If you’ve been following the news – as you should in the leadup to medical school interviews – you’ve probably heard about Martha’s Rule. It’s a new NHS patient safety initiative where patients and their families can trigger a review of a patient’s condition under certain limited circumstances. As one of the most recent patient safety cases in the NHS, it’s changing the landscape around safety to give more power to patients and their families. It’s a key ‘hot topic’ that it’s worth being familiar with for medical school interviews!

What Is Martha’s Rule?

Martha’s Rule came about as the result of campaigning by Merope Mills following her thirteen-year-old daughter, Martha’s, tragic and preventable death from sepsis. Merope was deeply angry and frustrated that her daughter’s death was preventable. She and other family members repeatedly raised concerns to doctors that Martha was deteriorating, but they were ignored. 

Martha’s Rule intends to stop this from happening again by enshrining patients and their families’ right to independently trigger a review by an independent clinical team with special training in critical care medicine in NHS policy. This would mean that if a patient is getting sicker, they or their family can request an independent review from expert clinicians.

On an ethical level, Martha’s Rule aims to give control back to patients and their families to enable better patient outcomes. It sits well within the four pillars of medical ethics as a particularly ethically supported intervention. 

Martha’s Rule promotes patient autonomy, as patients themselves can request a review if they feel it is needed. It should prevent harm and lead to better outcomes, supporting beneficence and non-maleficence.

It should also be just as the scheme is available to all patients, but there are concerns that smaller hospitals will be less able to offer Martha’s Rule promotes patient autonomy, as patients themselves can request a review if they feel it is needed. It should prevent harm and lead to better outcomes, supporting beneficence and non-maleficence.

It should also be just as the scheme is available to all patients, but there are concerns that smaller hospitals will be less able to offer outreach teams and that some patient groups may be less willing to challenge doctors and use the rule.

What Does Martha’s Rule Involve?    

Martha’s Rule is actually very specific. It applies to hospital inpatients whose condition is deteriorating. Reviews under Martha’s Rule are undertaken by a critical care outreach team, who are well placed to decide if patients need further support to stay alive, like being moved to intensive care and being ventilated, but cannot offer second opinions on other aspects of medical care.

It’s important to realise that Martha’s Rule is not the same as a right to a second opinion, which does not actually exist in the NHS. While the NHS and GMC both advise that patients should be able to seek second opinions if they want to, in practice, there is no framework to enable this in most cases.

It can be challenging to secure a second opinion from, say, a GP or hospital consultant. Martha’s Rule doesn’t address this directly, but it provides a pathway to get a second opinion in some specific and time-urgent cases. It also allows patients to directly request this opinion, bypassing clinical staff, which is new for the NHS.

Martha’s Rule is also interesting as it mainly involves making patients aware of a hospital service that already exists. Many hospitals already have critical care outreach teams, who are available 24/7 to review deteriorating patients and assess if they need intensive care support.

Therefore, for many hospitals, implementing Martha’s Rule can be as simple as displaying posters with the team’s number in wards. This is based on similar programmes in Australia, the US and some UK hospitals which work well.

However, it will still take time to roll out Martha’s Rule as some hospitals do not have critical care outreach support available 24/7. It will be rolled out in 100 hospitals from April 2024 and this will be evaluated to explore how it might be rolled out across the NHS and in non-acute settings.

Real-Life Application of Martha’s Rule

It is therefore likely that the real-life applications of Martha’s Rule will be somewhat limited. It is more important as a principle for understanding how the NHS is changing: it shows a commitment to listening to patients and to patient autonomy. It also recognises that patients and their families are often best placed to know when something is going wrong.

Martha’s Rule will come into play in hospitals where it has been rolled out and when inpatients are getting sicker. For example, we could imagine an elderly man, Ahmed, who is admitted to hospital with pneumonia who is normally fit and well. His husband,

Paul, visits him in hospital and is worried that Ahmed is more confused than normal and struggling to breathe. A week later, Ahmed still isn’t getting better and his husband is more concerned. Paul asks the nursing team if Ahmed needs more help, but they tell him not to worry.

Paul sees a poster about Martha’s Rule and calls the critical care team to ask them to review Ahmed, who actually was sicker than his doctors realised. Ahmed is then moved to critical care and makes a full recovery.

Equally, the critical care team might decide that nothing extra is needed – but Martha’s Rule means that patients can get a review of their condition without having to convince their medical team. It has the potential to prevent serious harm to patients in some situations.

Preparing for Interview Questions on Martha’s Rule

It’s not likely that you would get a specific interview question on Martha’s Rule – questions tend to be more general or case-based, allowing you to bring in your own knowledge. You might get asked a very broad question such as “tell us about something related to medicine you’ve read about in the news recently”. This is a great opportunity to talk about something you’re interested in and know a lot about, like Martha’s Rule.

Preparing for any ethical interview question means having a good awareness of underlying principles which will help more than specific knowledge of particular cases. Try brainstorming how each principle might apply to Martha’s Rule, and what else might be relevant in cases where Martha’s Rule comes up – for example, why might doctors not listen to patients and their families in the first place?

You don’t need to know everything, but you should show a logical and well-structured answer that addresses why this is an ethical dilemma. What ethical principles might be in conflict, for example?

Discussing Martha’s Rule in Interviews

Here are some of our top tips for considering Martha’s Rule in your interviews:

  • Make sure it’s relevant: interviewers won’t be impressed just by namedropping topical ethical discussions. If you bring something like Martha’s Rule up, make sure you can justify why it’s relevant to the discussion.
  • Show an understanding of the underlying ethical principles: can you show where there is ethical conflict, or explain the case in terms of ethical principles?
  • Show you understand the specifics: bringing up Martha’s Rule as if it’s a blanket right to a second opinion, for example, will show the interviewer you don’t really understand it. Showing an understanding of barriers on the ground, like doctor burnout or lack of access to critical care facilities, will demonstrate that you have a deeper understanding.
  • Consider multiple perspectives. “This is a difficult situation and I can understand why people would hold opposing views” is a great way to start an ethics interview station! But make sure you do answer the question as well – showing you can see both sides isn’t the same as sitting on the fence and refusing to answer the question.
  • Be empathetic: the kinds of situations that trigger Martha’s Rule are very difficult and it came about following the tragic death of a young child. Be aware of the context and avoid blithe or over-generalized statements.

Ethical Dilemmas and Martha’s Rule

Remember that Martha’s Rule is a specific NHS patient safety initiative – it’s not an ethical principle that you can try and apply to other cases. Martha’s Rule may be relevant in other ethical scenarios to doctor-patient communication and seeking a second opinion.

It shows how practical changes are happening to make patients more involved in their care and ensure patient voices are listened to.

For example, if you’re asked about a case with poor communication between doctor and patient, you could reference Martha’s Rule as a guiding example when asked about what you would do and talk about the importance of introducing specific pathways for patients to raise concerns and request second opinions.


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