Patients undergoing craniotomy may experience moderate to severe pain postoperatively. An audit of analgesia of post-craniotomy patients at King's College Hospital demonstrated variable analgesic prescribing practices and suboptimal analgesia in some patients. Prior to introducing a formal post-operative analgesic regime, a survey of the adult neurosurgical units within the United Kingdom was undertaken to ascertain whether there was a general consensus regarding post-craniotomy pain management. Questions were asked as to whether there was a standardized analgesic regime/protocol; which first, second, third, and fourth-line analgesics were used; whether non-steroidal anti-inflammatory drugs were used; what the preferred anti-emetic was; and whether pain was routinely assessed. We also undertook a survey of neurosurgeons, neuroanaesthetists, intensivists, and neurosurgery high dependency nurses within our institution to ascertain what their perceptions were of post-craniotomy pain. All 31 adult neurosurgical units were surveyed. Twenty three percent (7 units) had a standardized analgesic regime/protocol and 65% routinely assessed pain post-operatively (20 units). Seventy percent of units used codeine phosphate or dihydrocodeine (22 units) as the first line opioid the other 30% using morphine (9 units). Forty two percent (13 units) used tramadol; patient controlled analgesia was used in 3 units. Regular paracetamol was prescribed in all but five (16%) units. Fifty two percent of units (16) used NSAIDs; of those that used NSAIDs 19% (3/16) prescribed them regularly. One unit used clonidine infusions. Anti-emetics were prescribed as required in all but two units. Cyclizine was the first-line anti-emetic in 45% of the units, ondansetron in 29% and metoclopramide in 16%. There is currently no consensus on pain management after craniotomy in neurosurgical centres in the UK. Until there are sufficiently powered randomized controlled studies to address the main safety and efficacy issues progress in this area will remain slow.
Confidentiality is a patient's right and is central to trust between doctors and patients. Any disclosure and use of confidential patient information needs to be both lawful and ethical. The duty of confidentiality arises out of the common law of confidentiality, the Human Rights Act, General Medical Council guidelines, NHS staff employment contracts and ethical mores. Breaches of confidence, inappropriate use of health records or abuse of computer systems may lead to disciplinary measures, bringing into question professional registration and possibly resulting in legal proceedings.
Whilst law and ethics in this area are largely in step, the law provides a minimum standard that does not always reflect the appropriate ethical standards that the government and the professional regulatory bodies require. The duty to preserve confidentiality can present intensivists with ethical and/or legal dilemmas. This article summarises the general principles of confidentiality and reviews the legal and professional requirements that intensivists need to be cognisant of when dealing with third party requests for patient information.
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