Multidisciplinary Team Decision Research Articles

Inverted aortic bioprosthetic for mitral valve replacement with Ross procedure: case report

BackgroundA 34-year-old gentleman presented with Staphylococcus salivarius infective endocarditis 13 years after aortic homograft and mitral valve repair for degenerative bicuspid aortic valve associated with rheumatic heart disease. The homograft had calcified, and the mitral repair had deteriorated with severe regurgitation. Multidisciplinary team decision to restore best quality of life was for re-do Ross procedure with bi-leaflet preserving mitral valve replacement with an inverted RESILIA aortic valve as the patient was fundamentally against lifelong anti-coagulation.Case presentationThe aortic homograft was excised, and coronary arteries dissected out followed by harvesting of the pulmonary autograft. The mitral valve was accessed via a trans-septal approach. On examination, there was a restricted and thickened posterior mitral valve leaflet. An inverted 27-mm INSPIRIS RESILIA aortic bio-prosthesis was placed with mitral cusps preserved. The pulmonary autograft was implanted in an intra-annular position, and a 26-mm pulmonary homograft was used to replace the pulmonary valve. Echocardiogram at 4 weeks revealed preserved LV function and well-functioning prosthetic, autograft and homograft.ConclusionAn inverted RESILIA valve, with its anti-structural valve deterioration properties, can be used in the mitral position with preservation of the mitral cusps to avoid anti-coagulation with the hope of reducing need for re-operation in line with patient wishes.

Safely Increasing Connection to Community-Based Services: A Study of Multidisciplinary Team Decision Making for Child Welfare Referrals.

Initial child welfare screening decisions, traditionally made by an individual worker, determine if a family will receive further intervention by child protective services. A multi-disciplinary team (MDT) decision-making approach for child welfare referrals aims to provide a more thorough assessment of needs and strengths and to connect families to appropriate community-based providers. This study examined 159 child welfare referrals handled by MDTs compared to 331 referrals handled via the traditional screening approach. The study used a pseudo randomization procedure to assign referrals to the study conditions: Referrals logged on 2.5 days of the week were assigned to the treatment group; all others were assigned to the comparison group. Referrals handled by an MDT were more than four times as likely as those not handled by an MDT to be referred to community-based organizations (OR = 4.32, p < .001). There were no statistically significant differences in families' engagement with community-based organizations or child welfare outcomes. MDTs are a promising step in the initial process of connecting families to services, although they did not affect this study's longer-term outcomes.

How was the management of patients scheduled for surgical biopsy through a multidisciplinary approach to the diagnosis of interstitial lung diseases? Was a pathological diagnosis alone enough?

OBJECTIVE: The present study examines the clinical and radiological findings and pathological diagnoses of patients undergoing surgical biopsy with an multidisciplinary team (MDT) decision and investigates whether final diagnoses change on the reevaluated of pathological diagnoses at MDT meetings. MATERIALS AND METHODS: A total of 416 patients were discussed at MDT meetings held at the University of Health Sciences Istanbul Sureyyapasa Chest Diseases and Thoracic, Surgery Training and Research Hospital January between January 2016 and May 2019, with surgical biopsy decisions made for 50 (12%) patients. RESULTS: Among the 50 patients, 26 (52%) were female, with a mean age of 53 ± 12 years. The most common locations of the surgical biopsy were the right lung (n = 27, 54%), lower lobe (n = 38, 76%) and single lobe (n = 35, 70%). A definitive pathological diagnosis was established in 41 (82%) patients following the biopsy. The most common diagnoses were usual interstitial pneumonia (UIP; n = 19, 38%), sarcoidosis (n = 11, 22%), unclassifiable fibrosis (n = 9, 18%), (non-specific interstitial pneumonia; n = 5, 10%), (hypersensitivity pneumonitis; n = 2, 4%) and others (n = 4, 8%), respectively. Diagnoses of 13 (26%) such patients were revised. The revision was most common in the unclassifiable fibrosis and UIP subgroups. The radiological appearance was classified based on the high-resolution computed tomography parameters for idiopathic pulmonary fibrosis (IPF). The final diagnosis was IPF in eight of 14 patients with “probable” diagnoses, all four patients with “indeterminate” diagnoses and three of the 28 patients with “alternative” diagnoses. CONCLUSION: Diagnosing interstitial lung diseases is difficult, and while surgical biopsy provides the most definitive diagnosis, it is not enough by itself. IPF may vary in radiology. Patients diagnosed with UIP and unclassifiable fibrosis after biopsy should be reevaluated, and the final diagnosis should be established through a multidisciplinary approach.

Surveillance imaging of grade 1 astrocytomas in children: can duration and frequency of follow-up imaging and the use of contrast agents be reduced?

PurposeThe optimum strategy for the surveillance of low-grade gliomas in children has not been established, and there is concern about the use of gadolinium-based contrast agents (GBCAs), particularly in children, due to their deposition in the brain. The number of surveillance scans and the use of GBCAs in surveillance of low-risk tumours should ideally be limited. We aimed to investigate the consistency and utility of our surveillance imaging and also determine to what extent the use of GBCAs contributed to decisions to escalate treatment in children with grade 1 astrocytomas.MethodsThis was a retrospective single-centre study at a tertiary paediatric hospital. All children with a new diagnosis of a non-syndromic World Health Organization (WHO) grade 1 astrocytoma between 2007 and 2013 were included, with surveillance imaging up to December 2018 included in analysis. The intervals of surveillance imaging were recorded, and imaging and electronic health records were examined for decisions related to treatment escalation.ResultsEighty-eight patients had 690 surveillance scans in the study period. Thirty-one patients had recurrence or progression leading to treatment escalation, 30 of whom were identified on surveillance imaging. The use of GBCAs did not appear to contribute to multidisciplinary team (MDT) decisions in the majority of cases.ConclusionSurveillance imaging could be reduced in number and duration for completely resected cerebellar tumours. MDT decisions were rarely made on the basis of post-contrast imaging, and GBCA administration could therefore potentially be restricted in the setting of surveillance of grade 1 astrocytomas in children.

Fetus-in-fetu found at excision of antenatally diagnosed abdominal mass: Multi-disciplinary approach

We present a case of antenatally detected abdominal mass and an alternative diagnostic course for suspected neonatal neuroblastoma as a result of investigative findings. A female infant presented antenatally with a left upper quadrant mass initially managed as a suspected neonatal neuroblastoma; further cross sectional imaging suggested a wider differential including teratoma and aided surgical planning. The multi disciplinary team (MDT) decision was for an early excision at 31 days and post operative histology identified a diagnosis of fetus-in-fetu (FIF). We describe this case as a compliment to the current literature and an example of a necessary variation to recognised diagnostic and treatment pathways as a result of investigative findings. This case highlights the use of cross sectional imaging in cases of diagnostic uncertainty in the situation of antenatally diagnosed left upper quadrant mass. The findings were unusual and present an interesting example of how the multi disciplinary team is essential in the approach and management of complex presentations.

Delivering esophago-gastric cancer care during the COVID-19 pandemic in the United Kingdom: a surgical perspective.

SummaryBackgroundThe COVID-19 pandemic continues to have a significant impact on the provision of medical care. Planning to ensure there is capability to treat those that become ill with the virus has led to an almost complete moratorium on elective work. This study evaluates the impact of COVID-19 on cancer, in particular surgical intervention, in patients with esophago-gastric cancer at a high-volume tertiary center.MethodsAll patients undergoing potential management for esophago-gastric cancer from 12 March to 22 May 2020 had their outcomes reviewed. Multi-disciplinary team (MDT) decisions, volume of cases, and outcomes following resection were evaluated.ResultsOverall 191 patients were discussed by the MDT, with a 12% fall from the same period in 2019, including a fall in new referrals from 120 to 83 (P = 0.0322). The majority of patients (80%) had no deviation from the pre-COVID-19 pathway. Sixteen patients had reduced staging investigations, 4 had potential changes to their treatment only, and 10 had a deviation from both investigation and potential treatment. Only one patient had palliation rather than potentially curative treatment. Overall 19 patients underwent surgical resection. Eight patients (41%) developed complications with two (11%) graded Clavien-Dindo 3 or greater. Two patients developed COVID-19 within a month of surgery, one spending 4 weeks in critical care due to respiratory complications; both recovered. Twelve patients underwent endoscopic resections with no complications.ConclusionCare must be taken not to compromise cancer treatment and outcomes during the COVID-19 pandemic. Excellent results can be achieved through meticulous logistical planning, good communication, and maintaining high-level clinical care.

Impact of COVID-19 pandemic on surgical neuro-oncology multi-disciplinary team decision making: a national survey (COVID-CNSMDT Study)

ObjectivesPressures on healthcare systems due to COVID-19 has impacted patients without COVID-19 with surgery disproportionally affected. This study aims to understand the impact on the initial management of patients with...

Ruptured Popliteal Artery Aneurysm Complicated with Acute Respiratory Distress Syndrome Secondary to SARS-CoV-2 Infection

We herein report a rare case of the ruptured popliteal artery aneurysm in an 89-year-old man, whose recovery after surgical treatment was complicated with acute respiratory distress syndrome secondary to confirmed infection with SARS-CoV-2. Presenting symptoms, patient's comorbidities, and postoperative course complicated with cardiac and respiratory failure leading to adverse outcome are discussed in this case report.

Safety and feasibility of percutaneous nephrolithotomy (PCNL) during pregnancy: A review of literature.

Management of nephrolithiasis during pregnancy can be challenging because of the potential risks to the mother and fetus. Diagnosis and treatment can be a dilemma owing to the anatomical and physiological changes, besides the limitation in the use of X-rays. The aim of this article was to identify any case series or case reports where percutaneous nephrolithotomy (PCNL) was used as a treatment modality for nephrolithiasis in pregnancy. A review of the literature was performed using Medline, EMBASE, CINAHL, and Scopus from 1990 to October 2019. A search was conducted using the following search terms: "urolithiasis," "renal stones," "stone disease," "kidney stones," "pregnancy," "pregnant," "percutaneous nephrolithotomy," "PNL," and "PCNL." The initial search strategy retrieved 52 articles, but after going through them, only 7 were suitable for inclusion in this review. Overall, seven studies reported regarding 16 patients who underwent PCNL procedure during pregnancy. The patients were aged 18-34 years and had the procedure between 11 and 32 weeks of gestation. Most stones were in the renal pelvis or pelvic-ureteric junction and sized 8-40 mm, with the most common indication for the intervention being refractory pain. Most treatments used ultrasound guidance, and X-ray fluoroscopy was employed only in two cases. No complications occurred to the mother or fetus in any of the case reports, suggesting that PCNL is a safe and feasible treatment for patients with persistent symptoms when conservative treatment has failed. All the reported cases of PCNL achieved stone-free status with no complications. Although PCNL has been evidenced to be safe, it must be performed by experienced endourologists after careful consultation with the obstetricians. Patient counseling and multidisciplinary team decision-making are paramount in such complex scenarios.

Improvement of the Efficiency and Completeness of Neuro-Oncology Patient Referrals to a Tertiary Center Through the Implementation of an Electronic Referral System: Retrospective Cohort Study.

BackgroundQuality referrals to specialist care are key for prompt, optimal decisions about the management of patients with brain tumors.ObjectiveThis study aimed to determine the impact of introducing a Web-based, electronic referral (eReferral) system to a specialized neuro-oncology center, using a service-developed proforma, in terms of waiting times and information completeness.MethodsWe carried out a retrospective cohort study based on the review of medical records of referred adult patients, excluding follow-ups. Primary outcome measures were durations of three key phases within the referral pathway and completion rates of six referral fields.ResultsA total of 248 patients were referred to the specialist center during the study period. Median (IQR) diagnostic imaging to referral intervals were 3 (1-5) days with eReferrals, and 9 (4-19), 19 (14-49), and 8 (4-23) days with paper proforma, paper letter, and internal referrals, respectively (P<.001). Median (IQR) referral to multidisciplinary team decision intervals were 3 (2-7), 2 (1-3), 8 (2-24), and 3 (2-6) days respectively (P=.01). For patients having surgery, median (IQR) diagnostic imaging to surgery intervals were 28 (21-41), 34 (27-51), 104 (69-143), and 32 (15-89) days, respectively (P<.001). Proportions of complete fields differed significantly by referral type in all study fields (all with Ps <.001) except for details of presentation, which were present in all referrals. All study fields were always present in eReferrals, as these are compulsory for referral submission. Depending on the data field, level of completeness in the remaining referral types ranged within 69% (65/94) to 87% (82/94), 15% (3/20) to 65% (13/20), and 22% (8/41) to 63% (26/41) in paper proforma, paper letter, and internal referrals, respectively.ConclusionsAn electronic, Web-based, service-developed specific proforma for neuro-oncology referrals performs significantly better, with shorter waiting times and greater completeness of information than other referral types. A wider application of eReferrals is an important first step to streamlining specialist care pathways and providing excellent care.International Registered Report Identifier (IRRID)RR2-10.2196/10.2196/15002

Referral patterns and outcomes of a highly specialised pelvic exenteration multidisciplinary team meeting: A retrospective cohort study

IntroductionThe purpose of this study was to review recommendations made from a specialist pelvic exenteration (PE) multidisciplinary team (MDT) and to provide insights as to the impact of the MDT on patient selection and clinical decision making. Materials & methodsA retrospective review was conducted at Royal Prince Alfred Hospital's PE MDT between June 2014 and December 2015. Data was collected from the recorded minutes of MDT meetings. Referral information and clinical data was extracted from individual patient files. Additional data including operative dates and surgical resection margins were collected from electronic medical records. ResultsOf the 183 patients considered for PE during the MDT meeting, 104 (57%) were recommended for surgery. Factors that influenced the recommendation in favour of surgery were referral by a surgeon (P = 0.004), referral from a rural location (P = 0.05) and having locally advanced primary cancer (P < 0.001). Patients who were seen by the unit's surgeon prior to the MDT did not impact on the MDT recommendation nor the decision for or against surgery (P = 0.771). The most common reason for recommendation against PE was unresectable distant metastatic disease (43%). ConclusionsThe PE MDT meeting is a critical step in the patient care pathway and facilitates critical decision making. Anatomically-based contraindications to surgery (i.e. involvement of adjacent organs, bone and neurovascular structures) do not appear to influence MDT decision making regarding resectability.

Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness

IntroductionAdrenal incidentalomas are lesions that are incidentally identified while scanning for other conditions. While most are benign and hormonally non-functional, around 20% are malignant and/or hormonally active, requiring prompt intervention....

The role of multidisciplinary decision making in oropharyngeal cancer: do we follow guidelines and are treatment decisions being implemented?

A multidisciplinary team (MDT) approach to cancer management is gold-standard. With an increasing disease incidence and growing research into human papillomavirus (HPV)-related oropharyngeal cancer (OPC), updated UK management guidelines were recently published. This study aimed to evaluate the MDT decision-making process among OPC patients at a tertiary centre. MDT meetings over a 12-month period were analysed retrospectively. MDT decisions were compared with guidelines and patient records examined to identify decision implementation. Reasons behind any discordant decisions were explored. This study included 140 OPC patients. Thirty-three (23.6%) were not tested for HPV. Patients over 70years with a smoking history treated palliatively were less likely to be tested (P = 0.017). Eighty-five percent of MDT decisions followed guidelines with the majority not complying (76.2%) related to patient comorbidity. Ten decisions (7.1%) were not implemented. Reasons included: Seven due to patient choice, of which four patients (57.1%) were only seen following the MDT meeting, and three due to clinician decisions as new clinical information emerged. The majority of MDT decisions followed guidelines and any discordant decisions were justifiable. Discussing management options with patients beforehand facilitates decision implementation as decisions can potentially change after seeing the patient. Progress is still needed with regards to HPV testing. Reasons for not testing could include subliminal decision-making among clinicians, and patients falling between centres. Crucially, the role of the MDT in head and neck cancer should be to ratify decisions rather than making them, hence the need to see patients prior to MDT discussion.

450 Balloon Aortic Valvuloplasty Alone Compared to Medical Therapy is Associated With Improved Long-Term Survival in Patients With Severe Aortic Stenosis

The role of balloon aortic valvuloplasty (BAV) has been questioned in an era of transcatheter aortic valve implantation (TAVI). Whether BAV alone is associated with improved outcomes when compared to medical management of patients with severe aortic stenosis (AS) is unclear. We assessed consecutive patients with echocardiographic evidence of severe AS between 2015-19. Patients were grouped according to the management instituted as determined by the multidisciplinary Heart Team decision; either BAV or medical management. The primary outcome was long-term all-cause mortality. Among the 187 patients with severe AS, 139 (74.3%) underwent medical management while 48 (25.7%) underwent BAV. Patients undergoing BAV were older (81.7 vs 85.8 years, p=0.01) and more likely to be female (33.3% vs 18.6%, p=0.02). No differences in individual covariates of the STS-PROM score or functional characteristics including living/mobility status or cognitive impairment were noted. 77(41.6%) deaths occurred over the study period. Patients treated with BAV had a significantly lower chance of death compared to those managed medically (HR 0.46, 95% CI 0.25-0.86, figure), even after adjustment for significant univariate clinical and functional predictors. In severe AS, BAV was independently associated with lower mortality when compared to medical therapy despite being performed in older patients. Due to limitations in access to TAVI, studies are warranted to assess whether BAV as opposed to medical therapy, can reduce wait-list mortality.

P182 Bleeding complications in a rendu-osler-weber syndrome patient with atrial fibrillation - challenging serial transoesophageal echocardiography

Abstract Rendu-Osler-Weber (ROW) syndrome or hereditary hemorrhagic telangiectasia is a rare autossomic dominant disease characterized by vascular dysplasia involving multiple systems and associated with an increased bleeding risk. The presence of atrial fibrillation in this population becomes a challenge, regarding the evaluation of bleeding and thrombotic risks and the best approach for the patient management. A 72 years-old female with ROW syndrome, atrial fibrillation and a CHA2DS2-VASc risk score of four, was admitted to our hospital for left atrial appendage (LAA) closure after a period of novel oral anticoagulation crowed with multiple haemorrhagic events and blood transfusions. After the implantation of a Watchman LAA number 33 closure device (Image 1A), and because of the concomitant diagnose of chronic pulmonary embolism, she was restarted on anticoagulation therapy in lower doses, with initial tolerance. For evaluation of LAA closure device during follow-up, after an unsuccessful attempt of transoesophageal echocardiography (TEE) because of severe epistaxis subsequent to oropharyngeal anaesthesia, the patient underwent a Cardiac Computed Tomography (CT) that showed a moderate peri-device leak (4.4x11mm, 0.73cm2) – (Image 1B). For better characterization, the patient underwent a new attempt of TEE with the support of an anaesthesiologist and the need of local vasoconstrictor agents and tranexamic acid for epistaxis and oropharyngeal bleeding control. TEE confirmed a moderate posterior device-leak (7.1mm) with absence of cavitary thrombus (Image 1C). After a year of anticoagulation with new significant bleeding events, TEE was repeated with the anaesthetic and pharmacologic preparation. This TEE showed a decrease in peri-device leak (&amp;lt;5mm wide – Image 1D), which was fundamental for supporting the multidisciplinary team decision of interruption of anticoagulation therapy. With this case we want to highlight the challenging decisions regarding patients with ROW syndrome and atrial fibrillation. Specifically, we must be alert about possible complications in trying to perform TEE in this population, once the frequent occurrence of telangiectasias in the oropharynges that may occur, as in this patient. Abstract P182 Figure. Image 1

Do We Need Multidisciplinary Team Decisions in Vascular Care: An Insight in Endovascular Pad Treatment?

Introduction - Worldwide prevalence of peripheral artery disease (PAD) has evolved to an intervention as the primary treatment option. There is evidence that multidisciplinary team decision-making (MTD) has an impact on in-hospital outcomes. This study aims to describe practice patterns and time changes in MTD between different health-care disciplines prior to endovascular percutaneous revascularizations.

Decision-Making in Gynaecological Oncology Multidisciplinary Team Meetings: A Cross-Sectional, Observational Study of Ovarian Cancer Cases

Introduction: Multidisciplinary team (MDT) meetings are widely used across the UK to provide expert decisions and improve cancer outcomes. However, little is known about the underlying mechanisms of MDT decision-making. We investigated how decisions are made regarding the management of advanced ovarian cancer in gynaecological oncology MDT meetings. Methods: A cross-sectional observational study was performed, focussing on 41/ 223 MDT case discussions across six hospitals. The validated MDT-MODe tool was adapted to increase relevance to gynaecological oncology. Case information and contributions from seven disciplines were rated on a five-point Likert scale. Spearman’s correlation investigated relationships between factors and an exploratory factor analysis examined the underlying structure of MDT discussion. Results: Forty-one MDT decisions were made for patients with FIGO Stage III/IV ovarian cancer. MDT case discussions were structured by four factors: “Clinical Presentation,” “Patient Factors,” “Chair’s Direction” and “Input from Other Specialties.” Nurses were often quiet but facilitated discussion of patient factors. Junior doctors were not involved in MDT decision-making. Conclusions: The decision-making process in MDT meetings is driven by four underlying factors, the most significant of which represents patient history, tumour markers, images and radiologist input. Patient factors were underrepresented, and nurses should be empowered to overcome this.

Exploring pornography use in secure hospitals: a qualitative analysis

PurposeThis research paper reports findings from a qualitative analysis which explored pornography use in secure hospitals. The purpose of this paper is to investigate what attitudes staff working in secure hospital have towards patients having access to pornography, how they make decisions regarding access to pornography and what factors they take into account during this process. This research is an extension of a prior quantitative research study (Mellor and Duff, 2019).Design/methodology/approachThe study utilised a qualitative approach using semi-structured interviews to explore professionals’ attitudes towards pornography use in a secure hospital. The sample comprised of six volunteers who had taken part in a previous research study (Mellor and Duff, 2019) requesting to discuss the topic area further. As such this research study was developed. Thematic analysis (Braun and Clarke, 2006) was used to analyse the qualitative data and the Attitudes towards Pornography Scale (Evans-DeCicco and Cowan, 2001) was used to collect demographic information.FindingsSix themes were identified from the transcripts. The first theme explores staff members’ attitudes towards pornography. The second relates to the use of boundaries and monitoring of pornography. The third theme looks at the potential impact that pornography could have on the patient, either positive or negative. The fourth theme explores the extent to which patients are still considered as human beings, whereas the fifth theme explores the vulnerabilities that may make patients more at risk of being negatively influenced by pornography. The final theme looks at decision making regarding access to pornography.Practical implicationsThe research offers an insight into how pornography within secure hospitals is managed. The research also provides an exploration into multi-disciplinary team decision making with regard to pornographic material and notes the general openness of staff towards patients having access to pornography.Originality/valueThe findings have important messages for services with regard to policy making. The findings are also relevant for understanding how pornography is managed with in secure hospitals.

163 Rehabilitation to Nursing Home - The Waiting Period

Abstract Background The average application processing time for the National Nursing Home Support Scheme (NHSS) has seen drastic improvement from 15 weeks in 2014 to 4 weeks in 20161. There is no available data of the duration of stay in rehabilitation beds after approval of NHSS application and reasons for delay in transition to nursing home. Aims (1) To examine average length of stay in rehabilitation before multidisciplinary team (MDT) decision is made for nursing home care. (2) To examine average length of stay in rehabilitation bed from the time of NHSS approval to discharge into nursing home. (3) To examine reasons for delay in discharge to nursing home after NHSS approval. Methods A retrospective chart review of patients discharged into nursing homes between January to June, 2018 from geriatric rehabilitation units. Data collected include age, length of stay in rehabilitation unit before multidisciplinary decision was made in conjunction with patients/family to seek nursing home care (LOS1), Length of stay in rehabilitation bed following decision for nursing home care (LOS 2). Reasons for the delay in the transition from rehabilitation bed to nursing home bed were also documented. Results Seventeen patients were discharged into nursing homes, LOS1 of 43.12 days and LOS2 of 50 days. Complexity of application in terms of financial evaluation especially for patients who were deemed cognitively incapable of managing their finances, lack of suitable nursing homes for patients with complex needs/challenging behaviours, family dynamics with regards to choice of nursing homes and medical stability to facilitate such transfers were reasons for delay in transition to nursing home beds. Conclusion Transitional care beds, which are generally acknowledged to be more appropriate to these patients' care needs and are less expensive than rehabilitation beds, need to be utilized more. Education of healthy adults over 65 years to proactively plan for future care needs and promote awareness of legislatures regarding capacity and decision making.

The multi-disciplinary team – Who is liable when things go wrong?

The question of culpability over decisions made by the multi-disciplinary team (MDT) is a contentious one. Currently, all members present remain responsible for the MDT's decision, but it is unclear whether the onus of decision making lies with the patient's “lead clinician”, and how straight to test pathways (bypassing a consultation with a specialist prior to MDT discussion) impact on this. Additionally, should a non-consensus recommendation be reached, it remains undetermined how dissenting members of the MDT would be viewed in a court of law. Given these uncertainties, there remains a substantial risk of legal action against the MDT as a group. Until case law materialises to provide clarification on these issues, clinicians should improve their awareness over their medico-legal responsibilities and proceed with caution.