidance, you should raise your concerns with your employer. You should make a record of your decisions and how you handled your safety concerns. 

Will doctors face action if they refuse to treat patients?

If a concern was raised with us about a doctor refusing to treat a patient because of their concerns about inadequate PPE, we would need to look at the specifics and manner of that refusal, as we would with any other concern referred to us. 

We updated our statement on supporting doctors in the pandemic and our guidance for decision makers. We also released a joint statement with other health regulators setting out how we will regulate during this unprecedented period. This makes clear that where a concern is raised about a registered professional, it will always be considered on the specific facts of the case, taking into account the factors relevant to the environment in which the professional is working. We would also take account of any relevant information about resource, guidelines or protocols in place at the time.

Does that mean it’s OK to refuse to treat a patient if a doctor doesn’t have the right PPE?

We expect patient safety to be a doctor’s priority and there would be a clear conflict with doctors’ ethical and professional values if patients did not receive treatment. We would expect you to use your professional judgement and to have considered carefully how to work together with colleagues to provide the best care possible in the circumstances. 

While a lower standard of PPE may increase risk to some degree, doctors would need to consider how to provide care to patients, including whether the available equipment allows treatment to continue. 

If having tried and exhausted alternative means of treating a patient you believe that this is not possible without unreasonable risk to you and to other healthcare professionals, you should escalate your concerns, record your decision and how you tried to address safety concerns.

It’s important that you keep a clear and contemporaneous record of your decisions in the event that a concern is raised about your practice.  

Can't you just set out ‘you would be right/wrong to make this/that decision’?

No two sets of circumstances are the same, and we would have to look at the specifics of any concern raised with us. We do not speculate on scenarios nor do we reach any conclusions without full knowledge of all of the factors involved.

Our expectation is that doctors will use our guidance and their professional judgement to take difficult decisions, and that they will work positively and constructively with colleagues and employers to try to find appropriate alternatives. They should document those discussions and decisions and be able to explain them.

What if I’m asked to work in a different speciality or outside my competence?

As a doctor you are playing a vital role in this pandemic. You may be working in unfamiliar circumstances or surroundings, or in clinical areas outside of your usual practice.

All doctors have a duty to recognise and work within their competence. But in these exceptional circumstances, doctors at every level may be required to work at the limits of their comfort zone and in some cases beyond.

When deciding the safest and best course of action in such circumstances, we advise you to:

• consider what is within your knowledge and skills, and how your existing skills could be used in a different healthcare setting
• identify what skills and experience other members of the healthcare team could offer 
• be willing to seek professional advice and clinical supervision from colleagues. This may come from a senior, peer or a more junior colleague who is acting within their usual clinical setting or scope of practice
• seek additional training and guidance as far as you reasonably can in the circumstances. This can include preparing for work in a new setting by accessing online or local training to help improve your knowledge and skills in advance
• make sure you know who go to for support and professional advice.

In an emergency you should provide the safest care you can. If you think that patients are being exposed to avoidable risk, you should tell a senior colleague or manager and work with colleagues to find the best possible solution in the circumstances. Make sure to record any concerns about working outside of your competence and how this could impact on patient safety. 

We recognise that doctors may feel anxious about how context is taken into account when concerns are raised about their decisions and actions in very challenging circumstances. We've provided guidance on how we will carry out our role at this difficult time. The primary requirement for all doctors is to respond responsibly and reasonably to the circumstances they face.

Doctors in training

If you are required to work in a less familiar clinical setting or at the limits of your competence for your stage of training, your employer should provide appropriate induction and clinical supervision. Supervision should be from an appropriately qualified senior doctor who is competent to make decisions within the relevant speciality or healthcare setting about treatment or discharge of patients. 

Medical students

Medical students who volunteer to work within the NHS during the pandemic should do so with the permission of their parent medical school and only be asked to work in an appropriate role within their level of competency. They should receive an induction to the role and be appropriately supervised. They should only undertake tasks which don’t require professional registration and which are covered by NHS indemnity. If they have any medico-legal questions, they should consider seeking advice from a medical defence organisation. The Medical Schools Council has published a statement of expectation for schools, students and employers on volunteering for the NHS. 

A friend/family member is worried that they have coronavirus and has asked for advice. What should I do?

It can be helpful and reassuring for a doctor to give advice to friends and family about coronavirus which explains and reinforces public health messages. But it can be more problematic if a doctor is providing medical care to someone they are close to.

In paragraph 16(g) of Good medical practice, we say doctors should ‘wherever possible’ avoid giving medical care to themselves or anyone with whom they have a close personal relationship. There are good reasons for giving this advice. Where a doctor provides care to a patient with whom they have a close personal relationship, a loss of objectivity may occur. And it can cause difficulties in terms of record keeping and continuity of care. 

But there will be circumstances where it is necessary or justified, for example in emergencies or in circumstances where it is not possible to seek medical care from another doctor. 

As in all situations, we expect doctors will behave responsibly, reasonably and will be able to explain their decisions and actions if they’re called on to do so.

Remote consultations

How can I provide good patient care in a remote consultation? 

Whether you consult with patients face to face or remotely, the fundamental principles remain the same: provide effective, evidence-based treatments that serve patients’ needs

Our remote consultation ethical hub sets out how our guidance applies when treating patients remotely. There are also resources to help put it into practice. 

Joint high level principles, agreed by UK health regulators, also set out what is expected of any professional who is delivering healthcare remotely.

And you may find it useful to keep these key points in mind:

• Make sure that you are speaking to the right person. Phone consultations can lead to inadvertently disclosing patient information to other people or family members. 
• Make sure the patient is ready for the consultation to begin. Give them time and check they have a private space for the discussion.
• When conducting video consultations, you should use a secure system approved for clinical use wherever possible. 

You may use a mixture of telephone, photographs and video consultation depending on the patient’s condition, your relationship with them and their preferences. You should consider the benefits and potential risks of each method, and which helps you to deliver safe care. 

I don’t think a remote consultation meets the needs of my patient. What should I do?

During the pandemic many healthcare services have changed the way they deliver care to protect patients and staff. Face to face appointments may not be available or patients may be reluctant to attend.  

The flowchart on our remote consultations page can help you to decide whether face to face care is necessary. You will have to balance the patient’s clinical needs with any other concerns or risks which might affect their care, including the risk of infection.  

What do I need to consider when consulting remotely with children and young people?

As in any consultation, face to face or remote, you must continue to safeguard and protect the health and wellbeing of children and young people. This includes treating them as individuals, respecting their views, as well as considering their physical and emotional welfare.

Communication

In paragraphs 14–21 of our 0–18 years: guidance for all doctors we say you should:

• find out what children, young people and their parents want and need to know 
• talk directly to children and young people who are able to take part in discussions about their care
• explain things using language or other forms of communication they can understand.

So that you can provide good care, it’s also important to consider the preferences of the child or young person. For example, would they prefer the consultation to be text-based, phone or video. You should check if they want anyone else with them, and that they’re clear on their right to confidentiality. 

Consent

As a general principle, obtaining consent before any procedure, involves providing your patient with information in a way that they can understand, so they can make an informed decision about whether or not to go ahead. 

You must decide whether a young person is able to consent to investigations or treatment. You should assess this on an individual basis. 

In paragraphs 22–26 of our 0–18 years guidance for all doctors, we say that at the age of 16 it can typically be presumed that a young person has capacity to make most decisions about their treatment and care. And we also stress that it is important to remember that consent is about the patient’s maturity and capacity to understand and make decisions rather than their number of years. 

If it’s clear that the child or young person isn’t able to give their consent, you should seek consent from a parent or guardian. But remember, even if a child or young person isn’t mature enough to make decisions for themselves, their views and preferences are still important and should be considered.

Safeguarding

You should always keep in mind your responsibility for safeguarding children and consider how this will work in a remote setting. The Royal College of Paediatrics and Child Health have published information on safeguarding during the pandemic, including the use of remote consultations.

When is it appropriate to use photographs and video consultations as part of patient care?

During a remote consultation you should consider using photographs and video consultations if it helps assess or diagnose a patient, and supports clinical decision making. 

However, it won’t always be possible or appropriate to assess a patient’s condition remotely. In these cases, you should consider if a face to face consultation to examine the patient is necessary, or signpost to other services where appropriate. Our remote consultations flowchart can help you with these decisions. 

How do I protect patients when images are needed to support clinical decision making?

You can protect patients by only asking for images if this is needed to support clinical decision making, and by using secure arrangements for storing and transferring them. You must seek informed consent (paragraphs 5, 10, 12-13, 16-20, 30 and 59, Decision making and consent) and be clear about the reason why a photograph or video consultation is needed, and how it will be kept secure (paragraph 13, Making and using visual and audio recordings of patients). 

It is important to be aware that photographs and recordings made as part of the patient’s care will form part of their medical record. The UK health departments publish guidance on how long health records should be kept and how they should be disposed of. You should follow this guidance whether or not you work in the NHS. 

If you have concerns about the security of patient information, you should speak to your employer. Every UK health organisation should have a Caldicott Guardian (sometimes known as a Personal Data Guardian in Northern Ireland) who is responsible for protecting patient information and making sure it is used properly.

What should I consider when deciding whether to carry out an intimate examination remotely?

An intimate examination carried out remotely may support clinical decision-making. However, you should carefully consider whether this is clinically necessary to provide a diagnosis, and whether it is more appropriate to examine the patient in person if this is possible. If you and the patient decide to proceed remotely, you should still offer a chaperone wherever possible.

You should also consider whether there are alternative ways to diagnose the patient’s condition. These could include showing the patient images of the condition or symptom they suspect they are experiencing, or asking patients to describe rashes, or lumps. 

When carrying out remote intimate examinations via video, it is important to consider:

• whether you can see well enough to assess the patient
• that patients may find it more embarrassing to present themselves to a camera/screen for examination than to a physical examination 
• that patients may have concerns about the security of the line, that the video might have been recorded or might otherwise be stored somewhere allowing access in the future.

Our guidance, Intimate examinations and chaperones, provides further information about issues to consider when carrying out intimate examinations.

What should I consider when dealing with images of intimate areas specifically?

You should be particularly cautious when requesting and storing images of patients’ intimate areas. 

What you consider to be intimate may not reflect the patient’s view. Patients may find it embarrassing or distressing to share images of their body. They may need additional reassurance about how their images will be kept secure before providing consent for storage and processing.

You should also consider relevant laws regarding intimate images of adults, as well as safeguarding issues for vulnerable adults. 

What do I need to consider when dealing with intimate images of children and young people?

If you have considered all options and you believe that intimate images of a child are needed to support clinical decision-making, you should follow your local information governance policies and seek advice from your medical defence organisation.  

In Making and using audio and visual recordings of patients, we say children or young people under 16 who have the capacity and understanding to give consent for a recording may do so, but you should encourage them to involve their parents in the decision making. Where a child or young person is not able to understand the nature, purpose and possible consequences of the recording, you must get consent from a person with parental responsibility to make the recording (paragraph 21). 

You should be aware of and follow relevant laws regarding intimate images of children and young people. You should also remember your responsibility to safeguard children at all times (paragraphs 8–11, 0–18 years guidance for all doctors).

How can remote consultations be used to support pregnancy prevention for patients on valproate?

Valproate is harmful in pregnancy and contraindicated in women and girls of childbearing potential. The Medicines and Healthcare products Regulatory Authority has published temporary guidance for specialist doctors on how to do an annual review via remote consultation for patients on valproate during the pandemic.

If a patient is shielding, doctors can also initiate valproate via video consultation following a suitable risk assessment where this is the only effective and tolerable treatment.  

Decision making and consent

How does your guidance on consent apply during the pandemic?

All our ethical guidance continues to apply as far as is practical in the circumstances. The primary requirement for all doctors is to react responsibly and reasonably to the circumstances they face.

While some interventions need a signature because of local policies, nothing in our guidance requires that patients’ written consent must be obtained. For most healthcare decisions doctors can rely on a patient's verbal consent. The important thing is that the patient has had the opportunity to consider relevant information and has decided to go ahead with the intervention. In other words, the patient:

• understands what they're giving their consent to
• is aware of the likely outcome
• as far as possible, has time and support to consider information (including risks of harm, potential benefits, uncertainties and likelihood of success) about the recommended option and reasonable alternatives, including the option to take no action.

For doctors carrying out procedures which routinely need a patient's written consent, they should still try to obtain this. But all decisions about a patients’ treatment and care should be recorded in the patient’s record even if written consent is not obtained.

How should doctors make decisions about prioritising access to treatment or care?

In the highly challenging circumstances of this pandemic, doctors will need to provide the best service possible within the resources available.

If options are limited by available resources, doctors may have to make very difficult decisions about how to prioritise access to treatment or care. We advise doctors who are faced with these decisions to:

• take account of current local and national policies that set out agreed criteria for access to treatment
• be confident that decisions are based on clinical need and the likely effectiveness of treatments, and don’t unfairly discriminate against particular groups
• take account of patient wishes and expectations when considering options for treatment and care
• be open and honest with patients and the rest of the healthcare team about the decision-making process and the criteria for setting priorities in individual cases
• keep a record of decisions and the reasons for them.

As far as practical, these decisions should not rest on individual clinicians’ shoulders. They should be taken following discussion with colleagues and, if possible, with input from local clinical ethics committees. It’s also essential that employers recognise the significant emotional distress that clinicians will experience. They should take steps to provide appropriate support, including psychological support and advice from any local clinical ethics committees, where they exist. 

If a decision is taken not to start or to withdraw some forms of treatment from a patient, doctors should still take all possible steps to alleviate the patient’s symptoms and distress and respect their dignity. The patient’s wishes, preferences and fears in relation to their future treatment and care should be explored as far as possible. This includes what interventions would be considered or undertaken in an emergency, such as cardiopulmonary resuscitation. If the patient is dying, they should receive the best available end of life care. We have detailed advice about treatment and care towards the end of life.

We recognise that doctors may feel anxious about how context is taken into account when concerns are raised about their decisions and actions in very challenging circumstances. We've provided guidance as to how we will carry out our role at this difficult time. The primary requirement for all doctors is to respond responsibly and reasonably to the circumstances they face.

Confidentiality and social media 

How does your confidentiality guidance apply during the pandemic?

The principles in our Confidentiality guidance still apply. 

If a disclosure is required by law (for example, under health protection regulations) doctors must disclose information relevant to the request (paragraphs 17 and 18).

If disclosure is not required by law, doctors should usually ask for a patient’s consent to disclose information. But that is not always possible - for example because action must be taken quickly to detect or control outbreaks of communicable diseases (paragraph 14e).

Doctors can disclose information about patients without consent in the public interest if failure to do so may expose others to a risk of death or serious harm. The benefits to an individual or to society of the disclosure must outweigh both the patient’s and the public interest in keeping the information confidential (paragraphs 63-70).

The Information Commissioner’s Office has published a statement about how it will consider complaints about data protection practices during the pandemic along with resources that answer frequently asked questions. NHS X has also published information governance advice which sets out some of the tools that doctors can use to support individual care, share information and communicate with colleagues during this challenging time.

How does your social media guidance apply when sharing information about coronavirus?

Our guidance Doctors’ use of social media recognises the benefits that online platforms can have for patient care and communication but also reminds doctors:

• not to use publicly accessible social media to discuss individual patients or their care (paragraph 14)
• not to disclose identifiable information about patients online (paragraph 12) 
• that communications intended for friends or family may become more widely available (paragraph 69).

The guidance also says that, if doctors identify themselves as a doctor in publicly accessible social media, they should identify themselves by name (paragraph 17). This is because patients and the public generally respect doctors and trust their views – particularly about health and healthcare. Doctors are accountable for their actions and decisions in other aspects of their professional lives – and their behaviour must not undermine public trust in the profession. This shouldn’t be any different online.

Leadership

How can I best support my team?

Doctors in leadership roles are under unprecedented pressure and making decisions amid uncertainty, and rapidly evolving guidance. Self-care and seeking any support you need is vital so that you can, in turn, support your colleagues. 

Dame Clare Marx wrote about the importance of compassionate leadership  and how ‘kindness, civility and collaboration are not a distraction from delivering care, they’re an essential part of it’. Professor Michael West, co-author of the independent wellbeing report Caring for doctors, Caring for patients, and Suzie Bailey, Director of Leadership and Organisational Development at The King's Fund, have written about why compassionate leadership matters in a time of crisis. 

Our Leadership and management guidance says that doctors in leadership positions must promote the health and wellbeing of staff they manage. It emphasises working collaboratively across the multi-disciplinary team, demonstrating respect and kindness, and stressing the importance of clear communication. Now more than ever leadership needs to encourage kindness, civility and collaboration.

These are extraordinarily difficult times for all healthcare staff, which are likely to continue for some time. Ensuring good support is in place will help reduce staff exhaustion and moral injury. 

Information and resources about managing fatigue and supporting doctors returning to practice are in the Your health and wellbeing section of this Q&A.

What should I do if colleagues raise concerns?

It's important to create a culture in your workplace where staff feel safe and supported to raise any concerns. Our speaking up web guide gives advice and tools to help doctors follow the processes set out in our guidance. Ensure you have a system in place for raising concerns that is open, transparent and fair. Log these and let colleagues know what actions have been taken in response.

Identify colleagues who may have additional vulnerabilities and follow national guidelines for clinical staff with underlying health conditions. Be mindful that all colleagues will respond to this situation differently and those who don't have vulnerabilities may nevertheless experience significant anxiety.  This should be managed supportively.

Our Leadership and management guidance says:  

87 If you have a management role or responsibility, you will often have to make judgements about competing demands on available resources. When making these decisions, you must consider your primary duty for the care and safety of patients. You must take account of any local and national policies that set out agreed criteria for access to particular treatments and allocating resources, and make sure that these policies are available to clinical staff.

88 If you are concerned about how management decisions might conflict with your primary duty to patients, you must take steps to manage or deal with any conflict; for example, by:

• asking for colleagues’ advice
• declaring the conflict to your board or other decision-making body
• asking for advice from external professional or regulatory bodies, including defence organisations, if necessary. 

We have more information about PPE in our Working safely section of this Q&A.

What should I do if colleagues are expressing their views directly through the media?

Doctors are entitled to hold and express personal views. They also have an overriding duty to patients, and to uphold the public’s confidence in the profession.  It's vital that doctors raise any concerns that may adversely affect patient safety and/or their own well-being, but it is also equally important that these are raised via the appropriate channels. Doctors should continue to follow our Raising and acting on concerns guidance and you should also direct colleagues to our guidance on Doctors’ use of social media.

You may also need to remind colleagues of the importance of protecting the privacy of high-profile patients from media intrusion, emphasising that all the normal rules of patient confidentiality apply.

There is more information for all doctors in our Confidentiality and social media section of this Q&A.

End of life care

What does advance care planning look like during a pandemic?  

Advance or anticipatory care planning (ACP) helps patients to consider what they want to happen if they become so unwell that they cannot make decisions about their medical care and treatment. It’s important that these discussions are personalised to the individual patient’s wishes and needs and that they are recorded. Advance care plans are not blanket policies that can be applied to a group of patients. 

Patients should be offered the opportunity to discuss ACP as early as possible, so they can explore options and express their preferences, including if they want an advance care plan at all. 

A good advance care plan is where the patient feels they have expressed their wishes and been heard. Those involved in providing care for the patient should know about the plan, including family and informal carers if the patient agrees. They may need to be involved with reviewing it, as the situation evolves.  

However, during the current crisis, ACP discussions and decisions may be taking place in highly pressurised situations and may often be extremely difficult for all concerned. You should do your best to ensure they are handled sensitively and with compassion.  

It may be helpful to draw on the patient centred resources available from organisations such as Age UK and Compassion in Dying. The Resuscitations Council’s Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) can also support personalised care planning for a person’s clinical care.

Why advance care planning matters 

What should I discuss with my patient when creating an advance care plan?

Discussions should be tailored to the individual patient, but could include: 

• the goals of treatment  
• care at different stages in the patient’s journey
• types of interventions, including palliative treatments. 

It’s important to be clear and honest about options. Cardiopulmonary resuscitation (CPR) is one area of decision making where patients and their carers highly value clear explanations.

For example, if the clinical team decides that CPR will not work for the patient in certain circumstances, and a do not attempt CPR (DNACPR) notice is appropriate, this should normally be discussed with the patient directly, or with family, friends or carers if the patient lacks capacity.  

Patients and those close to them may have unrealistic expectations about the likely success of CPR, or not realise the risks of serious injuries or complications that may result from attempting CPR. It’s also important to explain that a decision on DNACPR doesn’t mean that other care would be denied or stopped.

Having an ACP discussion

What if a patient already has an advance care plan?

You should review the plan to make sure it remains relevant in the current circumstances and to explore specific issues related to care during the pandemic. For example, a patient might not want to go to hospital or be put on a ventilator if they are ill with coronavirus, but they still might want to go to hospital and receive treatment for any other illness. 

Where the patient has capacity, discussions should be carried out directly with them, and with their permission, those close to them such as family, friends or carers. 

Where the patient doesn’t have capacity, you should consult those close to them for their views about what would be in that patient’s best interests or of overall benefit to them in the circumstances. You should do your best to find out if the patient has nominated someone to be consulted about their wishes and preferences, or if they’ve appointed a legal proxy (not available in Northern Ireland) who can make the relevant decisions on their behalf.  

How can I support caregivers where patients are treated at home?

Family and friends can play a vital role in supporting and helping to deliver care and treatment to their loved ones. Doctors play a key role in making sure local arrangements are appropriate and safe for the patient and the carer. 

Doctors should: 

• work collaboratively with carers and the whole healthcare team to develop an agreed care and treatment plan, which must be documented, and may need to be reviewed on a regular basis
• discuss and agree an advance care plan, in case the patient deteriorates 
• ensure anyone giving additional care is suitably trained and has support
• always ensure decisions about treatment and care are made on a personalised basis 
• be guided by relevant local and national guidance, although it may be necessary given the current exceptional circumstances to deviate from these. In such cases, the doctor should make a record and must be prepared to justify their decision.

How does your guidance on end of life care apply in a pandemic?

All our ethical guidance continues to apply as far as is practicable in the circumstances. The primary requirement is for doctors to act responsibly and reasonably.

You should follow our Treatment and care towards the end of life guidance covering ACP (paragraphs 50 – 74) and CPR (paragraphs 128-146), as far as possible, being honest about any uncertainties or likely outcomes for the patient.