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       kaplan medical usmle medical ethics - the 100 cases you are most likely to see kaplan medical usmle medical ethics - the 100 cases you are most likely to see Document Transcript

    • USMLE"MEDICAL ETHICS: THE IOOCASESYOU ARE MOST LIKELYTO SEEON THE EXAM
    • OTHERBOOKSBY KAPLANMEDICAL USMT.ETr Stcp 1 Qbook,Third Edition USMLETr Stcp2 CK Qbook,ThirclEdition USMI-EnStep2 ClinicalSkills, Third Edition LrSN{l.F.rNr 3 Qbook,Third ldition Stcp
    • USMLE" MedicalEthics: The 100CasesYouAre Most Likelyto See on the Exam Conrad Fischer, M.D. Associate Chief of Medicinefor Education SUNY Downstate Schoolof Medicine CaterinaOneto,M.D. I(APtAN PUBLISHING New York . Chicogo
    • USMLE" is a registered trademark the Federation State of of MedicalBoards(FSMI3) ofthe United States, Inc., and the National Board of MedicalExaniners@(NBMEo), neitherof which sponsors endorses product. or thisThis publication is designed provide accurate to and authoritativeinformation in regardto the sub.iect matter covered. is sold rvith the understanding It that the publisher is notengaged renderinglegal, in accounting, otherprofessional or service.Iflegal advice other orexpertassistance required,the serviccs a competentprofessional is of shouldbe sought.Editorial Director: fenniferFarthingEditor: CynthiaC. YazbekProductionEditor: LeahStraussProductionArtist: Ellen GurakCoverl)esigner:Carly SchnurO 2006by ConradFischerPublished KaplanPublishing, division of Kaplan,Inc. by a888 SeventhAvenueNewYork,NY 10106AIl rights reserved. text ofthis publication,or anypart thereol may not be reproduced Thein any mannerwhatsoever without written permissionfrom the publisher.P r i n t c dn t h e U n i t e d t a r e o f A m e r i c a i September 200610 9 8 7 6 5 4 3 2 | 978- -41 - 4209|I 3-ISBN: I 95 -l0-ISBN: l-4195-4209-5Kaplan Publishingbooks are available specialquantity discountsto use for sales at pro-motions, employeepremiums, or educationalpurposes.Pleasecall our Special SalesDepartment order or for more informationat 800-621 to 9621,ext.4444, ernailkaplan-pubsales@kaplan.com,or write to KaplanPublishing,30SouthWacker Drive,Suite2500,Chicago, 606067481. IL
    • )ofther;ardnot To:her:. Antonio Oneto Lawyer, Politician, Humanist, Fatheq and Loyal Frienil A man of honor and integrity c.o. To: Truth C.F.:d:s),
    • ContentsI N T R O D U CA N D O W T O S E H I S O O K T I OH N U T B ........xiiiABOUTTHEAUTHOR. .......xvCHAPTER I AutonomyCHAPTER 2 Competence Capacityto Decisions....... and the Make 5 Definitions............ . . . . . . . . . . . .5. . . . . Minors................... . . . . . . . . . . . .5. . . . . P s y c h i a t rPc t i e n t s . . . . . . . . . . . . . . . . . ia .............................8 Capacity Refuse to Procedures an C)therwisein Mentallyl)isabled Patient.................. 9CHAPTER5lnformedConsent. ..........11 A1lOptionsMust BeDescribed ........ ................ II All MajorAdverse Effects Must Be Described.............. ................... l2 Consent Required EachSpecific Is for Procedure ........................... 13 BeneficenceNot Sufficient Eliminate Needfor Consent................................ Is to the 13 Decisions MadeWhen Competent ValidWhen Capacity Lost.......................... Are Is 14 C o n s e n t I m p l i e dn a nE m e r g e n c y . . . . . . . . . . . . . . . . . . . . Is i . . . . . . . . . . . . . . . . . . .1 . . . . . . . .5 The Person Perforrning Procedure the ShouldObtainConsent .................................. l5 Telephone Consent Valid .............. ls ................ 16 Pregnant WomenCan Refuse Therapy ........................... ................ 17 InformedConsent a Never-Competent for Person..................................................,..... 17CHAPTER 4 Confidentialityand Records. Medical ......... 19 Confidentiality..... ................ t9 R e l e a so f l n f o r m a t i o n. . . . . . . . . . . . . . . . . . . . . . . e . . . . . . . . . . . . .0. 2. Give Medical lnformation to the Patientliirst, Not the Family....................................21 Release Information to Governnental Organizations of and the Courts........,.,,........ 2l BreakingConfidentialityto PreventHann to Others....... ..---.........22 M e d i c a lR e c o r d s . . ......---.......22 Correctins Medical Record Errors..... ............... 23
    • CHAPTER 6 Reproductive . lssues ........ 41C H A P T EO rT a n a n d T i s s u e D o n a t i o n R g ..........45C H A P T ER e p o r t a b l e l l l n e s s e s S .........47CHAPTER l0 SexuallyTransmitted(STD$. Diseases ....... 5iC H A P TlE R a l p r a c t i c e l M ........ 55 Definition . . . . . . . . . . . . . . . . . . . . .5 .5 . . . . . . Deviationsfrom Local Standards Care ...................... of ................. 56 Informed ConsentProtectionagainstLiability.... ...........................57 Informed Refusalls as Important as Informed Consent. ...............58 PatientsMust Fully lnform the Physicianof Their Medical Problems......................... 59 R i s kM a n a g e m e n t ................59 M e d i c a lE r r o r s . . . . . ................59
    • .tJ CHAPTER12tor/PatientRelationship ......... 6l Doc...25...27...33...35...37..37..37..38..384l.41.42.42.42 CHAPTERt4 Doctor/DoctorRelationship ......... 7t.4345 C H A P T E R x5 e r i m e n t a t i o n . . Ef p .........754047t9 PRACTTCEQUESTTONS ..........7s4950 ANSWERSAND LANATIONS... EXP .....12952i25;5o78999
    • l Chapter. Autonomy Patient autonomy is the most fundamental principle underlying all health-care ethics. Autonomy grants every competent adult patient the absolute right to do what he wishes rvith his own health care. The concept of autonorny is fundamental to the entirety of theU.S. legal system and has complete acceptance as an operating principle of day_to_daydecision making. Justice cardozo set this as a clear legar precedent in 1914, in the caseSchloendorff Society of New york Hospital, 105 N.E. 92 (1914). Justice Cardozo wrote, v."Every human being of adult years and a sound .rind has the right to determine what shallbe done with his own body and a surgeon who performs an operation without his patientsconsentcommits an assault,for which he is liable in damages,except in casesof emergencyrvherethe patient is unconscious and where it is necessaryto operate before consent canbe obtained." lustice cardozo was writing concerning the need for informed consent whena person undergoes surgery, ln this case it was made clear that to perform surgery on apatient without his direct consent was equivalent to assault and battery.Patient autonomy is a concept derived fron the property rights issues that led to theDeclaration of Independence, the U.S. Constitution, and the Bill of Rights. Autonomyover ones own medical care is seen in the same light as freedom of religior, freedom fron.rillegal search and seizure,freedom of speech,and freedom of assembly.These rights are soi n l r i , i c t o o u r c u l l u r e t h l t t h e y r r r c o n i d e r e d x i o m a l i c . V i t h i n t h e l . r r t3 0 y e a r r t h e y a have been legally extended to cover the freedon to choose ones own form of health care.Ior example, patients have the right to refuse undesired therapy, and they have the right tochoosewhether or not they will participate in experimentation. Each patient has the rightto have his wishes carried out even in the event that he loses consciousnessor the caoacitvto make dccisions for himsell I(APTAN M ED I C A L
    • Chapter OneI ln part because trcatments such as mechanical ventilation and artificial nutrition didnt exist in the past, re need nerv lar^sto delineate precisely the ethics of health care. our abil ity to devclop new forns of therapy has outpaccd our ability to create ethical svstemsthat detcrmine whethcr or not these svstemsr,vill be used in a specific case. . Does the developmellt and existence a treatnent_such as placementon a ventila_ of tor-mean we should alwaysuseit? . Docs the fact that we can place a nasogastric tube in a con.tatosepatient and admin_ ister artificial nutrition that can kecp that patient alive almost indefinitely rneanwe shoulddo so? Each patient should decidc the aswers to tlrese questions for hinrsell rhis is autonomy: I have the right to do what I choose with my own body as long as I understand the consc quencesofmy decisions.There is no form ofproperty more personal than one,sown bodyi so each patient has the right to deternire what is done to his body. These principles may seem obvious, but they are fundamental in medical ethics. This work is an examination of the various cthical situations faced claily by ph,vsicians. Autonomy represents a patients right to deter.rine his or her own health-care decisions. No form of a treatment can be pursued rvithout his or lter agreerrent,even if the pro posed therapy is "for her own good." Although beneficence-or doing rvhat is good for peoplc-is a high ain and ethical principle, autonomy is considereclmore important and takes precedence.Each patient has the right to refuse a treatment even ifthat treatment has no adverseeffects ad will heip her. You cannot trcat him or her aqainst his or her wil] even if the treatment is for her benefit. Think of your body as a piece of property such as your house or your car .fhe police do not have the right to search your house at their *him. They m.st obtain a warrant. They cannot even do something benign, such as step inside vour honc, without your express agreenent. Likewise, a physician cannot do a colonoscopv or a CBC without your consent. Unlessyou agreeto it, a physician cannot evcn do a urinalysis or an EKG, even though these are mild and uncomplicatedprocedures. Along the same lines, a painter cannot repaint your house without your consent even if he does it for free, the existing house color is ugly, ancl the service will only benefit you. A physician cannot treat your pneumonia or remove a cancer even though the procedure or treatment is benign and it will only benefit you. A doctor can violate this autonomy if you are doing something potentially dangerous, such as building a bomb, becausethis activity can harm others. A doctor can violate your MEDICAL
    • Autonomy Icn didnt onlyifyou haveHIV, tuberculosis, a sexually or transmitteddisease becausefur abil- conditions harm an innocent third party. Your right to autonomy is only limiterl can€ms that there potentialharm to an innocent third party. Even in these cases, is the violation is linited andtightly controlled. of@nfidentiality/entila- autonomy similarto that ofvoting.Ballotcounters ofpatient is cannotmake Theconcept based presumptions on rvhom they think you rvill vote for. They must definitely knowlmin- whom intended votefor when you werecastingyour vote.This must be basedon you tonwe whom specifically you votedfor Another person cannot bring your proxy ballot to the election on whichcandidate thinks you should vote for or which candidatewill based he belp themost. youcnomy: conse- must yourvotein a mannerbased your clearlystated You cast on wishes. havea right to You "wrong"n body; for candidate. havethe right to makethe vote therveakest You choice.In the samees may way, doctor only rendercarefor you based rvhatyou tell her you want. a can ontion of Patientautonoml givesyou the right to make the wrong choice about your health care. Even you are unable to make or expressyour health-care choices, the physician cannot if lhis:isions. simply makedecisionsfor,vou that go against your wishes. stands even if your choicese Pro- wouldbe harmful to you. This is one of tlre most difficult things for a physician to under-od for standand act on. l)octors are trained to act in the Lrestinterest of their patients, but thert and right to act against his orvn best interest comes first. Patients have the autonomy patientsnt has of freewill.I evence doTheypresslsent.theseen if,u.Ae orous,our !!!!p ueorcer -il
    • Chapter Competence the 2: and Capacity MakeDecisions toDEFINITIONSCompetenceis a legal term. Competency decisions transpire within the judicial s1steni.Only a court can determine that a patient is incompetent. All adult patients are consideredconpetent unless specifically proven otherwise. Physicians can determine whether or nota patient has the capacity to understand bis medical condition.The physician makes a determination of the capacity of a patient to comprehend herrnedicalproblems based on whether there is an organic delirium due to a medical condi-tjon such as a sodium problem, hypoxia, drug intoxication, meningitis, encephalitis, or apsychiatricdisorder. These detcnninations are based in large part on a neurological exami-nation testing memory, comprehension, reasoning, and judgment. Any physician can makethis determination. The physician does not have to be a psychiatrist. A psychiatrist maybe useful in rendering decision making capacity determinations in casesthat are complexor equivocal. If the patient obviously does or does not have the capacity to understand, apsychiatristis r.rotneeded.MINORSBv definition, a minor is a person under the age of 18. With some exceptions, minors aregenerallynot considered competent to n.raketheir own decisions. Only a parent or a legalguardian can give consent for a minor. Neighbors, aunts, uncles, and grandparents cannotgiveconsentfor treatment of a minor. This rule does not cover life-threateningor seri-ous emergencies.Consent is always implied for emergency trcatment. A physician shouldnot withhold blood or surgery in a life-threatening accident just becausethe parent is notPresent. I(APLAN MEOICAL
    • I chapter rwo For example, a 10-year_oldboy accider.rtally runs through a glasswidou, at school and laceratesthe raclial artery. His teacher brings hirn-to the emcrgcncy dcpart_ mcnt. The boy is bleedingand needsboth a blood transfusionand surgeryto cor_ rect the defect. What should you clo? Emergency treatment of a minor does not neeclexpressrr ritten consent. parental consent is implied. saying that you had .o ask aother p".ror, ru.h as the tcacher, thc principal, the school nurse, the babysitter, or the granclparents for consent belore givir.rgcmergency treatment would be the wrong answer. Seeking a court ordcr i, olrn u tv.,,,.rglhoi."l,., ur., emergency becauseit delays the treatment and becausein an emergency it is implicd that the parents rvould consent if they were there, Partial Emancipation Although only a parent or guardian can give consent for proccclures and therapies for minor there are some exception_s this rulc a to in thc areas of prenatal care, coutraception, sexuallytransmitted discases (STDs),and substance abusc.The mature minor is generay one.abovethe age of I5, although this raries by state.USMLE wilt not make hairsplitting distinctions like giving you a r4-year-old the day before her r5th birlhday. Thc caseon the exam will be clear For example, a l6-year-old girl comes to see you in clinic to discuss contracep_ tion. She is generally healthy but is not accompanied bv a parent. What should ,vou do? h all caseslike this involving prenatal care, STDs, contraccption, Hrv ancl substanceabuse the answer should bc to trcat rhe patient. Saying thut 1.ou_urt notily thc parents, get court order) seeklegal counser,refuse therapy, a or to go to the ethics corr[]rttee are aI incor_ rect answers. These interventions uwantecr pregnan.y,,. i,i,.,,,ij:::i:: ffiI :;::X lTr:Xil.::,:"T,rj;;::,,,:,f than it is to take the risk that a teenagcrwill get pregnant and neccl an abortion later Aboftion a Minor in The rules on parental notification for abortion are less crear becarse there is no national standard.Some states require parentalnotification and some don,t.I(AI.AN MEDICAL
    • Competence and the Capacity Make Decisions torol For example, 16-year-old a girl comcsto seeyou in her first trimester of preg-rt- nancy. is seeking abortion. What shouldyou do? She an)r- Inthiscase, thereis no clearanswer aboutwhether not the physician or sl.rould notif, the parents.Thereis no clearnationalstandardand it depends upon the stateyou are in. The)nsent most likelyright ansrver indicatethe nceclto encourage child to notify the parcnts will thcrcipal, herself, whichwould be best.So the corrcctanswerchoicewill saysomethir.rg like,,encour-gency "counsel agediscussion," her to tell the parentsherself," "suggest fan.rily or a meeting.,Onin an theethics questions USMLE,if there is a choiccthat savsto discuss, for confer,meet,ord that havevoluntarynotification,this rvill generallv the right thirg to do first. be Emancipated Minor A smallnumber of minors, particularly at older agessuch as l6 or 17, may bc consideredfor a emancipated or freed of the necd to have parental consent fbr any medical care.The critction, ria are that the minor is married, self-st4rporting and living indepenclently,in the military,rally or the parcntofa child that they themselves support.The criteria for being an emancipatedrung n]inor relate to being no longer dependent on ones parents for support, In other words, ifr the the minor does not livc with his parents, has a.job, ar.rdis self-supporting financially, thelr the minor no longer is dependentupon parentalconsentfor his actions, An emancipated minor is free to make health care decisions in all areas,not onh, just STDs. prenatal care,contraception, substance or abuse. Seriousmedical conditions or procedures such as organ donation, surgery, or abortion may require a specific court order to allotv the legal standing of enancipation to be fully valid. Only answer "court order,, .,judicial intervention," "court trial," or "seek legal resolution" if the caserepresentsdisagreement oruSe a lackof consensus the stem. in3ta:or-ing Limitations Parental of Refusal Minors on Right forIOn Although a competent adult can refuse any medical care she wishes, the same right does not automatically extend for parents concerning their children. parents cannot refuse life- saYingtreatment for their child based on religious beliel The state has an intercst in the nclfareof the child that exceedsthe parental righr to den1.therapy for the child if the child misht die.nal t ( A p tA N M E D I C A L -
    • r I cnupt", r*o For example, a child is in a motor vehicleacciclent and sustainshead trauma requiring surgeryto drain a hematomathat, if left untreated,will be fatal.As part l( of the surgerythe child will needa blood transfusion. The parentsare Jchovahs n Witnesses and refuseto give consentfor the transfusion.Ihe parentsstated reli I gious beliefsare that acceptingblood for their child would be a fate worsethan s death.4rat shouldyou do? c t If the child needsblood to save life you must give the blood evenover the objection his of the parents.It may seemcontradictoryto seekparentalconsentfor a procedurethat you will perform evenif they refuse, but in this case, you should attempt to obtain their permission nonetheless. Withholding lifesavingtherapy for a child is considered comparable child abuse. to The parentsright to practicetheir religion in terms of health carewould covertheir ability to refusea transfusionfor themselves, not for their child. but This ethicalconcepthasonly expanded. Parents cannotrefusetherapyfor childrenevenif they are severelybrain damaged otherwisedevelopmentally or disabled.Societydoesnot distinguish worth.In between individualsbased their relative on other words,parentscan- not refusetracheo-esophageal fistularepairon a patientwith Down syndrome just because the mentalcapacity and functionalability of the child will be much lessthan that of a child without this disease.From this point of view, treatmentagainstparentswishesin a life- threatening situationis equallyvalid for both a future geniusand a child with cerebral palsy who will not achieve mental ageabove2. a One of the only times parentsare allowedto refusecarefor their child is when the child is so ill or deformedthat deathis inevitable.This is not a true refusalon the part of the parent.This is reallyjust sayingthat parentscan refuseonly the futile carethat the doctor shouldntbe giving any.way. PSYCHIATRIC PATIENTS A patientspsychiatric history is intrinsic to the conceptof competence to the patients and capacityto understandher medicalproblems. patient with the clearcapacityto under- A stand or one who clearlydoesnot havecapacitydoesnot need a psychiatricevaluation. However, psychiatricevaluationcan be usefulto help makea determinationof capacity a in ecuivocalor questionablecases. MrDicAL $:."9
    • Competence and the Capacity Make Decisions toa All suicidalpatients are considered to lack capacity to understand becar.rse active suicidalt ideationis deemed to be a sign of impaircd jr.rdgment.In addition, thc level of compctence necessary make financial decisions is different fron.r that necessary for an informed to refusal. other words, a patient rnay have a history of bipolar disorder making it impos- In siblefor him to manage his financial decisions. Howevel the same person might still be considered have capacity to refuse rrearment. There is rvirylimitiil to iteiriiril liliced on p , r i c n l t o e s t J b l i h d p . t c i l y o r c f u et r c d t n t e t . ( l:tion that:heir CAPACITY REFUSE TO PROCEDURES OTHERWISE IN AN MENTAIIY DISABTED PATIENTThe A patient with mental illness or mental retardation that might be considered incompetentyto for other areasof life may still retain the right to refuse medical procedures. The criteria to determine conlpetence in areasof finance are at a higher standard than those for refus- ing nedical procedures. Your patient might have schizophrenia, mental retardation, or:n if autism to the point of needing to live in a group home, but that does not mean they arenot incapableof understanding medical procedures. This means that an adult with a mcntal?n- ageof 8 or l0 nay still be allowed to refuse medical procedures. Our society is reluctantruse to strap a patient to his bed and perform procedures that would be painful or uncomfortrild ablefor the patient without his consent. For irlstance, certain court casesin the past haveife- allorveda patient with mental illness to refuse diagnostic procedures even though twonl,I out of three of the reasons for the refusal were delusional. This is an affirn.ration of how deepthe principle of autonony goes in the managenent of patients. In addition, it shows that beneficence-trying to do the right thing for patients is considered less importantrild than autonomy. Autonomy is given more wcight in decision making than beneficience.the Autonomy has priority.tor A person may meet the legal standard of competence to refuse or accept medical care even if sheis not considered competent in other arcas of life, such as financial matters.rts)n,ity MEDICAL
    • I rr Chapter Informed 3: Consent Att OPTIONS BEDESCRIBED MUST bu nrust full,v inforrn the patient of the risks ancl benefitsof eachprocedureprior to undergoing procedure. explanation thc Thc must be in language that the paticntunder- stands includefull infbrnation regarding and alternative Ihe treatments. paticntcannot makean informcd choicefor one treatmentif shecloes latow of the existencc oth- not of For example, you inform a patient about the risks iurd benefits of bone marrow transplantationfcrr chronic myelogenousleukemia.You fully inform the patient about the risk of transplantation,including the possibility of deveJopinggraft versushost disease.Afier the transplantationthe patient developsgraft versushost disease, which is hard to control. The patient learns that there is an alternative treatmentcalledimitanib (gleevec),rvhich tloesnot includc the r isk of graft versus host disease,but which rvill not cure the lcukemia. The patient files suit against you. What rvill be the most likely outcomc of the suit? In this casethe patient rvill probably win the suit because was not fully intbrned about he the alternatives to the therapics mentioned. The physician has an ethical duty to ir.rfbrm thc patient about all the treirtmcnt options and then allorv thc patient to decidc among thcm. Although the phvsicianspref-erence procedure or treatment may differ from what of thc patient chooses,the patient has the option to choose therapy that may not be ^rltatthe doctor deemsis best for hin. I(APLAN MEDICALli
    • ChapterThree AtL MAJOR ADVERSE EFFECTS BEDESCRIBED MUST Advcrse effects ancl injury lrorn rnerlical care do not necessarilyrepresent a mistakc or fail urc of therapy. In the casedescribcd in the previous exantple, the error was not that graft versus host clisease developed.Thc patient was fully informed that this could occur and he chose the bone marrow triursplantation anyway. The error rasnot informing thc patient of an alternatir.e option in treatmcnt. At the same time, a patient could potentially die as an adverseeffect of treatment. This is only an ethical and legal problen if the adverseevent happcns and the patient was not told that it could have happened. The patient n.ight say, "Doctor, I would never havc taken digoxin if ,you had told me it night causea rhythm dis turbanceor visual problenr"or"I rvoulclnever havehad surgeryifyou had told mc I might nccd a bloocl transfusion." Thc m.rin point is tt rcpcct 3utonolly. The patieitt must be ir.rforn.red the therapeutic options, the adverseeff-ects the procedure, and the harm of of of not undergoingthe procedurc.If thcy have the capacityto understandand thcy chooseto do it ar.rvr,vay, have made an autonomous tlrerapelrtic choice, and therefore, thc patient they bearsthe burclenof any adversc cffect,not the physician. For example, a man underploescoronary angioplasty. He is inforned that tl.re artery may rupturc and that there is a srnallchancehe could bleed to dcath during the surgery to repair thc danaged vessel.He knorvs he could have bypass surgery instead. He understandsand choosesthe angioplasty. He dies from a ruptured blood vessel.The fanily files suit against you. What will be the n.rost likcly out come? Although it is unfortunate thal the patient died in this case,there is no liability with regard lhe to informed conscnt or ethical error. patielt was intbrmed of his trcatment options ancithe possiblecomplications, ancl he chosethe treatment. The patient mlrst undcrstand the risks of a procedure just as a drivcr rrust understand the risks before getting behind the wheel of a car. Why cant you sLlca car manufacturer if you die in a car accidcnt?Predominantly because you are an adult with the capacityto ur.rderstandthe risks of driving ancl you chose to drive an1.way. Tl.reliccnsing process is an education process that both tries to make you a safe driver, while also properly informing you of the risks of driving. Each time you get in a car, there is i.r.npliedconsent that you are choosing the risk of driving. Evcn if you €letinto a car accident and arreinjured or killecl, the manufacturer has no liability, as long as the car is well ntade, trecauseas a compctent adult you choseto put yourself at risk.!13!9 MEDTcAL
    • tnformed consent tr I In addition to understanding the risks of the procedurc, you must inforrn the patient of whatcould happen if she does not choose thcrapy that you offer.;raftlhe For example, a patient comcs to the emergency dcpartnent with appendicitis. Hei€[t is inforrned of the risks of surgery, and refusesthc procedurc both verbally and in lheeas rvriting. patient dies. Vhat was done rvrong here?rentsay,At. Thepatients must be informcd both of the risk of thc treatmentasrvellasu,hat will happcn ifthey dont undcrgo the procedure.In this casethe physicianis liable in court because heLght neverdocunented that he infornred the patient of the possibility of appendiceal rupturctbe anddcathif the patient did NOT havethc procedurc.rofetoient CONSENT ISREQUIRED EACH FOR SPECIFIC PROCEDURE If the patient signs a consent form for an opcration on hcr left knee, you cannot, in the operatingroom, decide to operate on her right knee and assumethat you have conscnt. If a patient signs a consent for an appcnclectomy,but when you open her up you find colon cancetyou cannot just do the colectomvwithout first informing the patient of the acldi- tionalprocedureand obtaining her consent.Thcre can be no presumption for conscntfor anythingbeyond what the patient specifically saiclshe consenteclto. lither the paticnt has to sign consent in advance for the other procedures or she has to regain consciousnessand havethe additional proccdure explained to her.ard)ns BTNEFICENCE SUFFICIENT ISNOT TO ETIMINATE NEED THE FORCONSENT.nd Trving to bc sincere anrl to do good is very important and takes primacy; howeter, therer patientsright to control what happcns r.vith his own body is more irnportant.toann8 For example, a 40 year-old man is undergoing a nasal polypectomy. In the opcrat-lre ing room you seea lesionon thc nasalturbinate that the frozen scctiondetermines",] to be a cancer, You have found the cancer early but will need to rcsect the nasalrnt turbinate to cure it. What should you do? I(APIAN MEDICAL
    • I chapter rhree t4 You cannot rcmoe tlre cancerous resior.rrvithout the patients approval. This is true evcn if the physicianis sincere, taleted, accurate,and helpful. fhis is truc eve if the procedure t will savethe patients life, unlessthe illnessis an emergencyrn an unconscrotrs patrelt. a Beneficcnce does not elirninate the need for informed consent. lf you live in a very messy b apartlnent your neighbor cannot break into your apartment to clean it el,enif he doesn,t a steal anvthil.lg.You must col]sent to the cleaning. His good intcntions are not as important as your right to do what you wanl nith your otvn property. DECISIONS WHEN MADE COMPETENT ARE VATIDWHEN CAPACITY ISTOST We must respectthe last known wishes of a patient if she losesthe capactty to con]munlcate and state those rrishes. Although it is preferable to have thc patients last kown wishes docunented in writing, following verbally expressedwishes is perfectly valid. oral cosent is valid for arry level ofproceclure if the orar consert can be proen. The basisfor varidit). of T oral or written conscnt is not whctrrerthe procedureis large or small. Ir.rother words, it is p not thc casetltat oral conscnt is valid for a stgmoicloscopybut a brain biopsy requires writ_ P tcn consent. A patient cal.tgive oral consent tbr ir heart transplant if the patient is lhe unable n to *rite. onlv diffrculty is that if challenged, orally exprcssedwishes for treatnrent are tl more difficult to prove than lvritten ones. For example, a 42-ycar-old nran with leukemia repeatcdly refuseschenrotherapy. He loses consciousless and his rnother tclls you to givc the chentotherapy. What T should you tell l.rer? s T s You must rcspect the l.st kntxvn rvishcsof thc patient. If the paticr.rtcloesnot wat a treat- o ment, you cannot iust $irit for him to lose consciousness then perfornt the treatmcnt. and If this rverepermissible, ther no one courd have an estatewiI. The ultimate form of ross of decisitur naking capacitv is death. ,Veurarkeout a will so that when rve lose the capac_ ity to speuk for ourselr.es,our wishes for rvhat to do with our property are respected after cleath. For example, a 64-ycar-old roman accontpanied by her husband comes to the emergency room seeking treatment for chest pain. The patient clearJy tells you that she wants to have her aorta repaired and she signs consent for the procedure. Y( She later becomes hypoter.rsive and loses consciousness.Her l.rusbandis now the OI decision maker and says,"Let her die.,,What do you tell him? aII(A9IAN MEDICAL
    • Informed consent ts Ie eyell A patientt family member cannot wait for her to lose consciousness and then go against:edure thepatientsprevrous expressedwishes regarding treatments and procedures. In the casertient. above, becausethe patient exprcssedthat she woulcr rike to have her aorta repaired her hus-messy bandcannotgo againstthis after shc losesconsciousness. The samereasoningholds true ifoesnt a patient refusesa procedure or treatnent and then losescolrsciousDess.)rtant CONSENT ISIMPTIED ANEMERGENCY IN For example, a sO-year old construction worker arrives at the emergency room by ambulance after an accident lacerating his arm. He has lost so much blood he rs unconscious. There is no family member available to signLlCate consent.What should you do?lshesrsentty of Thc management of an emergency is different. Consent is implied rn an emergency for a,ttls patientwithout the capacity to speak for himsell This would not apply to a terminally illurit- patientwith a pre existing DNR order Neither a court order, nor a hospital administrator,Lable nor the ethics committee is re<luired to give permission before the doctor can administert are roerap. an emergency, m THE PERSON PERFORMING PROCEDURE THE SHOUTD OBTAIN CONSENT Theperson who is most knowleclgeable about the procedurcshouldobtain informed con sent. Becausc must inform the patient about all the options of treatment, weeat- risks of the options,and risks of not performing the procedurein a language patient the can under-ent. stand, consent the must be obtained a person by qualificd makethe exDlanation. toloss,ac- For exemple,you are an intern who has consultedsurgeryto placefter a subclavian centralvenousline,Youonly know access you do not knorvwhv must be obtained. theinternaljugularapproach r.rot is beingused. thephonethesurgical On "Can resident says, ).ougo get the consentrvhileI am coming up?,What shouldyou do? Youmust not be in a position to explain the risks of procedures that you did not decide on.Ifthe patientdevelops pneumothoraxand you do not know why a the internaljugular approach not being used,you cannotadequately is inform the patient.you are not certain I(APIAN MDICAL j
    • 16 chapter rhree | why central accessis being obtained at all. You must, at the risk of seeming difficult, tell P the surgical resident that he must obtain the consent himsell If a complication occurs, you "l T] cannot say, was just getting a paper signed;I didnt know what it meant." wl The same is true for a patient who signs consent. If you tell the patient that he could have a Sc pneumothorax and might need a chest tube and document this, and the patient still signs fr, "l consent, then you are not at risk. The patient also cannot say latel rvas just signing a m piece of paper. I didnt know rvhat it meant." ol H c? TETEPHONE ISVATID CONSENT H Consent obtained by a family member, health-care proxy, or other valid surrogate decision s€ maker is valid even if obtained over the phone. This is a legitimate form of consent by an Fr authorized surrogate decision maker. For example, a 65 year-old r.nanis admitted to the hospital for a seizure.The head o CT shows a ring or contrast-enhancingi lesion consistent with a brain abscess. C The patient remains persistently confused, but is not deteriorating. You need to n perform a brain biopsy but there is no family member or health-care proxy who c( comes to visit hini. His wife is housebound from multiple sclerosis and cannot get to the hospital. You have hcr on the phone but the nurse is refusing to be the witness for the consent, saying that telephone consent is not valid. What should you do? ll T n As with all forms of verbal communication, oral advancedirectives, and telePhone consent a are more difficult to prove if contested. However, they are equally valid. If a health-care worker is uncomfortable taking the telephone consent, use another member of the health- c care team to act as your witness for the consent. You can educate the nurse later. You can b take consent tbr cardiothoracic surgery over the phone if that is the only way to speak to h the surrogate. 1 The real questions about telephone consent are these: n 1. Is the person you are speakingto really the surrogate? c 2. Does the person know the paticnts wishes? h c 3. Did you get the oral/telephone consent witnessedby another Person so that the person t giving consentcannot later deny havjng given consent? T ) MEDTCAL!(A9rAN
    • tnformed consent tz IIt,tell PREGNANT WOMEN REFUSE CAN THERAPYs,Iou The prevailing consensusholds that a fetus is not apersonuntil birth. Hence, no matter rights whatyour personal feeling may be, the fetus does not have any intrinsic as a person.uYea So,even though a 34-week-old fetus would be a viable child if the fetus were removed signs from the uterus, all health-care decision making and ethics are based on the choices of theringa mother and her interests.Ifparents have a child born at 34 weeks of gestational age in need of a blood transfusion to save its life, they cannot refuse lifesaving therapy for the child evenifthey are JehovahsWitnesses.The state would intervene in the interests of the child. However, the same child at 34 weeks of gestational age is still in the uterus, the mother if can reluse or accept whatever therapy she wishes without specific regard for the fetus. Hence, pregnant woman may refuse a lifesaving transfusion. She may refuse a Caesarian a:nl0n sectionto remove the child even if this will put the life of the fetus at risk.byan For an1.question concerning reproductive rights, decisions are based entirely on maternal wishes.The father has no legal right to make an informed consent fbr any pregnancy- relatedissuebecausethe questions concern the body of the mother. A mothers autonomyd overher own body is felt to be more important than the rights of the fetus or of the father.s, Only the mother can sign informed consent for any procedure or treatment during preg-0 Ask " nancy.Any answer choice that has the father. .. in it will alwaysbe wrong in terms of0 consentissuesduring pregnancy.ted INFORMED CONSENT A NEVER-COMPETENT FOR PERSON This is one of the most difficult subjects in ethics because the standard of this manage-nsent ment has significantly evolved over the last severalyears.Ifthe patient has Down syndromeFCAIE and has a family member to make decisions for her then the question will be straightfor-:alth- ward-ask for the consent of the parent or guardian. If there is no parent or guardian, theu can circumstanceis much more difficult. A third party court designeemust make a decision 1 , p based the best interests of the patient even though the patient may never hur,. ."p..rr.d onak to her feelingsbefore. The best way to obtain consent for a person who has lost the capacity to make decisions for him/herself is a health-care prorT or durable power of attorney. This is an advance directive (written or formal). An advance directive cannot even be given by a patient who hasnever had capacity. The same is true of a living will. The next best method of giving "substituted judgment." consentis In this case a person who knows the patient well tries to determine what decision she would make for herself if she were awake. This is also not possiblefor a person who has never been competent. The weakestform of consent is to act t(APt-Al{ MEDICAL
    • 18 chapter rhree | "best in the interests" of the patient. Tl.risis the weakestmethod of grvrng consent because it is filled with subjectivity and inprccision. However, it is thc best method of obtainins consent for doctors treating a person who has never had capacity. A legal guar.lian whici could be a fan.ri11.member must make the decision on behaif of the patient. In the absence of a family member the guardian is either appointed by the courts or is the administrator of the health care facility, such as the medical director.
    • I rgausening Chapter Confidentiality Medical 4: and Recordshichenceator CONFIDENTIATITY Physicians have a strong professional mandate to maintain the confidentiality of patients. Communications betseen paticnt and physician are highly privileged and this confiden tialit,vcar.ronly be violated when there is potential harm to a third party or if thcre is a court order demanding the information. Medical information cannot be passedto anyone l ithout thc direct consent of thc patient. Confidentiality also includes keeping a patients medical information priyate even from his friends and family unless the patient expressly saISit is okay to releasethe information. The fact that a patient may have a good rclation ship with his familv and fiiends is absolutely no excuseto assumethat the patient wants his medical information passedon to them. I have an exccllent relationship with my mother; honever, even though I am a doctor (or mavbe becauseofit) she does not want me to know her list of medications. Shehas no obligation to give me a reason rvhy she does not want rne to know which mcdications she is taklng. If I call her doctor and sa1 "l just want to help mom vvith hcr mecls.What is she on?" Her physician is supposed to respond, "Im sorry, but IoLrr mother hasnt authorized me to give you that information. I know you mean well, but I iust cant talk to you about your mothers medical problen.rs." For example, a 42-year-old man is hospitalized with chest pain. The patient is arake and alert. His wife comes to you demanding inforn.ration about the patient, saying that she is his wife. She shorvs her identification card verilying this. What should you tcll her? bu cannot releasemedical information to anyone about a patient unless the patient gives you pernission to do so. Although it may seem rude and unreasonable,you must tell the MEDICAL
    • 20 ChapterFour ] patients fan.rily members that you must ask your patient for permission befbre you release medical infornation. his For example, the wife becontes infuriatcd and storms off the floor, threatening to sue you. You apologize to the patient for upsetting his wife by not speaking.with her about his private medical problens. The patient responds "On the contrary, Doctor, you did great. Although she is still my wife, we arc finalizing our divorce and we do not live together. I expect to be clivorced and rcmarriecl lvithin the next few months. She only wanted information about me to use against me in thc divorce proceeding. Thanks for protecting my confidentiality." REI.EASEINFORMATION OF Information transfer between physicians involved in the care of patietts is a common occurrence. However, the information can only be transferred if the patient has signed a consent or releaseform requesting the transfer of information. It is the patient who must sign the consent to releasethe infornation, not the health,care provider. This is how the system guarantees that the patients medically privileged inforrnation only transfers to those people to whom the patient rvants it to go. For example, yott receivea phone call from another physician who is rvell known to you in your local community. The physician says that one of your former patients has transferred his care to him and he is asking for a copy of the patient$ meclical record. What do you tcll him? You should tell another physician requesting information to send you the patients signed releaseform befbre you send him the infonration.!!l!!p rreorcnr
    • confidentiality Medical and Records 21 I GIVE MEDICAL INFORMATION THE TO PATIENT FIRST, THE NOT FAMITY For example, your patient is awaiting the resr.rlts a biopsy to tell whether or not of shehascancer. Her son callsyou anclasksyou to give him the infornation bccausc the family is concerned that the bad news will depress his mothcr. He is sincerc and genuine in his concern. r{hat do you tell hin? information such as the result of a biopsy must go to the patient first. There is trledical no basisfor informing the family and not the patient. It is exactlythe oppositc: without direct instruction from the patient, the family shoulci not receivethe patients confidential nedical information. Maybe the patient wants her family to know and maybe she doesnt. It is alwaysthe patients decision. There is a rare exception in the caseof a patient with a psychiatric disturbancein rchom to inform if a meclicalcondition might induce a suicide00n attel1lpt.:darustthe RETEASEINFORMATION GOVERNMENTAL OF TOito ORGANIZATIONS COURTS ANDTHE For example, an investigator from a local law enforcement a€lency comes 1(]: your office. He shows )ou proper identification stating that he is a government employee.He is looking for your patients immigration status and for his medical condition. What do you tell the investigator? If a n.remberof a larv enforcel.rent agency comes to you with a subpoena or a court order that constitutes a search warrant then you must lurnish him with the information that he Ifthe investigator does not have a searchwarrant, then you must refuse him access requests. to the files. You are not under any obJigation to make immigration status investigations of vour patients nor to provide this information to third parties unless it is at the request of the patient. This right of privacy also covers genetic information. You must keep the medi cal information private from a patients co-workers as well. I(APLAI MEDICAL
    • Chapter Four I BREAKING CONFIDENTIAI.ITYPREVENT TO HARM OTHERS TO The^right of a patient to privacy is not absolute. .fhere are sonle exceptrons confidentialitycan be brokcn in order as to when to protect othc.s. The Tarasofcasc(1976), a mentally ill paticnt toid thc psychiatrist in which of his intent to harn sonreoDe, is a famous example of this ln this type of case,thc physician must inform larv enlorcement the potential victim. Confidentialitl. as rvell as is only broken ir-r,h;, ,;;;; pr.l=nr harrn to orhers; this is rarely donc. Other casesin which it is lawfrl. to break confidentiality inclucle partner notification sexuallytransmitted diseases for suchas syphilis and HtV fne patienfs right to confidential_ ity in such cascsis lessirr.rportant than anorher p.rr.r,, ,ish, ;; r;;.ty. Horvever, must first bc made to enlist the patient all efforts to inform tr.reintiiriate partrer. No a physicia for brenking c.nfidcntiality lawsuit agaist in order to nolify an ir_o..nt,f,la health may be at risk has been successful. purty that his MEDICAT RECORDS The physician or healtrr-carefacility physicalry owns tr.remedical record, but the informa_ holr contained rvithin it is the property of the patient. Although the medical p,hysicaloblect rcnrains al.waysin record as a the hands of ih" h"ultl,_.ar".fir.lfit1,, tt . parient has an absolute right to free access the to information it contar.ns. "-rrr.o.n,onon it uithin a patientt nedicar rccord is contained cnvered by a the same rures of confidentiarity other privilcged meticar information. you as any cannot relcasc the mecrical recrrd without consent of the patient No one except the thosc directry involved in th. .ur" ot a right to access the record. paticnts the patiert has to cirnuot tJkc sulc *rr""rr.,r, ., ,n" record but they have a rigltt to acccss O^ysical nteclical or copy thc information. For example, you have a new patient with a complex history r,ho has becn to get a copy of her record from her trying previous doctor. .fhe other practice said she must provide them rvith a valicl reason for u.hy she needs thc chart. lbu call other doctors office trying to get the the chart. The practice administrator inforns you that thc paticnt is extremely unpreasant and aim.utt. rr.,uiJrt,un, becausethe patient has not paid hcr bill thc prior practicefcelsno obligation to provide with the chart. The patient rcturns you to seeyou thc tbllowing iav ancl asks r.vhathas become of her record. What tlo ),ou tell her?I(AP!AN MFDICAL
    • Con{identiality Medical and Records I Thepatient has a right to her medical records. No one has a right to interfere with this for anyreason.You should tell her that she should be allowed a copy of the chart. A patientvhen doesnot have to give her doctor a reason for requesting hcr own property, and she ishich entitledto this information whether or not she is "pleasant." Furthermore, the mcdicallous "held record should not be hostage"to compel a patient to pay her medical bills. The need:ll as for information to take care of patients outweighs the physicians right to payment. for CORRECTING MEDICAT RECORD ERRORStial hen an error in a chart needs correcting the doctor should draw a line through it andbrts then initial the correction. This allows anyone reading the chart to seewhat was originallyinst thereand it ensures that medical errors are not being covereclup. you cannot just remove his pages from the chart or cover them over with correction fluid if there are mistakes. This makes look as if you are hiding medical errors. If you forget to put in a note or document it somcthingand want to add it the next day,you cannot put a note in the chart with the old date.If you forgot to put a note in the chart documenting a patients condition yesterday, cannot write a note today with yesterdaysdate on it. In other words, you canl]ot,back- ,youna- datenotes. Your notes must always bear the current date and time.N A altredrnythe!ascal I(AP:-AN MEDICAL
    • Chapter End-of-Life 5: lssuesWITHHOTDING WITHDRAWAT MEDICAT AND OF TREATMENTEverycompetent adult l.ith the capacity to understand his own medical problems has theright to determine what treatments he does or does not wish to receive.There is no ethicalor legal distinction between withholding and withdrawal of medical treatrnent. For example, a 60-year-old man with diabetes and hl.pertension develops renal insufficiency to the point of needing dialysis. He is equivocal about spending the rest of his life on dialysis, but he agreesto start. The patient is not depressedand is fully alert. Six months after starting dialysis, he comes to realizevery clearly that he absolutely does not wish to continue. You have no doubt that the patient has full capacity to understand the implications of this decision. What should _voudo?Although there may be an enotional distinction between withholding dialysis and stop-ping it after it has started, there is no ethical distinction between the two. lf I don,t like toplay basketball thcre is no legal distinction between my never starting to play basketballor playing a few games and then not doing it anymore. It is n.ryright to stop. If I hlre youto repair my house, but after a few days I deciclethat I dont like the work you are doing,I havethe right to tell you to stop working on my house. You cannot say,"Sorry, once westartajob we finish it whether the owner likes it or not." I have the right to refise to allorvyouto work on my house and the right to tell you to stop after you started. The patient hasthe right to stop treatment. For example, an elderly man with COPD progresses to the point of needing mechanical ventilation on a chronic basis. He tells you, alier long consideration, that he just does not want to live on a ventilator. What should you tell hirn? MFDICAL
    • 26 Y o u m u s th o r r o r i s w i . h e . h I h j r ) . r t i . nir. an adultrvith - l a - , , r , . r , . : , Lthe mcdicalproblems, he has,n.:,:l:t::t lt capacity understan<l to his so tator. r.he *oon*.un,*.,,,n.il:riliil:,,.i:.iT::::;:"l,",,_TJ asking the family for consent. For example, a 42_year_old reavins him p-"ry,;;;;;,il1;,i J.,i,"iTlll[Tl.#il.1],:,i.":*; upbcatand cheerful. He sayshc will ger better "r;;;;;; to-tb. n.,orntorrr"d p". manentlyon the ventilator.yo clearlyinform him .h;; ;; ;r*r."g 1 neverinrpror.c. sayshe wants and ire will He the ventirarorrn."*r n..rr.,,ir ne t do you tcll him? rs cured.what c c ()nce again, you must honor his wishes This is an I adult patient with the capacity understandhis meclical.on.litio,l to the hood riker or hi;;:;;;;:i":"T-,HX; :.:iil::Jill I equivalent of incompetencc. Overall, this case rvill be ,h" ";;i.:;,.,, Hi,:1:J::*ifj t tl most ethical dilemmas do not agree wirh, because inr u t:nttt:t. patient wishing to continue rather inolve patients ,.,ho have care, but P ,;l-tt capacrty and the dilemma rst u drirw treatment. of whether or not to with_ cr For example, a woman with T Arte _"",r,,,r," rarbw r,..",,1:iil:l : i."?::: :?"il ;i:,Til:.::ilj:r:: tl sions.Shehasthe capacity r( to understandthat shewill ai., .rriifrcr* ,fr" ar"nsfusion, although is not suicidal. shc Vhatdo you tell her? Youmusthonorherwishes. A She problcms. consequencesr]l,lt]-^Yl th,the capacity unclcrstand medical rhe .r to ircr an cthics conrnrilteeevaluation. l; D ;::.,i":.:;*j.,]:H.{*iirFFHil"lr;i::il::i to ruthorize the proccdurcor to ask foi ;::l::-i:t llt capacirytounderstancr,, h ";:;,;,:l:i;l;:;:T]11,::.J,"il:J:::nT.:ji:.i:T cl psyihi.rtric e v a l u a r i o n n c c c . r r ) . i tl rl For example, an HlV-positive,lehovah,s ft: Witness who is now pregnant transfusion to live and haye needs a a at deprcssed is fuuyalert. rcfuses. is ot she and {hf::t;:1:i, ;|,"..atcsoricauv lc bi!!!!p Meorcar_
    • End-of-Life lssues 27 J.dhis lbu must honor her wishes.Yon cannot transfuse!t competeDtadult againsther tvill. The situatior.r would be different if thc patient rvcre a n-rinor.in u,hich casc the doctor rvould becompclledto transfuse. The fact that the patient is pregnant does no1 alter the ansrver. The prevailingconsensus that personhood begins aftcr birth. Until delivered,the fetus is is considcred another part of thc mothers boclv.Ihe rvrong ansrverswill includc getting a courtordcr or asking the father of the child for consent.Another wrong ansrver would be uaiting until the paticnt is no longer consciousand then transfusingher. The anslvers all of the examplesdescribedin this scction are clear because each case to in thepatient is an adult rvith the capacitl,to understandhis or her nredicalproblems.If the case descritres deprcssion the patient then you should choosepsychiatricconsultation, in or choosea trial of cither belravjoral therapv or antidepressant ntedication as the ansrvcr. Patients have thc right to try therapy for a while ald thcn stop it if it does not suit then].:y to This is true even if it means they will clie from stopping dialysis, mechanical vcntilabout tion, HIV medications,or blood transfusions.The typc of treatnlent does not changet the the answer.A CBC or cardiac bypass is ethically antl lcgally indistinguishable. Ticatin€! aause palient wjthout consent is legally ecluivalent to assault and battery or any other form of but unwanted touching.Therefore, a scnsc, in treatinga paticr.rt againsthis wi)l and without hisdth- consent like mugging the patient or beating hirn up. is Thereis no distinction between withholding ancl withdrarving care. If you are doing sonc "We11, thing the patient does not ant,you cannot sa,v, sorry, but I already started, and I rcallvhaveto continuc." ADVANCE DIRECTIVESicallbe DefinitionLing An advance rlircctive is the tncthod by rvhich a Daticnt conmunicates his wishes for his tor healthcare in advanceof becoming unable to make dccisionsfor hirrself. The aclvancentt directive is a by procluct of the successof nredical thcrapies such as the mechanical vcn no tilator that can kccp a patient alive when in the past he would have cliecl.Becauseof thcse therapies, doctors are norv in the position of trying 1qictcmine u,hateachpatient wantcd for himself in terms of his health carc. Thc advancedirectivc is part of the concept of autonomy. The advancedirectiyetellsthc physicianrvhatthe paticnlswishesare so that the lcssaccurateforms of dccisionmcLking, such as substitutedjudgn.rcnt making a decisiou or based irnother persons on idea of the bcst interests the paticnt,bccome avoidable. of !!l!!p vrorcnr
    • F I crapter rive Health-Care Proxv The ttvo most comnon forms of aclvancedirectives are the living will and the health carc pror:7 Thc h ealth-care prorrr or ir.redical power of attorney" is thc durabre power of attor ney for health-care decisions medicalproxy.The conceptof a,durablc,,power or ofattorDey is critical becausethe word "durabre" means it remains in effect even after the patient roses decision-making capacity becauseof medical illness. Other forms of legal proxics, such as a finar.rcialproxy, bccome ineffective after the patient loses corsciousness. The health carc prorT is a person chosen specifically by the patient to lake health-care decisions for her in the evcnt that she cannot make decisions for hcrseH These decisions are limited to health care, not finance. Advance directive docunents ntay also have written instructions to give boundariesto care.For cxample,.r patient rnay want to receivc antibiotics,but not want to receive chenotherapy or diall.sis. However, the main focus of the proxy is to designate a person of "agent" who speaksto the physician regarding consent issuesfor aI treatments and tests, well as discusses as issues withdrawing and withholding treatment.The proT of speaks for the patient. Becausethe patient chooses the prorT as her representative, the proxy overrules all other decision ntakers. Therc is a strong presumption that the proxy knows the patients wishes. The proxy is not there to give his personal opinion as to what he thinks should be done for tl.repatient. The proxy is there to communicate the patient,s original wishcs in order to ensurethat they are carried out. The pror:y is like a messenger.Ihe patient writcs thc message-hcr wisrres for her own health care-and the pror:1,delivers the nessage.you woulcl not want your prorT to alter your wishes any more than you rvould want your mailntan to rcwritc your letters. The proxy is also like a waiter. The patient tells the waiter lvhat kind of food he wants to eat (what kind of medicines and tests he rvants). The proxT praccsthc order ir.rthe kitchen. The prory is not there to alter ).our expressedrvishcs.you would not want to order chicken and have the wartertell the kitchen you want fish. your waiter tries to understand what you want to eat. lhe waiter doesn,t walk up acl tell you,,,you look weak and anemic. you are having a rare steak toniglrt, which is what is bcst for you.,Now "restaurant" the main diffbrence is that this is a in which thc custon.rcris unconscious and can,t tell you exactly what he wants. The proxy makcs dccisions based on rwo paranteters: l. 1he patient.s directly expressed health carewishes 2. 4rat thc patient woulti havewanteclif he/shchad capacitv I(A PI"AN MFDICAL
    • End-of-Life lssues 2s | These the trvo overriding principles: areh-careattor- t. Thehealthcare pror.y must carry out the written and verbal wishes expressedto him regarding patientshealth care;the basisforwhich is sornetimesjust his understanding thetorney 0fwhatthe patient would rvant if shewere avake make the decision. tot loses 2. Theprox,v outweighsall othcr potcntjal dccision makcrs,including thc family.uch ash-careher in For example, a 75-year-old nar arrives at the emergency department febrile,health short of breath, and confused. Many family men.rbers accornpany the patient,o give includinghis wife, his siblings, his children, and his grandchildren. The physician lvants perform an emergency lumbar puncture, which the patients wife and to- wantignate siblings refusing. His 25-year-old granddaughter r,valksup rvith a health-care arements prory lbrm signed by the patient designating her as the proq. She insists that youproxy do the iumtrar puncture stating that was her understanding ofthe patients wishes.e, the Therestof the family, including the wife, refusesthe lumbar puncture stating thatProxF theyknorv the patients wishes better. What do 1ou do?what:ients you should honor the health-care prory above all other decision makers, regardless [egai, of thelevelof closeness biological relationship or frequency of contact. You cannot tell in ivhoin a family knows the paticnts wishes best unless the patient is awake to tell 1ou.The prox,vdesignationis thc patients wa). of telling ).ou who he feels will represent his rvishes. In the absenceof an advancc directive there is a list of relative importance in terms oflIs to surrogatedecision nakcrs. You should start first with the spouse,then parents, then adult;hen. children,then siblings, tl.renfriends. This is an approximation only. lf the farnily is split incken itsrvishesthcre is no easysolution. When the family is split and there is no proxy, you nrust. you r e t etro l h c c l h i c . e o m m i t t e c r t h c c o rr r t f o r a i u d s m e r r l . oI arethatryhat Living Will A living will is a written form of advance directive that outlines the care that a patient l,ould want for herself if she were to lose the ability to communicate or the capacity to The etiology of the lossof decision-makingcapacityis undcrstand medical problen.rs. her irrelevant. A living will can range from being an extremely precise document outlining the exact typesof care that a patient wants or does not want all the way to being a vague, useless "no document that makesnonspecificstatements such as heroic care."The nain problem MEDICAL
    • with the living will is trrat most of the tinrc it lacks precision bccause the patient does not explicitly statewhich testsaud treatmcnts she wants for herself,A clocumentsaying..no extraortlinary cilre" is virtua[y rvortrrless.wrr.t croes "extraordinary carc" nrean?I)oes that mean a yentilator or chemothcrapy, dialysis, or or blooci tcsts,or all of thcnr, or none of thenr?If the living l is cxpricit in listing thc prccise nanes of the tcsts and lreatments that thc patient *ould rike to receive(or not to receivc),then it is uselul. For instance,a living will that says"No intubatior, no cardiopulmonaryrcsuscitatron, no dialysis, and no blood transfusions" is vcry Lrsefuland allotvs fbr easyfollowinq. For example, a 78-year-old woman ts admitted with metastatic cancer Jeaclingto a change in mcntal status secondary to hypercalcenria. She has a lir.ing will in her record that states, "In the cvent that I become unable to speakfor mvself for any reason I rvish to expressmy r,r,ishthat I not be intubated or placed on a ventilator under any circumst.ruces. also do not wish to reccive I dialysis.Blood tcsting and antibioticsare acceptable.,, What should you do? Thc Iiving will is nost valid antr usabrc *.hcn specific tcsts and treatmerts are outrined. In the casc above follon the directio of the living will ancr carry out the patients wishes.A livig rvill woulcl overrurethe wishesof the fanrily beca,sc trrc riving will conmunicates the patieDts o.wn wishes. As a nlatter of autonon),, the patient! clearly expressedrvishes alrvavs take precedence over thc n ishesof other decisionmakers,such as tamily mentbers. Thc rnajor issueith the use of a living will is that it is very difficult, ur advanceof trrer- ness,to be celtain which medical treatmer.ttsand tcsts will be necessary.It is very difficuit "I for a layperson to sa1, do not tvant an albumin infusion with ny large volume paracen_ tesis," A or biopsy tbr diagnosticpLrrposes interventior.ral by radi.logy is acceptablc, Ibut do not want an opcn biopsv il the operatir.rg roorn,,,or.,l agreeto antibiotics,but not to amphotcricin." A hcalth-care proxy allows for far greatcr tt.*it itity. Hor.vevcl if a patient really does vvritc out the specific nantes of the nlost colftmon treatments and the param_ eters for their use, ther.rthe living rvill can bc a vcry usefui documelr. t t NoCapacity NoAdvance and Directives p ft Here is uhat is vcry ciear atrout withholding and withclrarval of care decisions: p An adult with capacitycan decideto acceptor refuse n anv therapy oflered. . An adult Iithout capacitycan be managedr,vitha health_care b proxy or a living will if the Iiving lill is sufficiently clear and specificenough. cl(ll!!p v:orcer
    • End-of-Life Issues 5l Iot Llnfortunately, the ast majority of patients, een at oldcr age ad with life-threatening-lo illnesses, not have a formal advance directive. Decision making ca be do rmLchmo.. diffilat cultin this circumstance. Ifthe family is united and in agreement,then there is o difficultyof llith making decisions for the patient. The main issue again comes to clemonstratjng tltetS best evidenccof lctowing the patier.rtswishes.aIO For example, a 64 year-old man suff-ersa severe iltracrallial bleed leavir]s him conatoseand paralyzed.His wife, sister,and four chjldren arc in the horpital. They come to seeyou bccause they are unanimously asking that you remove the endotracheal tube and lcave the patient to die. The patient repcatedlymadc this rvishknown to his family. What shoulcl you do? Fora patient without the capacitr to understand his redical problens and no hcarth care pror-v livirg will, the path of rnanagement is clear as rong as a[ of or the familv menrbers ar€in agreenlent.You can rcmovc the cnclotracheal tubc and let thc patrcnt dic if everv_ .ne savs that is what the patient has saitr he wanted.rhe endotrach.artube is r medi.al therapylikc any other. The patient has the right to refuse it. The patientt fanrily or otrrers whoknow the patient well can provicle the patients previously expressed wishes_an oral advanced directive. For example, a 78-year old wouran has been aclmitted to a nursing homc with adyanceddementia. She has difficulty maintaining oral intake sufficient to survive. The nursing home wantsto placea nasogastric tutre for-fecding. The husband and the son expressly state that the patient slid she.,never*lnted to be ntaintained "I like a vegetable"ar.rd dont want to be put on a ventilator or have a feedins tube dorvn my throat." What should you do? Are the family members passinplon information about what the patient said, or are thev tellingyou to do what the1,think is bcst fbr the patient? you can do virtually anything in the care of a patient, even without an aclvancedirectie, as long as the family is united in passing what the patient said she wanted for her own care. problems on arise when the familyis in disagreement about what the patient said or rvhcn. rnsteadof expressing the patientswishes, they are representing what they u.ant for the patient. Having a fan]ily member expressa patients wishes is equivalent to having him cast a vote on the patient,s behall If a person cannot speak, another person can mail in her vote for her if she has clearlytold this person which candidate she rvants to vote for. If she told her brother that lvantedto vote republican and he sends in her ballot stating this, then he is acting on her
    • r wishesasher agent.on the other hand,if he shewereawakeor he belicves berieves would preferto vote democrat she one candidateis better for her then tl.risrepresents lower levelof evidence her vote.Likewise, for a much if if he kows what shewantsbecause torrlshe him, then he can stop the ventilator,the blood tcsting,the .h.tno,t "rupy, the dialysis, or any other treatment. Ethics Committee ReferraltheCourts and to ihen there is no clear adyance directive and the family does not agreeon what the patient wanted for hin.rserfor herself, then the right answer is to refer to the etnrcs commrttee finally the courts. and Hcre is a list of thc various kinds of consent, with the most desirable listed first: . Direct patient rvish verbalizedby the patient . Forrnal advancedircctive such as a proxy or a living will . Oral advancedirective . United group of fimily and friends . Croup of family members disagreeing what thc patient on would have wanted In caseswhere there is no living will or proxy and the family members are not in agreement, is to "encourage consensus,",,request :h. :*:.:,:p discussion,,,or ..talk with the parties iltvolved" Ifconsensus is not possible,you should refer the caseto the hospital ethics mittee. The last step to pursue in the absence com_ "seek judicial of a clear consensusis relerral to the courts or intervention.,, For example, the Terry Schiavo caseended up in the courts becauseher husband and eral of her friends said the patient told them sev_ that shc ncver wantecrto be maintained r persrstent vegetative state. The patientt in a parents stated that she never saicl that. a The ethics does not have direct legal power and their ::-.TiU:: decisions are not alwaFsuniversally binding Ifthe ethics committee is unabrc to bucr consensus,or the involved parties the ethics committee, thcn judicial intervention ignore i, n.."rrn.y. t rl d li I(APLAN MEDICAL
    • End-of-Life tssues Iocrat if "00r much NoTRESUSCTTATE- ORDERS (DNR) "Do ..H.il?#J+,:i;:*,,jffii,H;[i.*he told A Not Resuscitate,, (DNR) or<ysis,or ;::t*:,f*.:f the ::i::::*::J:; patienr il;;;;;r/Lxrnrc ttr medicationsThat is all nothing more. Death of ruddenlossof pulse,blood breath. pressure,and the ability toatient For ex&mple, 42_year_old a HlV_positivernan is admittede and for hematuriathat is He DNR is u"r"gvi..""*r,ed andthevthink ffii:i"ilfiT:11]:tJ;;i ry"lllt-Tfhtectomv however do notwant doeith".on. b..or:^"11"1:-1 to sethe "patientis DNR thev what shouJd ad thereforepreterminal." you tell them? Themostcommon misunderstanding about DNR ordersis that DNR must mean being jT.ffH"t$lfr",tiJ,:,;:i*",, l" ,ti.. A"rh.;.;;;;; Jisuncrerstandins isthat other aspects routine good of bropsies, dialysis. or caresuch "r r;;;: o*o * ,r, "..9i1 noma a "J;;;il:IiJ:;"T and b,.0,, needs l]:lh,TiillT,il:[]::::i::fl.; $:lJ: *o;-p,t.;;,;;d;,ilo**o** -.u.,,;u.,ties ;l;::lT*ffffi:i:::: ": thnd-pointoftherapv. whenpatient tt ".. i, o ,uaa].ilp"1l^Tj:.1?,iT:trm- a dies rapto upgradein usually ing intravenous the amount of thetnpv,,u.hlrts ;.;t;;;;;r,;;tn u, giu- maystil Apatint uncrergo,",r;,;;;;;"::;1,;r,T:.,":il.1L..:i"j:T:fi:1,Ti,i:n. trhenpatientshavecardiopuln.ronary arrest,thereis presumedcon naresuscitation unlessthe1 a patient specifi calryand expressivety ;::i.J,X.*:tJi:;lcsIlvIE For example,a 42_year_old man with AII)S is bcing taken to the operatingroom j:1:::lfl*.-, r]re surgicar residenr shruss h;,";;i;;;;.,ays,.oh wel, itcr"oantmitie. s,,.g.,v :i:::::ff::iffifttli l*l)- a relicfl"What reav irth. i, of tls shouldyou tell hrm? DNR doesnot mean patients sh( resuscitation.DNRt,.;;;";;;;;#,;,,.._";::f dorng serves an excuse or as ruli?f J:J::illJ#:$T:ffi for making " _irtut". oNnlo;;;;.", letthe patient die, or thar thc I it is okayjust to doctor doesnot have,. b. ;;;;;;i,^ patienrcan stilt be
    • I intubated and maintained on a ventilator if she is DNR. This is a confusing point because endotracheal intubation is often a part of the normal resuscitativeprocess. the pl rientir If DNR and he loseshis pulse then the doctor would not intubate becausethe intubation here would be consicleredpart of theCode or resuscitative/CPRrlanagement. Honever, ifthe A patient remains alive and has advancing lung disease,the patient can still be intubated ln T] . this case,the doctor rvould only defer CPR if the patient were DNR. Doctors Jo not have th to rernove the endotracheal tube of all patients who choose to be DNR. Many patients will o1 not allow themselvesto be made DNR becausethey believe the medical staff will not be as rt aggressive their other treatments. in gi n For example,a 68 year-oldman with basalcell canceris aclmittedfor evaluation h and treatmentof a fever. hasbecnDNR for the last six months.After the chest He and blood cultureare done he still hasa feverof unknown etiol X ray,urinal)sis, ogy.When you ask the residentwhy he hasnt done more tests,the response is, "Well, we rvill get to it, but thereisnt much of a rush,alier all, thc patient is DNR." What do you tell hin.r? DNR doesnot mean arrythingmore than deferringCPR,such aschestconpressions and cardioversion. this case, would alsoeliminateendotracheal electrical In it intubation if this effort. That is all. The doctor is expected man- treatmentwerepart of the resuscitativc to agepain and the diaplnosis other medicalproblemsjust asaggressively shewould in of as a non-DNR patient unless patienthasspecifically the chosen deferthoseother forms of to therapy.Doctorsdo not automatically haveto havethc DNR order rcversed just to be in the intensivecareunit or to go to surgery.I(A?LAN MEDICAL
    • - End-of-Life rssues Iie FTUIDS NUTRITION AND ISSUESise€ Adults theCapacity Understand with ton The artificial administration of fluidse a<1 nutrition is a medical procedure and treatment that can be acccpted or refused t nlt competent adult in exactry the same manner as any other treatn.rent.,Artificial odr,ir"s rhan .Artinciar,,,o;;*, eatins. :::l:: r.ffii:xffi:;T,f,::.Ti :i::il:l: Sastricor jejunostomy turre pracement. Artificial nutrition" il would also refer to intrave- ]onsly administered nutrition such as totar parentcrar nutrition (TpN), also referred to as hyperalin.rentation. For exqmple, a 47-year_oldtheoretical physicist with amyotrophic lateral sclerosis nas Decomcprogressively nore clisabled to thc point of beinj virtually immobiie in a rvhcelchairHe is unablc gastric ,ut.u,,a reeding ,.ru,.o,lo :illT::,:,:?tijJil,,";#;":JJ:l;:j,*: nurse,is insistingthat you reinsertit. What shouldyou tell her? Forcible inscrtion by anyoneof an artificial feeding deviceinto an adurt patient with the capacity understandthe meaningof to its rcmoval is not allowed.If the patient,s are clearly wishes exprcsscd, is the samcasrefusinga ventilator, this blood testing, dialysis. or This refusal subjectto the samecriteria as is the refusaiof oth", tl.,.rupiar.you must there isnt a severe be sure depressi.nunderryingthe refur", "ra ,n"t,i. hema,v without the tube. If there is die riiuent undcrstands that no depression, tn"n tn. fnt,.r.,t has thc right to refttse therapyeen ifhe will die without putting a it. thc tube tru.t in,o a personwho has rcfused is considered san.re assault it the as and battery,. Adults Have theCapacity Understand Who Lost to Deciding what to do about artificial nutrition vher the pati.rt cannotspeakfor herserfis amuchhardercircurnstance. Nutrition is the singlemost difficult issue holding and withdrawing treatment.We can never rn termsof witb_ I withhold ordinary nutrition like food to eatand water to drink. The stanclard of certaintyregardinga patientt wishesin of.artificial terms nutrition is much higher than wirh other ,i.ropri."- il"rnort havevery clear efidence what the patient,s of wishes werein regardto artificial nutrition. I(APAN MEDICAL -
    • If there is a health-care proxy, and thc healthcare agent says,"The patient clearly told me P that they didnt want tube feeds,"you nay withhold the therapy. If there is a living will rvhere the patient themselves wrote, "I do not tvish to have a nasogastric tube or other In forms of artificial nutrition," you may withhold the therapy. lf there is no advancedirective, hir but the family is in uniforrn agreement that the patient had expressedthe wish never to lif, have tube fecds, you may withhold the therapy. If clear wishes regarding fluids and nutri- clr tion were ncver clearly expressed,thcn there is inplied consent for the feeding based on TT the presumption that it would be the patients wish to be fed and on the f-actthat feeding nc and hydration are in thc patients best interest. Pa se Emotionally, the standard is different from the standard used to dcternrine whether or not th ordinary testing such as blood tests or CT scans should be donc. The proxy and fanily pr "The can say, patient never specifically told rne that he would not want a liver biopsy or to MRI of the brain, but mv understanding of his wishcs in general is that he doesnt want to as undergo these procedurcs." This would not be the same for nutrition. Decisions on with- m holding and withdrawing of artificial fluids and nutrition should bc treated the same way as any other medical treatnent. There is a higher standard of evidence for decision making in some states.That is why this issue is so complex. Fcw people have left a specific, written E document concerningtheir desirefor tube feecling. The evidence has to be clear that a paticnt does not want artificial nutritjon. Thc routine AS assumption is that rnost people wish to be fed as a part of ordinary care. If the evidence is ac not clear, then a referral to an ethics comnittee, or possibly to the courts, is necessary. The ni level of evidence regarding the patients wishes necessaryfor withholding and withdraw- th ing artificial nutrition has been treated by some courts as the same as the level of evidence et required in a criminal case.The system errs on the sidc of caution-perhaps letting a few guilty people go free rather than sending a single innocent person to jail or execution. If you lost consciousnesssuddenly and left no specific instructions, wouldnt you want there to be a need fbr colrvincing evidence that you didnt want to be fed before your relatives T rvere able to withhold nutrition and possibly let you die? Ethical consensus holds that TI decisiolrs to provide or forgo artificial nutrition and hydration (ANH) for patients who m lack capacity should be made according to thc same standards as those uscd for any other th medical treatment. Despite this consensus,ccrtain statesimpose more stringent standards AI for withholding or withdrawal of ANH compared to other medical trearmenrs. ls $l BI(1:.^9 MEDTcAL
    • End-of-Life lssues Ime PHYSICIAN-ASSISTED SUICIDEvill hr physician assistedsuicide, the physician provides the patient rvith the means of endinghcr hisown life. The doctor does not actuallyaclminister that ends the patients the substanceive, life.Although there is national controversy on the issue,the answer on the USMLE is ver1. to physician assistedsuicide is always considered incorrect and ethically unacceptablc. clear;.ri- Thisis true even if there is a local state law permitting the procedure. W1rat is legal doeson n0t automatically equal rvhat is ethical. Generally, physician assistedsuicide is requestedby patients who have a terminal diseaseand a limited life expectancyanyway.Neverthelcss,the and even the discomfort and sufferingof the patient do not change severity the disease ofrot Physician assistedsuicide is alwaysconsidered to bc wrong on the USMLE. The theansu,er.ilv primaryissueis one of intent. Physician assistedsuicide is inimical, or absolutely contrary,OI to the role of the physician to save life. This is true even if thc patient is requesting the to assistance. physician cannot ethically honor a patients wishcs to bc provided with the AL means end his life. toay..n EUTHANASIA fith euthanasiathe physician goes even L.rrther in ending a patients life than in physician-1e suicide. Euthanasia actually means that the health-care worker is prescribing and assistcdis administering the method of death. Thele is no place in the United Stateswhere eutha-te nasiais legal.A physician cannot legally administer a lethal injection or any other form of therapythat will help end life. This is true even if the patient is preterminal. Fluthanasiaisle cthicallyunacceptable.Ife TERMINAT "tAW OFDOUBTE SEDATIONTHE OF EFFECT"]Slt Thereis an enormous difference between administering a lethal injection and givir.rgpaino that might inadvertentlyshorten a patientslife. The issueis one of intent. If medicationsI the intent is to end life, it is wrong. If thc intent is to relieve suffering and accidentally-ass an unintended effect-the patients life is shortened, then the treatment is acceptable.This is comparable to the differencc bctwcen a charitable donation and being robbed. If I give S1,000 charity to help othersit is a virtue. IfI stealevenone dollar from you, it is a crime. to Both events result in thc transfer of monev. however. the ethical distinction is erormous. For example, a 67 year old man is admitted with metastatic prostate cancer to the bones. He is in cxcruciating pain despite your present treatment. He has a history !!!!p iiaeorcer
    • I chapter Five of COPD and the house staffareconccrnedthat increasing parnmedications his will decrease rcspiratorydrive.What shoulcll.ou do? his As long asyou are not purposelygiving high_dose opiatesin order to end the patient,slife. it is acceptabie givethe pain medicatior.rs to evenif it might decrease rcspiratorvdrive. his The primary ethicalduty is to rclievesuffering. you cannot .iustleavetl.repatientto suffer. Givethe patientthe amountof ntedication theyneedto rclieve parncvenif, uninten_ the tionally,thereis an adverse cffecton the respiratorydrive. FUTITE CARE Br The physicianis not urder an obrigationto give treatmentor perform tests Br that wi rot an benefitthe patient.This is true evenif the patientor the family is demanding .I.he it. major br problemin withholding withdrawing or therapy the basis it beingfutileis being on of sure that therewill be no bencfit.It is hard always be certainif the treatrent tr Br rvill not herp. If it is clearthat therewill be no benefitthcn you shoLrld qiveit. not For example, a 57 year-old woman with cryptogenic cirrhosis is uncler your care.Sheis septic and hassevcre varicealbleeding well as encephalopathv as not respondingto lactulose. Sheis hypotensive and on pressors lvell as intubated as from respiratoryfailure and you expecther to die from her liver disease in the next few days.She developsHepatorenalsyndromeand has developed uremia. Yc The family is requestingplacementof a fistula for rlialysis. What should you tcll them? of st br In this case, thereis a clearurderlying preterminar condition.you shouldnot start diarvsis of or placethe fistula.Dialysisin this case wi| not change outcome.DirJysis this casc the in Br would not prolong meaningfullife. Because this casetlialysisrvould in only prolong the of dying process, withholding it is ethical,evenif the family is requestingn. p. u! tn DETERMINATION OFDEATH BRAIN AND DEATH lhc trvo nethods of def ing death arc ternination of heartbeat and brain death. rf the heart is still beating,but thc paticnt is brain dead, thcn thc person is clead.Brain_death criteria have enormous significance for the abilitv to harvest organs for donation as well as in criminal cases.t!l!!p rueorcar-
    • End-of-Life tssues i9 I For example, a man is arrested fcrr arrned robbery in which hc assaultsanothcr man. The victim has sustained cerebral hcrniation and has lost all spontaneous respirations, cognitive function, and brainstem reflexes. you are called as an expert witness to advisethe court. The allegedassailant,sclefenselawyer tells the.judge thatt s Life, thechargeonhisclientshouldor.ybcassaultandbattery,notmurcler,becausethe drive. patients heart is still beating. The defcnse lawyer contends that thesuffer. victim can bc alive for many ycars ir.rthis condition. l,hc ma,rimum penaltv ininten some states for murdcr is life imprisonment or cxecution.The penaltyfor assault may be onlv l0 to 20 years in prison. What shoulcl vou tell the juclge? Brain death is the legal definition of death. An assault leading to brain death is a murder. Braindeath is irreversibleand permanent.A bcating heart that maintains brood pressurell not and pulse does not equal being alivc. When wc, as physicians, determine the criteria formalor brain death are present, this is the legally acceptedstandard of death.gsureelp.If Braindeath is a lossof brainstemreflexes such as: Pupilary light reflex Corneal reflexesI Oculocephalic(dolls cyes)reflexes,t Calotic responses iced rvater stintulation of the tynrpanic membrane toc f h e . r b : e n ( c f . f u r r t . r n e o rr e s p i r .ir t n s o rs oL. bu can deternine loss of respirations by rentoving the ventilator and observing for signsI of respiration. lf the criteria for brain death are rnet, theD an EEG or ccrebral blood-flow stud)are not necessary. other words, the clinical criteria of the absence In of breathins and brainstcm reflexes more important than an EEG.This is because are EEC activity wou]d be vsis of limited mcaning if a patier.rtmects tl.reclinical brain-death crjteria. case Brain dcath should only be determined to be present if you have excluded other causesg the of markedly decreasedbrainstem and rcspiratory function. you must be certain that the patientis not suffering fron an overdose of barbiturates, hypothermia, hypotension, or the use neuromuscular of blocking agentssuclras pancuroniumrvecurontum,or succinvlcho line. Thesecan all simulate brain death. For example, a 35-year-old yroman is admitted aftcr having a serzuref the ar a parr)i. Her headCT scanshowsan intracranialbleed.Sheis intubatedbecauseteath of the loss of spoDtaneous respiration.There arc no pupilary, corneal,oculocephalic, coldwell or caloric reflexeselicited. Which of the follorving shoultl you clo next? I ( A P L A N MEDICAL H
    • r | $rapter rive a, EEG b. EKG c. Urine toxicologyscreen d. Psychiatriccvaluation e. Ethicscommitteeevaluation This patient has met most of the criteria for brain death. An EKG j nosedeathat any point. Auscultationof the heart is all ,h", i, ..;"irt":",:t::::t#tlf: stopping of the hcart you should excrucre intoxication with cNs depressant drugs and hypothermiaprior to determiningthat the patient is brain dead. Brain death doesnot specifically require determinationby a neurologistif the physician managingthe patient is comfortablewith the criteria describedanclhow to verify them. A Thisis similar to not needinga psychiatrist in order to determinccapacity. the patient If clearlynot brain deadbecause is their pupils arc reactive they havespontaneous or breathing, te a neurologistis unnecessary. c( If the patient is brain dead,then they are dead. sl The physiciandoesnor needa court order or a relatives pern.rission removelife support.The to te doctor doesnot needto askanyone,s permissionto stop the ventilator or.other at treatment,although USMLE will alwayswant you to answer"discuss your finding.s,,, ..build consensus,, with the family,,,,explain or first Pi rather than just turning offthe ventirator. This may see- .nritrudi.tory. vou shouldalways P( explain what brain death meansto the patient,s AI fanily. you need to answer.,explain the meaningof brain deathto the family,,asthe first n( choiceif it appears. on the other hand the farnilyi permission or conscntis not requiredfor terminatinglife T] support,because personwho is brain clead a th is considered dead.Insurance companres will not pay for the hospitalizationor managcment at of thosepatientswl.roare dead.you can harvestorgansfor transplantation from a brain-deadpersonif the family consents. you do In not haveto wait for the person,s heartto stop.Actually,it is preferable remove to the organs of while the heart is still beatingbecause viability the of th" t."nrplur.,t.aorgan stronglycor_ fe relates how long it wasunperfused to after removalfrom the donor,sbodv- !(AplAN ) MFDtcAl
    • l + r Chapter Reproductive 6: lssuesABORTIONAr adult woman has an unrestricted acccssto abortion through the end ofthe first trimes-ter First-trimester abortions are clearly unrestricted. Women do not need the approval orconsent ofanyone elseto obtain a first-trimester abortion. In the second trimester the deci_sionis still between a woman and her physician, but the easeof access a second trimes_ toterabortion is less clear Statesmay place regulations on free accessto a second_trimesterabortion. However, second-trimester abortions arc preponderantly still performed at thepatientsdiscretion. Third-trimester abortions are not freely available, becausethe fetus isptentiall)viable. Third-trimester abortions are clearry restricted. consent by the father foranabortionis not required; the fetus is considered as a part of the woman,s body antl doesnothavethe individual rights of,personhood until after birth.There no compulsion on the part of the physician to perform is an abortron if performingthisprocedureis ethically unacceptableto the physician. The patient has a right to have anabortion, they dont have a right to force you to but do it, if it is objectionable to you.In addition,it is considered unethical for a patient to seek an abortion for the purposesot gendcrselection.It is considered ethically unacceptable to cretermine the gender of thefetus then abort the fetus if the sex in unacceptable and to the patient. For example, a 23-year-old woman contes to your office seeking an abortion. you perform gynecologic procedures and you have been trained to d-oabortions in the past.However,you no longer find it morally acceptableto perform the procedure althoughyou know how. The paticnt is insisting on having the abortion and is angry with you for "abandoningyour parjcnr...,!hat should you tell her?
    • 42 chapter six | O: q:"*t rule, if therc is a procedure I that the patient wants but that you do ethicallycomfortableperfornir.rg,you not feel should rcfer the patient to onoth.. physician. you D cannotbe compelred accept paticnt to a you d., not want or to do a procedure T with rvhich ),oudo not agrce. Jhephysicianmust voluntarily agree to the relationship. Ir T] CONTRACEPTION d( Thcre is no limitation on the access to contraception for either a lran cntirelyat the discretion of the patient. or a wontan. lt is This is equally t..r. fo, ,rri,.,o.r. Contraception one of the issuesfor which a n.rin, is considered partially emancipated Parental is not necessaryto ot,anir, consent .onrro.lJ,ls STERII.IZATION Both women and men have free access sterilization. Consent is or. y to necessaryfrom the patient. Spousalconsent is not I insl aborti,o, .on.,u."p,io,,, ona",:J.fi1,**l,jIl;# J:ri:..Tft:::il:?:f; spouse.Each person has autonomv over hr.sor her own bodv. MINORS not necessary cither contraception for l"j:11^.:.1:, l, or prenatatcare.ln cases involr- lng reproductive issues minor-s, ansrver for -encourage the rvi te either to just treat thc minor discussion, the or to with usMrF;r,tr;;;;r";;:;::".*:1,:il1"J*l:..."x,:;ff :T::i[?:::,.,,J; issuesinvolving minors. The rules on parental consent in the caseof abortion Some statesrequire parental consent are lessclear. for abortions and others do not. Because a national exanrination and the rules USMLE is on parental _r*n, fJ"rion vary frorn state to state,there cannot be a single answer that cither says,,noparental consent,, ,,Ies, consent is necessary.,, or parental Therefore, the ansrver will be,.eniourage the patient to discuss the rssuelvith parents.,I(APLAN MEDICAL
    • Reproductive tssues Ilo rot feel lclan. you DONATION SPERM EGGS OF ANDith rvhich #::il,::,:T:1."1i,:l"i:"j::::::"J^:::10l,r:donate and In addition, paymeut nlay --.---" t be recei, , ror spcrm ilncl /eo - spern unfertirized slcrrD ano untertrfized eggs eggs. rvords, rvords, unti:rtilizecl cgg donations. In L oonattons.ln ot_h"er there nn legal there is no l.-.r or ethical - c, onrrnndr.rtion t,r sellingspernt Jlrurr. sPcr and unfertilized Thercis, however,a prohibition lherr. ic h^-,-.,-_ or ano un .. Lgainstselling tertilizecleggs. .loner.r r.,,+_^. - rr donated, not sold. Fertiljzcd eggsmay b e y butnan.It iseptionis consentromtheincludr of thcnvolr-rortoessarl)uctive clear.ILE isatetorental;sthe qj:19 MTDICAL
    • l 4 s Chapter Organ Tissue 7. and DonationAUTONOMY DONOR OFTHEOrganand tissue donation is a voluntary event entirely at the discretion of the live donor,Theprinciple of autonomy is fully in play here. For example, a 35-year-old-man is dying of hepatic failure. His brother is fully HLA rnatched and a highly compatible donor. There are no other donors at this time and the patient will likely not survive long enough to find another donor. You are screening the brother for the donation, but hc is not willing to undergo the surgery the partial donation. What should you do? forThereis nothing you or anyone-including a court of law can do to compel a person todonate organ or tissue if he clearly choosesnot to do so. The need of the recipient has no animpacton mandatin€l a donor to donate. This is true even if the donation is uncomplicatedfor the donor and the recipient will die without it. DONORORGAN NETWORK FOR ASKS CONSENT DONATION FOR For example, a 30-year-old woman is your patient in the intensive care unit for respiratory failure. The patient has had a motor vehicle accident and has sustained a massiveintracranial hemorrhage. The patient is brain dead and will be removed from the ventilator. You know that there are numerous patients in your hospital waiting for organs. The family of the patient is with you. You have an excellent relationship with the family and they trust you. What should you do about the donation? I(APLAI MFDICAL
    • I chapter seven 46 Only the organ donor neturcrk or uniform network for organ sharing shoulci obtain con_ sent for an organ donation. The medical tcant taking care of the patient shoukl not ask for the donation. Even if your relationship witr.r the familv is excelent, the organ donor network has an enormously greatersuccess rate in obtaining consent.physiciansthat ask for consent for organ donatiolr are far rnore likely to be refused. Becausea greater number .f refusals would lead to a lossof potentiarorgansfor donation when the shortagestatute of availableorgans is critical, it is againstthe raw f.r doctors to obtain this consent. By legal statute,only those specificallytrained to obtain consentfor orqan donation should approachthe family for this consent. In addition, there is thc perception of an enormous conflict of intereston the part of the family nhen a caregiver attempts to obtain consent. {4ren a caregivcr asks for consent, it leadssome families to believethat the health-care team is not doing everything possible P to preserve the lifc of the paticnt. This makes it scer that the priority of the health-care II team is to obtain organs. It is essentiarfor the hcarth-care teanl to preserve its reration o ship rvith thc family as the advocatesfor prcserving the rife of the patient. In addition, the S organ donation network has a much greaterchanccof obtaining colscnt, so if the primarv rl health care team tries to obtain consent,it cor.rldlcad to a lossof neededorsans. r( P PAYMENT DONATIONS tl FOR rl With the exception of renewatrle tissues such as spermr unfertilizcd eggs,and blood, pay_ P n.rcnt for organs is considered ethicarly unacceptable.peoplc must not bc in the busincss of sellingorgans.The economic aspects organ clonationmust be ninimizecl so that pcople of P believe that the patients who need organs the most w I get them, not that the rvealthv lc will get preferential treatment. It is, howeveq acceptableto cover the cost to the donor l of dona- tior.r. here is a differencebetwecn reimbursing the donor for the cost of donation tl and creatinga finalcial incentivcfor pcople to,,sell,organs. Pi al ca ORGAN DONOR CARDS SC Although an organ donor card gives an indication of a patients wishcs for donation, ir fam ily consent is still necessaryfor donation. Family objection can overrule the or gan donor card. Tr tr fc al bi!t,qp tl N) N4 orc.Ar r
    • 47n conot ask Chapter Reportable B: lllnessesdonorLat askrnbcr;latutcnt. Byhouldof theent, ttrssible Physicians laboratoriesare mandatedto report a nunber and of medicai illnesses. Ther-care maipurpose reporting in inncsses both epicremiologicwenasto rnterrupt spread is as thettion- of certaincommunicable diseases. illnesses The that are alrval.s reportableincludeAIDS,n, the qphilis, tuberculosis, gonorrhea, and all ofthe childhooddiseases asmeaslcs, such mumos.LlTlAIV rubella pertussis. and Thc list of other reportablediscases extensiye. is Thesediseases are reportable sonrebody, necessarily physician. by not the Phvsicians always are legallyprotectedfor participatingin partner notification.In gcneral, thehealth departmentperformsthe majority of contact_tracing events well asnotilying as those havebeenilr closecontactof the possib ity of infection.fhe that nameof the so,.rrce pay- patient always is protected.:ss of Partner notificationexists diseases asHIV/AIDS, syphilis, for sucheople gonorrhea, tubercu and losis. addition, health In the department incarcerate can patientsywill with tuberculosis pre to r,ent spread diseasc. a patient won,t tell his or her partner, the of Ifona- then you must ansu/er thatyou must follow your duty to report. If the sourcepatiertLand still won,t tell his or her partner, arewithin your legar you right to tell the innocentthird party.partnernotification andreportable illnesses an example onc of the few timesthat thc patrents autonomy arc of can superseded be becauseofthe necessity ofprotecting othcrs.My right to autonomyends rvhere your safetybegins.I havean absoluteright to privacy,exceptwhen my restaurant seres foodinfected with sarmonera, thenthepatients and rightstoautonomy become ress[am important than protectingothersfron harm.lnor Tuberculosis specialreporting and public health issues. additron has In to doing contact tracing ofthe contacts order to do ppD testing,thereis the speciar in rssue incarceration of fortuberculosis. Patients with tubercurosis shouldbe isolated abouttwo weeks, for which is approximately amount of time that is takesfor sputumto become the negative acid-fast for bacillilf a patient refuses take antituberculosis to therapy,physicianshavethe option of MTDICAL
    • | .ruo,"r rirr, lrcarceratingthe patientto preventthem from spreading disease. the This is only for those who stiJlhavepositivestainsof their sputum for acid_faitbacilli. Incarceration tuberculosis not the same for is thing asbeing arrested. hasnothing to d0 It with the criminal-justicesystem. The incarcerationo..ur,-in a hosprtalnot in a prison or jail. You cannot force-feed tuberculosis medications, you can preventpeoplefrom but walking at their leisurein the community to spreaddisease. Incarceratton a last resort is and is.onlyusedafter aother optionshavebeen exhausted termsot havingdiscussions in with the patient and offering directlyobservecl therapyat home. co As phv ity r ther hen wh add aut( test Altl nan righ HI Pre POSll{!!P urorcer-
    • lrs Chapter HIV-Related 9: lssuesldoisonromSOItions CONFIDENTIATITY Aswith all medical information there is a presumption of confidentiality on the part ofthe phvsician.Becauseof the social stigma of HIV there is an additional layer of confidential- ity and consent required. When a patient enters the hospital or other health-care facility thereis general consent given that allows the routine testing of blood for chernistry and hematology and so on. There is an additional HIV-related consent required to test for HIV. hen a patient signs a releaseto distribute or transmit medical information there is an additional consent required for HIV or AIDS-related information. You cannot mandate automaticHIV testing of patients without their specific informed consent that you will be testingfor HIV For example, a woman com€s at 10 weeks of pregnancy for prenatal care. She has a historv of sexually transmitted diseasessuch as gonorrhea. You offer HIV test- ing, which the patient refuses,as a routine part of prenatal care. She returns at 14 and l8 weeks of pregnancy but is still refusing becauseof anxiety that she may be positive.You inform the patient that there are medications that can reduce trans- mission from mother to child to less than 2 percent. She persists in her refusal. 4rat should you do now? Although there are medications to prevent transmission of HIV to the fetus during preg- nancl, you cannot compel mandatory testing of pregnant women. The woman has the right to refuse testing as well as to refuse antiretrovirals. Therefore, you should offer HIV testing universally to all pregnant women-but there is no mandatory testing of the pregnantwoman without her expressconsent to do so. If the woman is found to be HIV- positive you cannot mandate the use of antiretrovirals even though they are safe and I ( A P L A N MEDICAL
    • 50 chapter Nine | effective in preventing transmission of the virus from mother to ch d. Althoueh from T] time to time, there is aberrancyin the Jegal systen.rthat tries to prosecutea drug_u.ingor til alcohol-using pregnant woman, the autonomy of the mother lcgalry outweighs thc safety Pi of the fetus. ol T For example, an HlV-positive tvoman comes to labor and clelit ery at 40 weeks tt of pregnancy. She has a very low CD4 coult (less than 50) and a high viral load (more than 500,000). You offer her a Caesarian section and intravenous rf zidovu_ dine, which can cut the transmission rate in half even on the day of delivery. The t( woman is anxious, but clearly has the capacity to understand the implications of P this decisionon both her health and the health ofher child. Sheis stirrrefusinsthe y( C sectionand medications. yl What should you do next? st s( Fortunately this circumstance is rare and the HIV perinatar transmission rate in the united Statesis well undcr 5 percent. However, a rvomans right to choose her own forms ofhealth care are considered superior to virtually all other treatment concerns.The wrong answer in a question like this would be to give the medications an1.way, gct a court order to to compel the patient to take the zidovudine, to ask the father for consent for either the zidovudine or the C section, or to sedatethe patient and pcrforn the C sectior.r. The autonomy of the mother is regarlvsuperior to beneficence for the fetus. Althoush a 40- lveekfetus is a viable child, the fetus is still inside the womans body and doesn t become a person until it is delivered. A noman has the right to refuse HIV testing in pregnancl, to refuse antiretroviral medicati.ns in pregnancy, anci to refuse a c-section even if it will markedly benefit the child. t t PARTNER NOTIFICATION v s Thc high levelof confidentialityconcerning HIV can only be breached under very specific cucumstances such as when the health of a third party is at risk. A crrcumstance suchas thiswouldbervhen HIV-positive an person a sexual needle-sharing has or partnerthatis at risk. The method of notificationfollowsthe stepsof first counsering patient to notiry t a his partnersvoluntarilyThis wourd be idealand follows the general themeof uSMLE, rvhich is to first answer"encourage discussions,,when listed as one of the choices. the patient If is either emotionallyunableor unwilling to notj$ their partnersthe next stepis to notiry the Departmentof Health to start the process contacttracing.The health department of interviewsthe patient and attemptsto constructa list of partnersin order to notify them.!l!!!p rureorcar-
    • ntV-Related rssues Ih from This a voruntaryprocess is and therc is neither a penaltynorsingor tlonif thepatient chooses to criminal threat of prosecu- not corply. fhe h*ih d"p".t;;r,t.,.nr satcty partner thereis a bealth_relatr ,.rr.t, notice to the that or potentiar il:iiil.:.jlHffj,I#Hii:,i:jift:;*:.T their "*.*;; reveared partner theconndentiaritv tothe andks ;[:ffi[i[::]ff;l;;.:*er orrd lf thepatiert is stilJunwilling tol- disclose namesofhis contacts the todo so.Thereis no incarceration you cannotcompelhimle rrmtnal penaltyfor not disclosing paticnt not notiff his partncrs rvill thesenames. a Iftf rou resar ,., ;::X.r.T.,*.::,"j#j#5ffi:i haver--,,i,, .,,.f youdo notify the partner,but it is r i::,T..HJj* :iffi:i,:: **{:t_#;1tiliilLt;:#J:::i"i"ffi#;:,TJffnitcdealth For example,you havea patienter in in your cJinicwho is accompaned ui"il tn: is ciearlyhaving unpru-recred by her boynpel sexbecause " l, pi.grru.rt. When ,t askif her boyfriend knows her youleor HIV staru.., ,"ys, _;;:.;; ,Jr" leave if I told him.,you haye not_he might me a protracteddiscussion about the critical inrpor tance not puttingherpartner of at risk.you strongly enco"r"r" i., a ,.,, nr_ n* HIV status. a subscquent On visit, whenyuu urk h"".ifrh" t shesays, "Not or"noiln.a 1", po.,n.,)me yet.,,you krow the boyfriend b.."",. h. ;..;;;ai., --- -!!vir( he, to th.rcy, officevisits.4rat shoulclyou do?will 0",n," duty to the patient in rerms I"^:..Ll. of her health carean<ther confidentiality. ,toneyer, alsohavea duty protect ),ou to the partncr.you f,"". f.g"f i_.r",ty thepartnly. this point cither At ifyou notii/ you can askthe heaitha.pur,rn..* a ,ro,ify the partner or yo^urself. thepartner wereto If ::: lr:i lvasI Ir notified seroconvert HIV and you did for sure he you rvould be legallyliable not makefic becauseyou aJ ,.rJ,tolto* your duty ivarn. This is similar to having a psychiatric toas patient who told rr"lvu, gorngto harm youhave dutytomaintain confia"",.ii,i"i rouat a the ill.ili:-1tjn:rln ]laea duty to iDfofln the person ,n" p"tient, also youis at rrsk.:hItirtt. (lPt,!p rarorcar-
    • 52 I cnapter ltine HIV-POSITIVE HEATTH-CARE WORKERS There is no duty on the part of an Hlv-positive health care worker to inforn.r his patientl of his HIV status.Universalprecautionsare supposedto be maintained.Theseshouldpro- tect the patients. An HIV-positive physician who practices high-risk surgical and obstetric procedures is expected to maintain precautions to protccl tlre patients fiom transnission, REFUSAI-TREAT TO HIV-POSITIVE PATIENTS It is ethically unacceptable to refuse to treat Hlv or take care of HlV,positive patients simply becausethey are HIV-positive. lf you have a physician to whom you refer patients for various treatments, it would not be ethical for that person to discriminate only on the T} basis of the patient being HIV-positive. On the other hand, you cannot con.rpela physician an to take over the management of any patient if the physician doesn,t u.ant to do so. If your to question brings up the subject of rcfusal, the best answcr is to refcr the paticnt to someone H else who will perfnrm the care. Cr bt AI th h Ir d c t1 tl tl tlI(API.AN MEDICAL
    • ] s r 1O: Transmitted Chapter Sexuallyntsro- (STDs) Diseasesr1c)n,rtshe Theethicalissuessurrounding STDs havc to do lith partner notification, contact tracing,1n andreporting requirements. Although reporting requirernents vary somewhat fron-t stateur t0 state, certain diseasesare reportable nationally such as syphilis, gonorrhea, and AIDS.ne Herpessimplex is generally not reportable and there is no contact tracing for herpes. tracing is predominantly used to intcrrupt a cyclc of transmission. Herpes cannot Contact beeradicatedfrom the body; hence there is no utility in treating the partner. Gonorrhea however, can be asymptomatically carried try the contacts of our patients and ands,vphilis, they be transmitted to additional partners even if the sourcepatient is asymptomatic. can syphilisand gonorrhea can be eradicated(cured) with treatment. In addition, For exomple,tsob is a 32-year-old man in your clinic being treated for primary syphilis.He is very embarrassedabout his diagnosis and he asksyou if his condi- tion rvill be kept confidential. Wliat should you tell him? because,voumust contact and treat partners of patients rsith STDs such as syphilis Just does not mean you will breach his confidentiality and identit| him as the source to lris contacts.here is a clearorder oftracing and treatinghis sexuaL l contacts.Ifthere is a choice "encourage "ask thatsays him to notif. his partners" or if he has already told his contacts" thatshouldbe the first thing 1o clo.If that is not a choice,then you should ofler to inform thecontacts the patient if he does Dot want to do it. At all points you should be clear for "llob that,vouwiJl not contact his partners and say, gaveyou a disease." For example, Bob tellsyou that he is rot confortable informing his partnershim- selfand he does not want you to clo it either.What should you tell him? !l!!!p nreorcer-
    • ChapterTen The Department of Health car.r compile a list of contacts of patients with STDs and notifi the contacts that they are at risk. The Department of Health does not dir.r"rlge Bobs name to the contact. The Department of Health contacts the partners and saysthere is an impor- tant health issue concerning them that has come to the departments attention and then asks them to come to the hcalth departrnent. 4ren they arrive, the partners are told for which diseasethey are at risk, but they are r.rottold the identity ofthe source. The1.n1. 1h.n encouraged to seek testing and treatment. The najority of patierts r^/ish to be inforned, tested, and treated in order to protect their own health. For example, Bob does not want to tell eithcr you or the Department of Health the names of his partners. He says he is mor.rogamous now and, in fact, he is accon.rpanied his pregnant wife. He has not told his wife ofhis condition. What by DE should vou do now? Ma1 "encouragc "offer Mal As always, you should answer him to disclose," counselingfor partner dar< notification,"or somestatement that is gentlein terms of respecting patientsautono- the thin my. If theseare not in the choices the patient refuses or then you nust directly notif. his Pat pregnantwife immediately. Her testingand treatmentis essential protectboth her own to rele health as well as to preventperinatal transmission. Congenitalsyphilis is a seriousand tive dangerous disease is entirelypreventable. but occ For example,you politely inform Bob that you have a duty to protect both his an rvife aswell ashis child and you are forcedto noti$. her or havethe l)epartment sui of Health noti$. her of her risk of syphilisif he will not do it. Ilob becomesfuri- ous and threatens sueyou if you violate his confidentiality. to What should you tell him? You are legallyprotectedif you inform a person at risk of harm. ln addition, there is a duty to warn peopleat risk of harnr.Bob can get asupsetashe wants.You are not legall,v at risk. ln UI drI(APLAN MEDTCAL
    • ssotifyLame Chapter1: Malpractice 1POI-thenlforhen DEFINITION Nlaipracticeis a preventable errrter Marpractice oi::?.:n:jJT,i:Hl"T:]:i: ;:*:f""Hl: is a"p",,a.ni ur- ;:,LT dirrd carein a local commLrnity. other of Into words,if the plysician alA or did not do some- thingthat wasdiff-erent from what is locallyaccep,"ap.u.,i." *u,ris .esultedin harm to thc patientthen malpractice occurrecr. intent or ievcrofgoodwl Thevn ofthe practitioneris r.1..,t relevantifharm occurred. ver Ifard tir.efaiiureinsteadorr,,.,"-,o"liXi,,""Jln,Jr...l"J,""l:lfll:,.|lJ,l#:?rf" occurred thepatients if condition worsened he washarmed. the best and If surgeon the in wofldamputates wrongfoot,thennaipracticc the hasoc.o.rJ. Uo* ni." ,oneoneis has anenormouscorrelationwith ho gry Pattets may be and how likely they suit, it doesntestablish but are to fi]e liablif,i For exampre,a surgeonis consultedto place a centrarline. Hc rs very rude and arrogantand speaks harshlyto the patient.The patient signs conser.rt alter being informed of the conplicationsand alternatives in manng.i.n,. o pn"uroorl.,oru" occurs and thc paticntis infuriatedthat this,,high_hand"ed bastard,,hurt hirn.He filessuit against surgeon malpractice. the for Wl;1 will be the most likely outcome ofthc suit? In the same_ that being pleasantdoes way not absolve you of liability, being harsh and unpleasant not equalrnalpracticc. pneumothorax do A il; nn n..^innut complication of central placement. line The patientwasfully informed of this and still agreed the proce- to durc.Therehasnot automaticaliy becnwrongdolDg this case. in !!l!!P ueorc,rL I
    • .huo,u, a"u"n | Evidence of harm is an important part of establishing marpractice. lhere must be both error ln the care, as well as evidence that an there has been an adyerseeffect on the patient. For example, a patient with diabeteshas osteomyelitis on an X ray ofhis foot. The physician does not perform a bone biopsy and givcs the patient oral cefadro:i:7l for six weeks. After therapy is over, the osteomyelitis has completely resolved. The patient secs some literature on the Internet several months later conclu_ sively showing that a bone biopsy is an indispensable part of osteonyelitis care to determine an organism and its sensitivities. In addition, he seesthat intravenous therapy is the standard of care. He files suit against the physician. What will be the most likely outcome? The patient is right that the physician deviated from the standard of care on these two points. However, his diseasewas effectively treatecl and thcre was no harm clone to the patient, and in fact there was benefit. Therefore, malpractice has not occurred. DEVIATIONS I.OCAL FROM STANDARDS OFCARE Physiciansmust practiceaccordingto accepted therapybasedon demonstrated efficacy. Because thereis a certainamount of subjectivityin care,it is incumbent upon the physi cranto determinewhat the locallyaccepted standardof careis. In addition,you must fully inform the patientof all options in carein order to makea truly iformed choice. For example, a surgeonhas_ just moved into private practicein BeverlyHills, California,afler his research fellowship. patientwith lymphomasrgns His consent for an exploratorylaparotomyto stage lymphoma.He doesnot inform the patient that CT scanning a valid option. The surgeon is tellsher,,,I don,t trust thosescans. We always laparotomies my fellowship.,, did in The patientdevelops abdominal an wound infection leavingher with a scarthat ends h...n..., o, a swimsuitmodel. In the suit that follows the surgeonstates,,,l did the most accurate procedurefor my patrentto excludecancerin the abdomen. That is what all my protessors did in their studies."Wlat will most likely be the outcome? The surgeon erredin two ways.First,he did not explainto the patientthat a CT scanof the abdomenis a valid option to exclude stage ly_pho_u. Because did not fully inform III he her, he will probably lose the case. Second, local standardof care outsideof the certain!(AP!AN ) MEDTCAL
    • Malpraaice I,othan research protocols is to do only the scans.Becausethe patient developed a complicationtient. hom an avoidable procedure and there has been harm, the physician is at fault and will probablylose the case.The same reasoning would be true for a surgeon insisting on anhe arillarylymph node dissection for evcry patient with breast cancer instead of a sentinel lymphnode dissection. If the patient develops edema and cellulitis from an unnecessaryrylrd. procedure, then there has been harm. The sentinel node dissection is most often the localu- standard care. In addition, if the patient was not informed of the option of an axillary ofto dissection, then there has not been full informed consent. The patient cannot choose aIS procedure she has never hcard of it. ifle INFORMED CONSENT PROTECTION AGAINST LIABILITYe trvo Errors complications not autornatically and do imply malpractice. terms of errors,part Ino the of theliability depends whetheror not the error resultedin harm to tne parlent. on For example,a patient admits to the hospital for a knee replacement.The staff forgetsto start the patient on deepvenousthrombosis (DVT) prophylaxis.The patient does not developa DVT, On transferringcare severalmonths later the patientobtainsa copy of the chart and sees omission.He filessuit for a devia- the tion of care. What is the most likely outcome? Although is a clearerror to omit DVT prophylaxisin this case, harm hasoccurredto it no thepatientand it would be difficult to obtain monetaryreimbursement damages the for if patient unharmed. is Complications therapydo not imply malpractice. of The main issuein determiningmal- practice whetherthe patient wasfully informed that the Itarm could occur and whether is or not he wasinformed of other valid options in therapy.If he wasfully informed and he signed consentan).way, then malpractice not necessarily has occurred. For exemplq an actress develops stage non-Hodgkinslymphoma.you inform IV her that neither surgerynor local radiation will be appropriate.She agrees to undergocombination chemotherapy and has beeninformed of all the potential adverseeffectsincluding hair loss,sterility,and peripheralneuropathy. Ihe usualthe and customary doseofthe chemotherapy givenand the patientloses hair and is herrm develops neuropathyfrom the vincristine.Sheis not ableto work because her oflin appearance. filessuit because this.What will be the ntostlikely outcome? She of !!l!!p urorcar
    • Although in this caseharm hasoccurredto the patient,the physicianis not herdliabrefor malpractice. has fully informcd the patient that her besi option for survival He P was che, nrotherapy and that hair lossand europathy could occur.Although it is unfortunatethat o this hasoccurred,that doesnot makeit malpractice. INFORMED REFUSATASIMPORTANT INFORMED IS AS CONSENT lf a paticnt refusestherapy it is not sufficient to say that the patient was a competent adult who had the ability to refuse therapy. The patient must be fully informed of the effects and possible outcomes of refusing therapy incruding all the harm that courd occur rf the patient still refusesthen there has been no malpractice. It is also not acceptabre say that a to paticnt was difficult, abusivc,or unable to understand English. The physician Lr has an obliga_ tron to provide information to adult patients with decision-rnakig capacity in Pi a language that they can understand. m y( For example, a 60-year-old rlan conles to the emergetcy department P with one p( hour of chest pain and an ST seglnent elev.rtion myocardial infarction. The patient is a recent immigrant who speaks French and untlerstands little English. you inform the patient that the best therapy is angioplasty and possibly thrombolytics. You explain that they can develop intracranial bleeding from the thrombolytics R ancl a hematoma at the site of the catheter placement from the angioplasty. R The patient, anxio,s to avoid thcse complications, refuses both. you do not [( double check the refusal with a translator. The patient dies and his family sues you for ill malpractice. In your defense you point out the clear fact that you offered o the patier.rtlifesaving therapy and he refused.what wiI be the most like]v outcome? In addition to informing a patient of the complications of therapy, you must atso infbrm I them of the complications of not receiving the therapy. ln addition, if there is the question 1 of a languageproblem, you must obtain a translator to double checkyour patient under ir standsthe impact of withholding the treatment.In this caseit was not docunrentecr that n you told the patient that he could die without the treatment. He was not fully informed. Ir You would lose the lawsuit. lt nI(APIAN MEDICAL
    • tvtalpractice ss Iable foras che- PATIENTS FUttYINFORM PHYSICIAN MUST THErte that OF THEIRMEDICAT PROBTEMS For example, a man is admitted for a possible DVT. He denies any past medical history. He does not infornt you of his recent diagnosis of a gastric ulcer after encloscopy severeuppcr gastrointestinal bleeding. There is no previous record forNT at this hospital. You give him heparin anrl he hemorrhages rnassively. suesyou Hct adult for harn.ringhim. His lanlrcr knorvs 1ou gave heparin to a patient rvith a history ofeffects bleedingtl.ratharmed the patient. What rvill be the most likely outconc? If thc that a In addition to a patients rigl.rt to be fully infonned of the risks and benefits of therapr,,thebliga- patientalso has a responsibilityto inforn you of their entirc medical history.There is noguage malpractice the patient has a complication from a previoLrs if illnessthat he did not tell )rcuabout and you hacl no way of knorvir.rgol If the patient has a history of an allergy to penicillinand he does not tell you when you ask,you are not held liatrleif ,votL administere penicillinnnd he developsan allcrgic reaction.tI RISK MANAGEMENT Riskmanagement is thc term applied to the administrative portion of the hospital devoted to assessing liability issuesin terms of care.Risk managententassesses deviationsin carc andanalyzescases which rvrongdoing might have occurred in order to mininrize the risk in of litigation for the hospital. MEDICAT ERRORS Thc pl.rvsicianhas a duty to inform patients of crrors in care if those errors will have an impact on the paticr.rtscare. The patient has a right to hnolwhat is happening in his management. This includes all errors that ntay affect the outcorrc of the patients care. lnforn.ring the patient is not limited just to telling him about the errors that you krow he lill find out about or to infbrm hin.r just about thc ones that may rcsult in litigation ar.rd malpractice. I bring my car to you for repair and,vour assistant If breaksthe lvindshieldby rnistake,I l.ravea right to be informed. The car is my propertv and I havc a right to knorv r.vhat happeninglrrith it. is !j!!p rrarorcnr
    • 50 Chapter eteven I On the other hand there is no mandate to inform a paticltt about minor errors that will have no impact on her care or treatment. If thc blood tests wcre delayed or a single test forgotten the patient does not have to be informed of this as rong as the informatiois obtained in a timely fashion and as long as it will not impact her care. The main dcterni, nant of the rced to inform the patient is not the rnagnitude of the n.ristake, rather the but impact on her life and health carc. B T CI Pi tc nl n( T] tl1 su a ca ar ot ITI m se I(A PIAN MEDICALI- r
    • l s tat willJe test Chapter Doctor/patient 12: Refationshipion isermi-T the BEGINNING ENDING REI.ATIONSHIP AND THE Therelationshipbetrveen docl a is a voluntarv rclationshipthat is to entered frcetyon both sides. :ti.:],.-^i.."."-tlt be t.,:: particurarh.. croctorph^i;;il1il:ff1" as il,.IlHl$;::ff.1ffH: :.lfi::l]:; to accepta paticnt without his agreentent. A doctor must agr." to u.c.pt o patrent. no obligation on the part of thc physician There is ,o ,...p, u pu,iJn,.-r.i,l ,, ,.u" ,.,u needthc patient has and whatever ,.,,atterwhat expertise the docto, n.,oypnrr"rr. For example, a patient with diabetes lives in a small town with onJy nologist. The cndocrinologist has one endocri- a fulJ practice ancf is,.ro, o...prurg n._ puai.n,.. The patient has very bad diabctes and has^a..,ery cornplcx ,"gin-r.r, tlrot lr., fn-ity practitionerinsistsis beyond.thc scopeof his ,nde.rt"ndiri. .l.hc patient up in the office and insists to the office shows managcr that she b. a.l.pt.a. Wfrut bc done? st nuta Thephysicianis under no legalobligation to acceptthe patient. There is considerablc understandingof this issue.The physician, mis- by training and ,".iir",ar, ,, ,*.ed to aicl thc suffering However there is stilr no mandate for rhe piysi.io.r ,o u...p, a patient force a physician to take ,r.,. patient nor can care of her. Even .ood Sumorita., caregivers_from laws, which protects liability if they aid a sick person in ,fr" *r.",, ao norinrce the cloctor an injured person. you may feel a to aid m.ral obtigation,. h"ip ;;;;;;., obligationto enter into a doctor/paticnt but there is no tegal rclationship.ffri, i, i;f..",,t from mandateto provide emergency treatment a hospital! to an).one who comes to the encrgency mcnt. Hospitals cannot turn anyone depart_ aw:ryat the door of their._.rg"r,.y secking roo,, ifthey come care. This does not mean they must provide continuous careafter discharge, but it !(A PtAN ) MEDICAL
    • i twelve chapter I to provide energency manage sexual cloesmean there is a national legal mandate for all hospitals der ot ment and tleatment of all patients betwe relationship there is far greater com- Once a patient ancl physician have entered into a care foral end the relationship He plexity in ending that relationship A physician camot suddenl,v can find an aPplopliate altefnate must maintain the care of the patient until thc Patient "reasonable notice" source of care and he must piive PATIENTS FROM GIFTS on the part of th€ Srnallgifts trom Patlentsot nominal or modestvalue are acceptable different form of therapyor phyri.i t-t.This is provided that thcre is no expcctationof a at Christmasa balloonon o tligh., 1.u"1of carebasedor.rthe gift You can accePt cake a expects extraor difterent an your L,irthclay, other tokensof esteem, not if the patient or trut prescriptionfor something, exchange the gift in for The ruleson giftsfron patients far lessrigorous precise ctearthan the ruleson or -pharnaceutical are the industryThereis alr aut()matic presunlPtion giftsfrom that giftsfron.r tolvarda product serviceor prescribing practice Gifts i-ndustryahvayscarry an ir.rfluence from industry arevierveddifferentlybecausc thcre can bc no other intention behindthem except buy influenceand alter behavior to Tberc is no suchautomaticpresumPtion the on ftom Patients part of gifts received DOCTOR/PATIENT CONTACT SEXUAT inappropriate lt is unclear if Sexual contacl between a physicitrn and a patient is always alter the Physician/Patient rela there can ever be a completely acceptatrle,ethical rvay to leastthe fhy"iciin alld patient tionship so that sexualcontact is acceptabte the vcry At must mutually agree to encl the fornal prof-essional relationship of a doctor ancl a patient of the professional doctor/ It is not clear horv much time mlrst elapsebetween the ending patient rclationship ar.rd the beginning of a personal relationshipfhc recotlmendrtion Associatiotr guidelines for psychiatrists is somervhat unique The American Psychiatric intimate private relationship specifically state that there can never be a sexual or personally relationship has cnded ln other between doctor and Patient even after the professional with former Palient: words, a psychiatrist should not have sexual contact even In other words it is not These guidclines apPly no matter who initiates the relationship if thc patient initiates the more alceptable tbr a doctor and patient to have sexlral relationsI(APLAN MEDICAL
    • Doctor/Patient Relationship iage- sexual relationship rather than the physician. These guiclelinesalso take no account ofgen_ deror sexual orientation It is arways ethicalry unai-ceptabreto have a sexuar relationship between psychiatrist and cither a current alm or a formcr patient. It is ethicay unacccptable for a physician of any kind to have a sexual relationshipwith a current patient.tatetheorollenton)m.ftstn)hc ifa-ntlt.r/Intsplr
    • l 6 s Chapter Doctor 13: and Society CHITD ABUSE j}t:::_": reporters,ofchild abuse.This ncans rhat thc physicianhas a dutyto report Ti::":"ry child abuseevenif they fcel uncomfortatrl" tiononrvhetheror not to report ,t;i;g .; .fhere is no discre_ abuse. "aaiairt, ""." ,*0".1* r" teported. reporting to child protective .nuo abuscmust be The servicesshould n"Oi"" ,_,.Orrely so there be an urgent intervention can that to preventfurther abuse_ For example,a 20-yearold woman brings her seven_year_old tntoson genrydepartmentfor a broken the erter- arrn. The child hasf,".n ,o ,t.,. .-"rgency menrtwice beforefor variousin.juries. depart- Thc mother ,,"", *r,i il, boyfriend is not the childi fathcr you have_no who direct proof that at,rr. nn, o..rrr".f mothersimply states u,rAtl. that thc ch T:,l"r.:,i;; ; ;;"li; illi::y,I"","# oi:". ij.lli.i ouslydeniesit. What should you ;;.|.;]H::: do?Keportsuspectedchild abuse cases .:,,.,1, "fo,;,;.,i;."n:,THr:ffil::1,:,::0.,1"$ no abuse T,:::i":nlH1ili:* ?T:; I iound, the suspected abuserhas no standingto nf" rui, "g"inr, you aslong as wordslixilT:::.i.::Ji;:.:Tii1,:rTthcr as ",f"" ",.,**,,ancr ro"s honestrvreporters, r.,,, anyone "*ooa,lltJo:iJ:il::L#:r:Jjl:lJT:ll"";;1,i111il who criteria are operatins.you rnust have" ..",;;;;,;;;":.::j:l:mustbe no elementof trying to the abuseand rhere harm or cmbarrass familv the I(A P L.AN MEDICAL --
    • cirapter rhirteen I EI-DER ABUSE M The same critcria described for chilcl abuse generally SA apply to elder abuse. Instead of child protective services,thcre are adult protective scrvices. th Reports made igood faitl.r can be clone rvithout liability to the rcporter. The circurnstances th with ercler abuse are ress crear than with child abuse, because elderly person is often a still_cornpetent the adult who mar objcct to the report of the abuse on thc basis that they are afraid of repcrcu.sion. in the home or the loss of the home. Nevertheles., ynu -or, report elder abuse,and partiallvI breaching the confidentiality of the patient antr fanr y is permissible in the interest ofi protecting a vulnerableperson.: The other reason that elder abuse reporting is less clear is that there is no uniform national standard fbr it in all 50 states.l.hevast najority ofstates,I however,lrave a reportrng slstem similar to that for reporting child abuse.rhebottoline If for USMLE is that you should answer to "report the abuse to adult protective services, if the casers Drese.ted. P( th P. IMPAIRED DRIVERS tl( ol The rules on reporting impaired drivers vary enormously nationally.There is no other aspect medical of ethicsand heaitrr-care regaritythat hassuchstate-to-state variab ity as the m.rnagement the in.rpaired of drivcr,All states requirethe patient to report setzurec.lis orders;howcverthe period of tilrre that the crrivermust stayoff the .oaclvarlesvastryfrom one stateto anotherand thereforecannotbe tested on the USMLE. Physicians cannot suspenddriving privileges.Or.rlythe state sponsoredDepartmentof Motor Vehicles (DMV) cansuspend revokedriving privileges. or Arhen rlriver is impaired a In ln any way,thc first stepis to encourage driver the to report the impatrnent, to the DMV In additio, the physicianshould encourage impaired all drivers to rimit or curtair their to driving. There is no uniform agrecmentof what, beside seizuredisordersand visual trl impairment should be reportecl all states. in Only a few states havespecific lawsrequiring th reporting of sycopal episodes. Not ail statesoffer immunity to physicians, such as the hi protectionsofferedfor reporting child abuse, reporting for an impaireddriver. d( m For example,yo:uarethe attendingphysician a patient on lir admittedto the hospital with a first-time seizure. The headCT and EEGare normal.you will not be start_ ing antiseizure medications. patientdrivesto work regularly. The What shouldyou do concerning patient,s the ability to drive? I(APIAN M EDICAL
    • Doctor Society and 67 I i: Mandatory self-reporting seizures requiredin all 50 states. there is an answerthat of is If "encourage says refrainingfrom driving" or "counsel alternate on forms of transportation,"rild "recommend isthebestthing to do first. If that is not one of the answers that then choose be ftepatient inform the DMV" is the bestchoice .eaf1aythe Forexample, you are evaluatingan 87,year-oldman in your office for markedlyily rvorsening cognitivedysfi-rnction, is on a number ofcardiacmedications well He as of thatlear.r him sornewhat dizzy.Thereis evidence psychonrotor of retardationand delayedreactiontime on your examination.You are concerned that the patient regularlydrives. What shouldyou do about his driving?Ialrmtd If thepatientdoesnot havea specificdisease such as a seizuredisorderthat makeshim potentiallv unsafe, then it is much lessclear what your responsibilities toward both are the patient well asto society. cases this the bestansweris to recommendthat the as In like patientwith cognitiveproblemscurlail his driving or find alternateforms of transporta- tion.Giventhat the reporting requirements so variableon a state-to-state are basisthis is often bestanswerthat rvould be uniformlv true in all states. thetrls Forextmple,yo:uhave 65-year-old a man with progressiveglaucoma your o1fice. in Hisvision is severelyimpaired and gettingworse.You stronglydoubt that he cann readtraffic signson the highway.You haverepeatedly encouraged him to curtail hisdriving but he hasnot. What is your responsibility toward this patient?ft ln those caseswherethe patientsvisual acuity is so severely impairedthat you suspect he 1s danger himself and to otherswhen driving,you must stronglyencourage patient a to the tostopdriving.You can intervenedirectly in the states that requireintact vision for recer tification the driverslicense refusingto provide recertification. thosecases of by In where thisis not possibleyou must inform the patient that it is your duty to notify the DMV of hisinpairment. You do not havethe right to removeor suspenddrivir.rg privileges. you do, however, havea duty to report a visuallyinpaired driver to the DMV so that the DMV maymakeits orvn determinationof whether the patientslicenseshould be removedor limited. !<a ll x) tleorcel p
    • 58 Chapter Thirteen PHYSICIAN PARTICIPATION IN EXECUTIONS A physiciancan not ethicallyparticipatein executions prisons.This is true even though in the execution is legal in that state. Participating as a physician in any ay in an execution directly opposesthe ejthical imperative to preservelife. The physiciansethical duty to relievesufferingand to protect life supersedes ability to participatein the execution. any fhe For example, you are a psician ir a state prison. warcien has asked your assistance checkingthe apparatusthat clelivers lethal injection scheclulecl in a for use in an executiontonrorrow. He is not asking ynu to aclnlinisterthe injection. You have never met the patient before and you have no prior doctor/patientrcla tionship with the condemnedprisoner.{}rat should you tell the warden? A physiciancannot participatein any way in an executiolr a physician.Participatingin as an execution irnpairs your physician/patientrelationshipsrvith the other prisoners who arc ,vour paticnts. It is ethically inpcrmissible to participate even at the level of a technical cor.rsultant-cven if you have no doctor/paticnt relationship with the prisoner. You ma1 not give the injeclion, start the IV lir.re,mix thc medications for injcction, or dcsign the formulation for the lethal injection. It is not even permissible for you to ccrtift that dcath has occurred unlessanothcr party has dctcnnined it first. TORTURE lhe Physicianscannot partjcipate in torture at any level. knowJedgeof torture must be reporteclancl opposed as you ivould report and oppose elder abuse,child abuse,or an impaired driver. You may treat those injurecl by torture once the victins have been removedfrom an environment $heretofiure may occur; you cannot treat injuries to allorv paticnts to bccome well enough to withstand nlore tor ture. I -
    • Doctor and Society 59 ] SPOUSAT ABUSErougl.r Thecthicsar.rcr legalities surrotindingspousar abuse.rc somcwhatdifreret from those:ution childabuse and etderab,se.tn the case spousal for of "b;;;, .;;;;;. dealing.ltv to patient that.isgenerilllv with a. adult competent consequentl). do not havetheron. report abuse 1.ou samcauthorityto the against wishes thclvictimas the .f Nlany ,., .";i;i;; " ;;; ilffi;* victimsexpcricncing spousar abuse berieve thci ";" Il;;;r; positionto be abrer leave relationshipor to report the to the abuscfor fear of worse oli.rre. cal]n-ot Co,,r"q.r.lrtly ynur report the abuseto the police or to alyone .lr. rithout the ."press consentl. vlctim. of the For example, a 45_vear_old rvr inhcr rn e - o*n,n g a he osb J,T,",,lilli ::il:"":iilf i:i:ij[T:ijl]" *,-18 past.rhcn 1.oLr her,vou rvill report tell ll-r the injury to th. poli." ,lr. beconres anxious and insists vcryu4ro you tcll no one because husbara hcr ir, ffi* officer. {,hatnical should you do?ma)r the Wher.th_epatientr.villnot givc cosent to havc "encourilgc the injury reportccl, sould answer youeath vouw,ill , that the victim to rcport,,or ,,offer.ou,.r.ling.,, GUNSHOT WOUNDS RcportingofgrLnshot rvounds is mandatorybut from a clifferent perspectivethan therust tonru ofreportinpl. The mandatory other reportrng of gunshot wounds is,or criminatinvcstigationrheperson of doing shootig. the o.o"* " ,.;:T:l;:.i#:H:,?cen theictinrobjects. societal fu, ,"f.,y,.,p..r.a., The need iiri"orrr""., rn. patient thelow case gunshots. of ,r in GIFTS INDUSTRY AND FUNDING ciftsfrom industry arc to be limitetr in both type and by numericai monerary presumptionis that all gifts fronr value.Thc industry are an indirect attempt to obtain influence from phyricians tcrrns of thcrrprcscribing in patteflrs.Modest gif*;;r, than $100 in value areacccptableonly if they are netlical or educational in *,ur". fn oaf,., words, you can receive $100.i.vorth books or medical equipment of nr, ,., ."r."i get a $100 check ;"st the industry.mal. slonsor educatior.ral l".l::1-1:1OUt::, prcsentatrons long as they as co not lnterlere witll the content. Physicians nray accclrt mea.s that are in association educational experiences with such as lecturesor contcrenccs. Phvsicians prohibited from accepting are r,arorcer gifts from the industry that are purely !l!!p enhance inconte of the physician the geared to or D.terelv entcrtairrrr,"r,t. ""0-ple, for Fn. clancannotaccepttickcts to baskctball the physi- gantcsor otlter sportitrge€r]ts, trtps, gift certificates to cleparfpsll tlteatertickets,ski or 51e1g5. I I I - i
    • l z t Chapter Doctor/Doctor t4: Relationship REPORTING IMPAIRED PHYSICIANS Phvsicianshave as much of a du chird Arthough abuse. *",;;,ji,:":?:::il]ffT.i.r,1tl:T,::",,|jl 1lff::; avoiding reporting an impairedphysicianwhen the impairment is clear.If you know trratanotherphysicianis not functioning nornaily and may be a dangerto pahents,the privacy the physicianis lessimportant than of .I.his the safetyof his patients. is true whethertheimpairmentis from substance abuse, psychiatric a disorder,Alzheimcr,s disease, an oremotionaldisturbance.You shouldreport physicians students_in_training and to their local supervisortirst; reportaresident his program dircctor or dcpartment to chair; and report a meclical studentto hisdean coursedirector.you shorrldreport or attendingphysiciurxto th. a.pnrtment chairdivisionhead.If the attendingphysicianis or a self_employed physicianrn private practice,thelrthereis no departmentchair or dir.ision t "ua to r,vt you can rnakea report.you i.t,should report physicians the community in private in practiceto the stateboard of medicalconduct the statehealth or educationdepartment. or The key is to go to *ho.rr.. .ighthave authority overthat physician. The linesofsupervisionar.m.ch cl.ar., i the hospitalor in medicalschool,wherether. a." .1"a, ,.r;re.uirors. For example,Dr. Smith is an attencling in endocrinologythat is doing a month as the attending on the generalmedical scrviceat Ki"ng,sCounty Hospital in Brooklyn.Unfortunately, housestaff finds his him gettiu; lost on the way to the bathroom in the hospital.In addition, he has no t-no*t."ag" of generalmedical practiceand he cant rcnember thc cases after the residen-ts presentthem. The seniorresidenton servicementionsthis to you anclasksyou. ndui.. "oout *not to do giventhat Alzheimer,smight be deveioping. What shouldyou tell hin? I ( A P L A N MTOICAL
    • J Chapter rourteen The residenthas a dr.rtyto report the potentially impaired physrcian chairThis wr alrowfor a private, to the department fir confidentiarinterventio,,.ith tn" utt.nding physicia. can allow for an evaluationtl It ch sibre impai,"o .fifi:;::::jll:fiiHffiJ ..;ltilT*::*:** that a ;;,;.* ch come to light without this report. ln addition, the ha ratesof substance abusefor physicians are the sameas the ratesof impaired -ay thffi Ti;i, r:::,i::,j;ffil:il:,*:,::L.i"i:ffi:"lT physicia., b" abuse.Catchingsubstance abusebefore patientharn o..r., physician can be successfully Or"u"rrr, malpractice. The rehabilitatejand r""r".i ,. f".,U.. . Youonly havea duty to report behaviorthat affectspatient care.If a physician wild partiesbut thereis no detectable goesout to i_pni."nt of pnti"n, .o;., ,n,, ,. nu, ,omethingto use ransuage, inamotorcycre bad andricre :."r,Tj;::_:ffiijlll:.::,",:i,,oos, sins behaviors .uruu. ua-1,!:::1il:i:il:,L.JJdutv roreportba,"d is e.ru.l,.er"yoi rou.,a o,, The bottorn line is that it is your.mandatory duty to report an impairedphysician who may You the irotections have ame ror you.,"rr."pn.-ti,,! on :#:ili:;,:T-;::JrH* as as repo.,-"0",,,tijl}ffiXil:f}"#the rong the report isfoundbe to untrui ,, PHYSICIAN DISAGREEMENTS If an,attendingphysiciandisagrees with a residents improper management, prob,lembecause attendingphysician thereis rittre the h". ,h. "u;;.i;;;o ou.rrur. the resident.It is much nore problematicif the resident disagrecswith the attendingphysician. ,i::::*l finds what may be an error in management li with the attendingphysician, the USMLE first wantsyou to a evidence-based medicine.,,,r;lJ;il:,::::i;,.J:fJ*;:H.,T:l;:il;T:.,:it .,rocary.,, of a . to whatever is the version not ;;;J.r,H -Dog,.."*;, il:lilii:::ill.*fiffi:il:;**: ;:i without first trying to havc a discussio rvith trre division head or clcpartmentchair. In addition, do not answer,.Inform the patient.,, what if the residentis wrong?Disagreements between physicians handredin much are samewayasthe reportingan impaired thc physician t.,ur.,atea, i, .*."pt that you shouldalwavsI(API"AN MEDICAL -
    • Doctor/Doctor Relationship itment Ofu.l*t:n with theperson with whomyouaredisagreeing. you:ian. It lillli-r1"" a patientt changes tn cannot makes pos- changa ;h;i:;;;i"::,ff rhe ",,",di., care without -; n:,11,:i:l:;:1ilffi jl;ifwtse has absoluteright to direct the care an of the patient, $:i::,.":l:icians ur.,dkrrnlv , ,hut ,s gorng on.g thetance, Theut torg tolangIonnayruellets tllllP ueotcnr -
    • l r s Chapter5: Experimentatio 1 RESEARCH EXPERIMENTATION-PARTICIPATION AND CONSENT In most w?ys, the consent issues for participation in expcrimentation and research are notvery different from those surrounding any other mcdical treatntent or procedure. Thc research subject must be fully informed of the potential risks of the intervention as well as possiblebenefits. The sub.iector participant must bc entering the trial voluntarily- theilithout cocrcion. If the subject is not an adult or lacks the capacitv to unclerstand the riskof thetrial, then a valid surrogatesuch as a parent or guardianmust give consent.Thediffcrence between participating in experincntation and receiving a treatment is thatthestudy medication may be given in a way that is knorvn, in advance,to have no benefitandthe subject is participating simply out of othcr motives to advar.rce accumulatjon thcof scientific data. The bottom line on experimentation is that participation must be vol-unfary.PRISONER PARTICIPATIONThe same rulesapplyto theparticipation ofprisoners research applyto nonprisoners. in asPrisoners havethe sameright of refusaland informed consent. Thereis to be no removalor abridgement rightssimplybecause patientis a prisoner. of thcTNSTITUTTONAT BOARD REVTEW (tRB)An Institutional Review Board (IllB) is an independent reviei.ving body that evaluatesinvestigationalprotocols prior to their implenrentation to ensure their validity and ethical t!!!!p rrarorc,rr
    • ChapterFifteen integrity.Thc IRB is comprisedof representartives ofdifferent areasofthe hospitalor medi- F cal school that includc clinicians,educators, ethicists, clergl and scientists. The idea is to l.ravca broad based group that can evaluate not only the scientific pararneters fir of a protocol, but also ensurethat the process intbrmed consentis accurateand that the of re treatmentsand proccdurcsbcing studicd do lot presentan undue risk to the patientsbeing hr enrollcd. The IRB also ensures periodic revievv of the data so that a trial can be stopped il early on occasion.A study cannot con.rmencervithin an irstitLrtion without IRB approval. lI ir For example, a group of invcstigators stud]-jng the eff-ects artiretroviral medi of T cations on paticnts with HIV/AIDS submits their study to the IRB for revierv and P approval prior to implementation. The pianned protocol is to study rvhether giv irg antiretroviral medicatiols to patients rvith AII)S makes a difference in their ll outcome rvher.r conpared to starting the rredications after clischarge. I] c 7 Half the patients will rcceivea placebo and the other half rvill receivethe antiretroviral n nedications. The study r.vill randonize patients adnitted to the hospital for acute oppor ll tunistic infectior.rs.Thc IRB rejects the study on the basis that it would not be ethical to ir rvithhold potentially lifesaving therap,vfrom a group of patients in rvhich the efficacy l.ras d already been proven. ln addition, the llll3 rejects the study becausethe consent fonr was not translated into Spanish. valid questions. is not The IRBspurposeis alsoto make surethat a study seeks ansrver to It valid to l.ithl.rold proven cffcctive therapy to gather data on how some patients are harmed just to produce a publication. There is no randomized, placebo-controlled trial proving that antibiotics arc better than placebo in patients with severepneumonia. This is because sincethe secondhalf of thc the conceptof the randomized trial has only been in existence 20th centuqr RecausePenicillin was already the stanclarclof care for pneumonia, it rvould have been unethical to perforrn a study in which antibiotics rvere withhcld from patients with pneruronia and to watch thesepatieDtsdie. It would also be unethical to do a study of steroidsin minimal changenephrotic syndrome when the efficacyis clear. l he I RU is a response the Nuremberg War Crimes Tiibunal, tlurir.rgwhich thc rvorld to that experimertation rvithout consent is unethical and not allowablc bccame consensus clear. Nazi experimentation during Vorld War II lvas coerccd, without corsent of the participants,and collectecl clatathat involvecl the unnecessary and willful harm of human subjccts.The moclern IRB is tl.remethod of ensuring safcty, cthical integrity, and freedom from coercior.r clinical investieatron. inr(Apt_AN MEDICAL
    • I txpeamentatron Idr- FINANCIAI. DISCTOSURE hcn inestigators publish or present research data, clisclosurc of all relcvant sources ofers iinancinpl the rvork is required. If r am p.brishing a study for conparing two crifrcrent anti,:he retroviralmedications, is important to clisclose thc audienccin a it to Grand Rounds that I ng har.erecciyed fr.rndingl from antirctroviral rnanufacturcts. If I am putrlishing a stucly on an,eci inplantabledefibrillator,it is mandatory that I revealthat I ou,part of thc company thatal. nanufactures the cquipr.nent. Financial clisclosurc essential help ensurean obJectiye is to jnte4)retation of research clata. Thereasonfor doble-blind placebo cor.rtro ccrtriars is rrr.t we know that the cresire the of people running the study ar.rd collcctingthe data can influencetlte stlrdy results. Disclosure financig helps undcrstancr possiblebias ir.r of a a study.The m.st important moderncxample is an article in thc journal Thc Lo.tlcet the oi danplers ofthc measles vac_ cruation ln addition to nrany othcr flaws in the studl, the author failed to crisclose.and-al The Laucet farled to inyestigate,the financiar arrangenent of the autrror with a rival vaccine nanufacturer. The study was invalid, although published,because author wastr- the attempt_ iugto invalidatea current measles vaccinein hopes of acquiring approval for the nrarkct_to ingand rcimbursenent of his own vaccine.This is an cxcellcntas exampleof lvhy financial disclosurecan help preservescientific intcgrity.asot:d)gSCtedtstydnn I(AP!AN MEDICAL I I
    • l r g Practice QuestionsBRAIN DEATHl, An 80 ,vear-old man is adn.itted to the hospital with a massive intracranial bleed. He has been placed on a ventilator becauseof tbe respiratory failure associatedwitlr intracranial herniation, When you try to remove the ventilato5 there are no respira- tions. The patient makes no purposeful moventents. There is no pupilary reaction when you shine a light in his eyes.There is no nystagmus on cold caloric question testing. Oculocephalic and corneal reflexes are absent. Hc left no specific wishes for his care. Which of the following is the most appropriate action regarding this patent? a, Remove the ventilator. b. Make the patient DNR. c. Place a nasogastrictube to prevent aspiration. d. Get a court order authorizing you to remove the ventilator. Do an EEG (electroencephalogram) three times separated by slr hours each trme. tl!!P r,rrorcar
    • ! rt eractice Questions I CHITD ABUSE cl 2. Youarea resident the emergency in department. irate Parentcomes you furious An to because social the rvorker beenasking has him aboutstrikinghis child.The childisr. 5-year-oldboy who hasbeenin the emergency departnent four timcs this yearwitl severalepisodes trauma that did not seemrelated.Today, child is broughtin of the "slipping into a hot bathtub" with a burn wound on hit with a child complaint of "How tlareyou think that about m€? I legs.The parentthreatens sueyou and says to lovemy son!" What shouldyou do? a. to and trcat the patientsiniury approPriately, Give reassurance the Parents b. Ask risk management evaluate case. to the c. Admit the child to removehim from the possiblydalgerousenvironment. d. Call the police. e. Ask the fatheryourselfif therehasbeenany abuse. f. Speak the wife privatelyabout possible to episodes abuse. of g. you will haveto call chiid Explainto the parentsthat the nexl time this happens prolectrveserYlces. h. Reportthe family to child protectiveservices. i. Give the parentsa referralto a family theraPistthey can seewith the child the following week. t!l!!P mrorc*
    • CONFIDENTIATITYcus 3. Youare working at the deskin your hospitalwhen anotheremployee of the hospitalisa asksfor information about a paticnt who wasadmittedlast night withirh a pulmonary ernbolussecondary cancer. to you know the detailsof the .ua.. personrecuest_ Th. tn ing the information states that he is a closefriend and co_worker your patie;r. He ofhis shows you proper identificationproving he reallyis a co_worker your patient of who:?I a ] . o$ . r k i n r h eh o s p i t . r l . hich of thc following is the most appropnateresponse this requesti to a. Give hin the information on the patient. b. Give him the information only if he is a relativeof the patient. c. Inform him that you are not at liberty to give details regarding the patient without the patientspermission. d. Havehim sign a release consentform beforerevealing information. or the 4 You are seeingpatients in clinic when two men in dark suits and dark glassescome in and show you badgesmarking them as members ofa federal law enforcement agency. The identification is legitimate. These,.men in black,,inform Fou that they are mak_ ing a "minor investigation" of one of your patients. They ask to look at the patient,s chart for a few minutes, saying, "you wouidr.rt want to interfere with a federal inves_ trgation, would you?" {hat should you do? a. Give them the chart. b. Give them the chart but watchwhat they do with it. c. Ask them to sign a release the chart so you are absolved responsibility. for of d. Tell them you cannot show them the chart unlessthereis a signed release from the patient. Tell them that you can give copiesbut not the original record. f. Dont givethem the chart but readthe relevantinformation to the[r. !!!!!!) raeotcnr
    • eractice Questions ] 5 . You area psychiatrist session in rvith a patientwho tellsyou he thinks his bossatworli is persecuting him. The patient has had mild schizophrenia. patient asks if The you "when you can kccp a secretand then tells you that he is planning to kill his boss "Of everythingvou tell me during the session wtll the time is right." You say, course, alrvays confidential." bc What shouldyou do? a. the Keep the patients sessionconfidential but make attempts to discourage patientfrom his plan. b. lnform your medicaldirectorand let him handleit. c. Inform law enforcernent agenciesof the threat to the patients boss. d. Inform the patients boss that he is in danger. Inform both the patients boss as well as law enforcement of the threat. 6. Youarediscussing careof an elderlywomanwith her family.Although sheis awake the fragile.You are awaitingthe results and alert,the patientis very ill and physically ofa biopsy for what will likely be cancer,which hasalreadymetastasized throughoutthe body.The family asksthat you inform them tirst aboutthe resultsof the biopsy. They are very loving and caring and are constantlysurroundingthe Patient.They do not want to depress patientfurther,and because the therewill be no hope for a curethel seeno reason ruin her rcmaininglife with this inforrnation. to What shouldyou tell them? a. You will honor their wishes. b. You agree and you askthem to giveyou the neccssary with their rsishes written request. c, Youaskthem to involvethe ethicscommitleefor the hospital. d. You tell them that you are obligatedto inform the paticnt of all the findings. proxy. Explainto them that that decisioncan only tre madeby the health-caref A P LAIt) MEDIcAL
    • Pradice Questions 85 Iwork just recently bcen cliagnosedwith familial adenomatous polyposis fJ Yourpaticnt hasou if (IAP). This disorder is chronic, progressive,and fatal. There is a genetic test that canvhen tell rvhether children of parents r.vith the diseasewill develop it. The test is very accu- rvill rate.The patient has becone divorced and refuses to give you his consent to infornl his ex-wife who nor,vhas custody of their three children. He threatens to sue you if you reveal elements of his medical care to his ex-wife. Vhat should you do? a, Respectthe patients right to confidentiality. b, Transfer the patients care to another physician as long as the patient agrecs. c. Ask the health departnent to inform the patients ex-wife about the disease risk. d. Seeka court order to inform the patients ex-wife. Inform the patients ex-rvife of thc risk to the children.ke f. Inform the ex-wifes doctor.Ia (} Youare seeinga patient in clinic who has developedtuberculosis. is an undocu- Hery mented(illegal)immigrant. His family will needto be screened tuberculosis for withf,t PPD skin testing.He is frightcned of being deportedif the Department of Health:y learns in.rmigration his status. rhatshouldyou tell him? "Don t rvorry, the Depafimcnt of Health does not ask or report immigration status." "Only b. people who are noncompliant with medications are repofted to the government." "Dont c. r/orry, I will fully treat you before we deport you." "l d. am sorry br.rt there is nothing I can do about it; there is nandatory reporting to the govcrnment,
    • a4 PradiceQuestions ] DONATION ORGANS OF 9. A couplc comes to see you after having tried in-vitro fcrtilization and artificial insemination. They are very happybecause they haverecentlybeensuccessful giv- in ing birth to a child. They havea significantan-lount leftovcrsperm,eggs, of anclsome fertilizedgametes/embryos they are thinking about sellingthem. and What shouldyou tell thcm? a. It is legalto sell only thc eggs. b. It is legalto sellonly the sperm. c. lt is legalto sellboth the spern.r eggs not the embryos. and but d. It is illegalto sell any of thenr. e. It is legal sellall of them. to 1 0 . You are a fburth-year medical student with a patient who has bcen in a severcmotor vehicle accident. The patient has a subdural hematoma that led to cerebral herniation before it could be drained. C)ver the last ferv days, the patient has lost all brainstem reflexes and is now brain dcad. You have the closest relationship with the family of anyone on the team.Ihe ventilator is to be removed soon and organ donation is con- sidered. Who should ask for consent for organ donation in this casc? a. You, becauseyou are the person with the best relationship with the tamily b. The rcsidentbecause you are only a student c. Attending of record d. Hospitaladministration e. Organ donor network I(A PLAN MFDICALIt l
    • Practice euestions I Il. A 50 year-old malc gambler owes money to everyone antl is seekrng a rapid source of cash.He answers an aclyertisementin a foreign newspaper off..lng S:O,OOO oo" of fo. his kidneys. He comes to seeyou for medi.ui "*f""iir" prio, to th" upprurrnl to b" o donor. What should you tell hin? a. It is never acceptabieto receiveany money for solid organs or bone rnarrow. b. It is acceptable long as the recipient as truly need the organ. c. It is okay as long as the donors ren.raining kidney is healthy. o. It is acccptableifthe surgery for both the donation as well at the impiantation in thc recipient is occLrrring in a forergn country. I{eimbursement for cost of traycl and lodging for the donation is acceptable, profiting frorn the donation is unacccptable. but12. A man.arrives at the emergcncy department on a ventilator after an accident, I{e is brain deacl by all criteria. He has an organ-donor card in his wallet indicating his desireto donate. Thc organ_donor team contacts the fanily. The fan.rily rcfusesto sign consent the donation. for Vhat should be donc? a. Remove the organs an.v.{ay. b. rait for the patient,s heart to stop and then remove the organs. c. Stop the ventilator and remove the organs. d. Seeka court order to overrule the famil,v, Honor the wishes of the family; r.ro donation. MTICAL
    • eractice Questions I DNR ORDERS 13. You have a patient with severemultiple sclerosisthat is advanced and progressivewho now develops renal failure secondary to diabetes.The patient is alert and has elected to put the DNR order in place at her own d.iscretion.The patients potassium levelis now markedly elevated at 8 meq/L. Which of the following is thc most aPpropriate management of this Patient? a. Dialysis cannot be done becauseof the DNR order. b. You can do the dialysis if the DNR is reversedfor the procedure. c. Go ahead with the dialysis; ignore the DNR order. d. with the family. Give kayexalatc until the DNR status is discr.rssed 14. A patient from a skilled-nursingfacility is admittedto the hosPitalfor severe uppet blceding.The patient has a l)NR order in place.The blcedinghas gastrointestinal not stoppeddespitemultiple transfusions,octreotide,Proton Pump inhibitors, and endoscopy. needsmonitoring and evaluationin an intensive He careunit. trat shouldyou do? a. Reverse DNR orderandtransfer the ICU asnecdcd. the to b. ou cannot be DNR and be in the ICU. c. okay to be DNR in the lCU. Transferto the ICU asneeded; d. He can go to the ICU with the DNR but cannot8o to surgery. e. He can go to the ICU with the DNR but cannotbe intubated. 15. A man is admitted for acute appendicitis. is elderly and has had a home DNR He order in placesincehe had a previous admissionfor another reasonlast year.He needs urgent surgeryfor the appendicitis. still uishes be DNR. He to What shouldyou do about the surgery? a. No surgerycan be done with a patientwho is DNR. b. Revcrse DNR order for the surgery. the c. only ifthe surgerydoesnot requireintubation. DNR is acceptable d. while DNR if an additionalconsentis signed. Surgeryis acceptable e. DNR doesnot precludesurgery;proceedrvith thc appendectomy.!!l!!P meorcar- i
    • Practice euestions az I EI,DER ABUSE;sivewho 16. An 84-year-old woman is seenby you in clinic for routine management.selectcd of her multi_ plemedicalproblems.Shecomes aloneanclyou noticethat shehls beenlosingweightn level is andhasseveral contusions. is a widow and liveswith her granddaughter She and her granddaughtershusbandwho recentlylost his job. On questilning shetellsyou that hergranddaughtershusbanddoesoccasionally strike her when he rs drunk. hat shouldyou do? a. Reportthe abuseonly at hcr specificreqLrest. b. Arrangefor a meetingwith your patient and the grandson_in_law. c. Remove patientfrom the home and place the her in an adult homc. d. Hayea homc healthaid placedto keepan eye on the patient. upper e, Arrangefor an order of protectionfrom the policc.rg has f. Reportthe grandsoninlauts abuscto adult protectives ,a n d service g. Speak directly to thc grandsonin law about the problem. EXECUTIONS 17. You are the staff physician in a state penitentiary in a state where capital punishmcnt is legal. An execution is in process and thc warden calls you becausetl.retechnician is unable to start the intravenousline that is necessary the lethal injection. The for warden wants you to start thc line and supcrvise the pharmacist. rlrat should you tell him?NR "No a. problem, I will start the line right away.,,He "I b. can start the line, but I cannot push the medications.,, "I c. can start the line, but I cantror prepare or tnlect the medicatrons.,, d. "I am sorry; I cannot participate in thc execution at all as a physician.,, "I e. can take care of all of it.,, I(APIAN MEDIAL
    • PracticeQuestions ] EXPERIMENTATION lg. Youarepreparinga clinicaltrial of differentdoses a certainmedication. of This medi- cationhasalreadybeenprovento be clinically and is nlready effective approved the by Food and Drug Administration (FDA).You areonly studyingto seewhethera higher benefit. doseof the medicationwill leadto enhanced Which of the following is true concerningyour study? a. Institntional reviewboard (IRB) approvalis not necessary. b. lnformed consentis requiredto participate. c. Informed consent not requiredbecause medicationhasalready is the bcenFDA- approved. d, you benefit, Informed consentis not requiredbecause aretrying to demonstrate not harm. 1g. which of the following most accurately describes the ParticiPation of prisoners in clinical trials and research? a. There is no need for informed consent. b. N o m o n e l a r yc o m P e r l q a l i otn a yo c c u r . n c. Prisoners are not Permitted to participate as researchsubjects d. Their rights are identical to a nonprisoner e. Researchon prisoners is always considered unethical. f. Participation in research is an accePted means of winning early release from Prlson.I(APLAN MEDICAL
    • PracticeQuestions 20. You arc in the process of finalizing the results of your rcsearch for publication. younedi- are the principal investigator of a clinical trial studying the effects of HMG-CoAry the reductase inhibitors on cardiac mortality. A prominent manufacturer of one of theseigher medications provided major funding for thc study. hich of the following is the most accurate in an ethical prcparation for authorship of the publication? a. Accepting money from a company prohibits you from being listed as an author. b. Funding sourcehas no impact on publication rcquiremcnts.DA c. You can bc listed as the author after the institutional review board checks the paper for evidence of bias.Lefit, d. There are no restrictions on your authorship as long as you disclosethe financial affiliation. e. There are no requirements as long as the data are accurate.sln f. You do not have to do anything as long as the checks were written to the institu tion and not to you. 21, Vhich ofthe following most accurately describesthe primary role ofan institutional reviewboard (IRB)? a. Protect the institution from liability b. Protect the physician from liability c. Ensure the ethical and hunanc treatment of human subjects in experimenta_ tion d. Ensure the studv is scientifically accurate e. Ensure that the study is financially feasible for the institution t(Ap!A,N MEDICAL I
    • 90 Practice Questions GENEIIC IESIING Glf 22. A 35-year-old female patient comes to your oftr-cewith a large form to be filled out 24. certifiing that her health is within normal limits. This is as a part of pre-employment evaluation and is required in order for the patient to get the job. The form also ask for the results of the patients APC (adenomatous pol)?osis coli) gene.This is ir.rorder for the company to determine which of its long-term employees will need expensive carc. What should be 1.our response? a. Perform the test. b. Perform the test, but do not share the results with the employer. c. Do not perform the test. d. Ask the patient if she wants thc test performed and the results reported. e, Perform the colonoscopy; the employer is entitled to know about currert health problems but not future ones. f. lnclude the test only if the patient has family members with colon cancer. 25 23. You have a patient with a strong family history of breast cancer. As a matter of the patients request, you perforn.r a BRCA genetic test to seeif there is an increasedrisk for breast cancer. The patients employer is requesting a copy of any genetic testing that may have been done. What should you do? a, Give the cmplover the information. b. Refer the employer te the hospital lawTer. c. Bring the request to the ethics committee. d. Refuseto provide the information to the employer. e. C i v e l h e i n l o r m a t i o ni f i t i . p o i t i r e o n d r c p e a t a m . eI(APLAN MEDICAL
    • Practice Questions 9l OIFIS 24. Youare a resident invited to a dinncr given by a pharmaceutical compar.ry.tn addi tion to the dinner there is a lecrure pliven on a mcdical subject as rvell as a $500 gift certificate a department store for attending the presentation. to fhich of the following is thc most appropriate action in this case.a a. lt is entirely r.rnethicalto accept any of it; refirse everytbing. b. It is only ethicalto attend thc lecture. c, t)o not acceptthc noney, but the tlinncr ald thc iecture are ethici,rlly accept- aDle. d, You rnay acceptlll three cornponenrs. Cashpaynents from industry are acceptablc long as they as arc not tied to pre_ scribingspccifi medications. c You can acceptbecausc1,ouare a residentand not an attending.25. You havc been asked to give Grand Rounds at a hospital. A manulacturer of a llew medical deviceis sponsoringyou. ln cxchange, you are being offerecla $1,000tee for your talk. rhatshould you do? a. Younust refusethe money. b. Yourna).accept otrly aslong asyou donateit to charity, c. Younlal accept long asvou don,trcveal honorariumto the as the audience. d. It is permissible takethe money aslong asyou rlisclose to any other financialor business connectionwith this or auy othcr company. Youmay acceptthe money aslong asyou subnlit the contentof your talh to an independent panel for reviewto ensureobjectivity. pLnN) meorcnr [r,l
    • Practice Questions J 26. Youhavebeentaking careofa patientadmitted rvith palpitationslrom a panicattack He is somewhathyponranic with prcssuredspecch, :Lnxiety, flight of icleas. H ar.rd Aftu several dayshe is fcelingn.ruchbctterand he is extrcmelygratefulfor your help.He 29 -fron is rluitc wcaltl.ry he offersto borrow five million and dollars the bank,,tohchryou rvith your rcsearch." Wrat shoulcl tcll hiu? you a. "l accept!" b. "Tlrank you very n.ruch, I cannotaccept.,, but c. "I accept, only for a studyofbipolar disorder.,, but d. "I would bc happvto takc your rnoncy, I but must haveyou evaluated psl,chia_ by try first." 27. You ltave a patieltt in your clinic yrho is an elderly wornan rvith multrle medical problcns. Her familv is extrenrely grateful for your careand they bring you a neal they cooked at home, a cake,and a scart. hat should yoLrdo? a. Acccpt the gift but report rt. b. Accepr thc gift. 3( c. Offer payment for the food. d. Refr-rse gift. the e. T t i s e r h i c a lt o J c c c p tt h c $ i l i if vou sharethc food r.itl.r thc rest of the house staff. f. Accept the food but not thc scarl 28. You have been invited to participatein a.,Medical jcopardy,,game sponsoredby a pharmaceutrcaimanufacturer The rvinners arc to receive $1b0 gilt certificates to the medical schools bookstore- All of the participants arc to recervea stethoscope.The audience and all the participants arc offered a free meal. Which of the following is most appropriateto accept? a. All rhe gifts. b. Only the meal. c. C)nlythe stetlroscope. d. The meal ancl stethoscopc,but rot the gift certificate. e. None ofthc gifts are acceptable.r{APtA}l MFDICAL
    • Practice Questionstack.fter l|lv/ArDs-sPEcrFrc tssuEs 29. A 32-,vear-oldpregnantwoman comesto vour prenatalclinic. Shehas a history ofie is syphilisand gonorrheain the pastbut her VDRL/RPI{is ncgative now.An HIV testis you offered a routine part of her prenatalevaluation well asbecause as as ofthe history of previous STDs. Youexplainto her the importanceof the testfor her babysrvell being. She refuses testwhen offcrcd. thc trat shouldvou do? a. No test; she has the right to refusc. b. PCR RNA viral load testing as an alternative. c. Consent for HIV testing is r.rotneededin pregnancybecause is to protect tlte it health of the baby. Add the test to the other routine tests tltat are to be drawn. Administer enpiric antiretroviral therapy to prc€l.lt perinatal transnrission. f. HIV testir.rg nolv part of routine prenatal care and no specific consent is is needed. 30. You have a patient who is an HIV positive physician. He has reccntly found out that he is HlV-positive. He is very concernedabout confidentialityand you are the onlv one who knows he is HlV-positive. He asks you who you are legally obligatecl to inform. What sl.rouldyou tell him? His insurancecompany D. State€lovernment c, His patientsa d. His patients, only if he performs a procedure such as surgery wherc transnlrssjon can occLlr No onc without his direct written consent f. His employer The hospital human resources departntent I ( A P L A N MEDICAL r
    • j Practice Questions 3 I . You have an HIV positive patient in need of drainage of a dental abscess. Thereisa llt dentist in vour nultispecialty group practicc. He knows you are an infectious dls. 31 eases/HlV specialist.Your office manager tells you the dentist and his staff are ,,scared of your HIV-positive paticlrts" and tltey dont want to seethem. What is your response? a. This is illegal;the dcntist is liable and can be sued. b. You request the medical director and have hin.r instruct the dentist to sccthe pa etrt. c. You prescribethe use of oral antibioticsalone instead. d. Referyour patient to another dentist outside ofvour group practice. 32. You arc evaluating a new patient tltat has come to your clinic for nranagement ofhis HIV infection. He has high CD4 ccllsand a lorv viral load and does nor require Lrerl ment. He is marrieci and does not practice safe sex with l.riswifc. His wife is unatvare or ner nusDaltds HIV stittus- What is your duty? a. Encourage discr.rssionbetr,reen the husband ancl rvife and strongly suggesthe disclose his HIV status to his .wife. b, You urust keep his HIV status entirely confidential at all times c. Have the city Department of Health inforn.r the rvifc. d. Send the Iife a letter to con.reto your office becauseof an "urgent health issue, . r n d t h c r ri r r f o r m h ( r ) o u r 5 e l i . e. There is no need for partncr notification as long as they are practicing satesex, 33. You have ar.rHlV-positive paticnt in the office. you ask her if she has infbrrl.red her partncr that she is HIV-positive. She has rcpeatedlv resistedyour attempts to hayc her inforn the partner.Shc is pregnant njth his child. The partrcr is in the waiting roonr . r r r dy o u h , r v e c t h i m n r l r r l t i m r . . m What sl.rouldvou do? a. Infbrm thc partner no/. b. Respecther confidentiality. c. Refer your patient to another phl.sician r,vhois con.rfortablewith her wishes. d. Tell the partner to practice safe sex from now on but dont tell him her HIV srarus MEDICAL
    • PracticeQuestions 95 | a IMPAIRED DRIVERSs- 34, An {i7-year-old man contes to seeyou:d for foJlow-up to a minor concussion sustainecl a fervweeks ago. He was in a minor motor vehicle accident in whrch his head hit the d a s h h o r r b u t h e d i d n o t l o s ec , d cussis. hi, He renewed r;::::J;T:i*:;::j:"_*i]j,,11.iili;lllll"jli d.i"".,, thathe must wearglasses. arc uncertain you whetherthc patient shuld be drivi.s. hat shouldyou do? Inform the patients family ancl explain to them that they should not allow thc patient to continue driving becauseit is dangerous for hitn b. N{RI of the brain c. Neurology evaluationis d. Start aricept to improve his memc,ry Discussthe issue with the patient and encouragee him to fincl alternate methods of transportation f. Remove his license from him Mandatory reporting to the police !l!!p u:orcar
    • Practice Questions I CAPACITY CONSENT/DECISION-MAKING TNFORMED 37. L H 35. A 37 year-oldman comesto your office tbr his regularvisit. He hasseemed eitherhis feelings treatmentopti or n depressed sometime but refuses discuss for to p of any kind. He does not want to use antidepressant medications. His only medict rl tions are vitamins. Your relationship with him is excellent but he iust wont conftont his feelings of depression although he firmly denies suicidal ideation. You prescriber t serotonin reuptake inhibitor for him and tell hin that it is a vitamin. Over the nen months his mood markedlyinproves and he feelsmuch better. several your action towardtht Which of the following nost appropriatelycharacterizes patient? a. Your action is appropriatebecause benefitedthe Patient. it b. thereuere no sideeffects. Your action is appropriatebecause c, Your action is not appropriatetrecause are not a psychiatrist. you d. Your action is not appropriate becauseyou treated the patient without his coll- sent. Your action is appropriate becauseyou are sincerely trying to help the patient. i f. Your action is acceptableas long as you inforlll the patient now that he is feehrgi better. 36. A 67-year-old wornanis diagnosed with breastcancer. is fully alert and veryspe- She cificallyboth verballyarcl in writing tellsyou that shedoesnot want to havesurgety on her breast remove tumor, Shefully understands conditionand treatment to the her options.This is a decisionher husbandand son both disagree with. Over the next 39 several weeksthc patientbecomes confused and loses capacity understand the to the detailsof her medicalcarc.The hrrsband son now approach and you to performthe surgery. {hich of the following is most approPriate? a. Refuse do surgeryand follow the original advancc to directive. b. Performthe surgeryonly if the requcstis in writing. c. and perform the surgery. Honor the familysrequest d. Consult the ethicscommittee. e. Ask the family to seeka court order. f. Performthe surgeryonly if you reallybelieYe it will benefitthe patientin the that longterm,I ( A P L A N MEDICAL
    • Practice Questions 9z ] 37. A 52-year-old man with cerebral palsyis being evaluated screenrng for colonoscopy.severely He hasa mental ageof 8 and a second_grade readinglevelin terms ot comprehensiooptions n. He livesaloneand survives a combinationofpublic on assistance a low_paying andmedica part-timejob sweeping floors.you havethoroughly explainedthe procedure:onfront to him in terms of risks and benefits.He repeatedly relises the procedureentirely on the:scribe a basis "I just dont want it., of:he next What shouldyou do?ard the a. Performthe procedure. b, Seekconsentfrom the family. c. Honor his decisionand do not do the colonoscopy. d. Seek court order mandatingthe procedure. a 38. Mr. M. consents a procedureon his left ear. tols con- After the patient is anesthetized Dr. W. discovers that the right ear is in greater needof surgery.What shouldthe surgeon do? a, Perform the procedure the right ear if it is clearthat on it is more necessary. b. Wakethe patient up and seekconsentfor a differentprocedure. c, Seek secondopinion from anothersurgeonand proceed a with the more neces-y spe saryprocedure.urgery d. Perform the procedureon both ears.tment3 next 39 A 52-yearold spanish-speaking woman hasarrivedfor the first day of a clinicaltrialrd the of chemotherapy breastcancer. for you suddenlyrememberm the the need for signing a consent form. You ask a nredical studentto,,getthe consent.,,He walksup to the patientand says English,,,Sign in this,,and shesigns.Shecompletes trial but her the hair fallsout and shefilessuit againstyou for an improper informed consent. Why will this lawsuitbe successful? a. The risks of the treatment were not explained. b. The explanation was not in a language Fou were sure she could understand. c. She experienced harm from the study medication. d. Someone who didnt understand the study obtained the consent.r thc All of the above. (l!!P rrtorcnr
    • Practice Questions I 40. An unconscious man is brought to the emergency department for a motor vehicle accitlent hemorrhaging profusely, hypotensive and stuporous. you have never met the patient before and no one at your institution knows hin.r. He is rvearing a T-shirt that "Kiss says, me, Im il JehovahsWitness." Mrat should you do about the blood transfusion? a. Give the blood. b. Wait for him to awaken enough to sign conscnt. c. Wait for the family. d. Seeka court order. e. Giye intravenousfluids alone, 41. A 34 year-old man is brought to the emergency department with f-ever, headache,and a change in mental status leading to significant disorientation. His head CT js normal and he is ir.rneed of an urgent lumbar puncture and intravenous antibiotics. He is agitated and is laving off anyone who tries to get near him. Co rvorhers accompanv him. The resident informs you that the patient is pushing away the Iumbar puncture needle. rtrat should you do? a. Sedalethe patient with Jorazcpamand perform the lumbar puncture b. Wait for the family to obtain consent c, U e b l o o . lc u l t u r e s : . r n l l t e n u t i r e a d. MRI of the brain e. Ask the co workers to sign conselt )L(Aar-AN MaDtCAL
    • Practice Questions 99A man is admitted for the mana€lementof neutropenia and fever from aplastic anemia. His anemia is severear.rdhis medical care requires blood in addition to antibi-otics.He is suffering from a profound delirium from the fever and has lost capacityto understand his problems. His brother is his health-care proxy. The patient is aJehovahsWitness and is adamantly opposed to transtusion even if he dies, and thebrotheris not opposed.The patient has clearlytold both you and the brother this inthe past.The patientsbrother believesthat the proscription againsttransfusionsis"barbaric and stupid."hat should the patients brother do?a. Arrange a Jehovahs Witness meeting to discussthe situation.b. Ask their parentsto make the decision.c. Ask the doctor to make the decrsron.d. He should not giye consentfor the transfusion.e. He should give consent for transfusion.Mr. Sakierviecis a 32-year-old man with severe mental retardation who has beeninstitutionalizcd since childhood. He is noncommunicative and has never been ableto r.erbalizehis preferenceson any decision. His parents are dead and the institutionand a court-appointed guardian manages him. He has developed leukemia that issevereand incurablc. Chemotherapy involves significant risk ancl discomfort andonly a small chance of prolonging his survival.Vhatshould be done in terms of his medical treatment?a. Proceedwith the chemotherapy "expcrtb. Confer an panel" to deterrnine therapyc. Bone marrow transplantationd, Ask the guardian what is in the best interests of tire patient I(A PA N ) MCDICAL
    • Practice Questions I 44. A 27-year-old pregnant woman presentsin her last trinlester ofpregnancy with severe cephalopelvic disproportion. Her physicians have recommcnded a caesariansectior, She does not want to undergo the surgery. She tirlly understands the procedurc anrl she is unwilling to suffer the discornfort of surgery. she has been informed that rvith- out the C-scctionher fetus may not survive childbirth. What should you do? a. Honor her wishesand do not perform the C section b. Psychiatryevaluation c. Sedateher and perform the surgery d. Obtain a court order to perform the surgery e. Explain the situation to the babysfather and ask him for consent 45. A 5z-year-old man seesyou in follow-up after a radical prostatectomy. He had been fully ir.rforrnedabout the risk of the procedure such as incontinence and impotence, Neither ofthese adverseeffectsoccurs. While searchingon the reb he finds that there rs treatment without surgery involving the implantation of radioactive seedsor pellets in the prostate. He files suit against you becauseof an improper informed consent. What will be the rnost likely outcome of the suit? a. He will lose becar.rse there were no adversceffects. b. He will lose becauseall the risks of thc surgery were explained to him before he signedconseut. c. He will lose becauseradical prostatectomy is a standard procedure. d. He will win bccauseyou did not inform him of the risks and benefits of alterna_ tive therapy to surgery. e. He will win becauscradioactive scedsarc the superior form oftherapy.I(A PLAN MEDICAL
    • Practice euestions tol Iarith severe 46. A 58-year-old man is out oftt) sectlon. town on business in New york. He has a myocardial infarction and deteriorates cedurc andthat with arddisoriented is ""0 """J,:o,liJ;:l,.]lJHilii,ri,illil,l;Ji,::i:lij;i bypass.His wife is the health_care proxy but sheis in anothercity.you consent order to perform the surgery would likc her in becaus.rhe is th. a.rignutedsurrogate. rhichof the follorvingis true in this case? a. Shemust cometo the hospital to sign conscntin pcrson. b. The wife mLrst dcsignate local pluardian a until her arrival. c. Younust repeatthe angioplasty instead. d. lblephoneconser.rt only valid is for ninor procedures. e Take consent thc bypass for over the phoneancr havea secondpersonwitnessthe telephoneconsent.ad been)otence. 47. trlr.Doroneis a 22_year_old man who sustaincd subdural a hcmatomaat there c(rttusron a motor vehicleaccident. and a brain rn He needsblood in order to havethe- pellets necessary lifesaving. surgerydone. His parentsrefuseto allorv the transfusionbasedon theirrsent. religious beiiefs. Whatshouldbe done? a. Honor the parentswishes and do not givethc blood.ore ]re b. Givethe blood. c. Wait for a formal hearingwith a judge and a court.:erna- 48. A 27-year-oldJehovah,s Witnr rcf,ses a, transfusi.;;",;"i,TH ; $i jli"i1l3.Ji#lr fi1.*#:,lliJi,.|; standsshe may die without the blood. Whe.nshe tur., .onr.i-orrn.rs her husband nho is not a lehovaht Witnesssaysto plive blood and hc will srgn the consent. What shouldyou tell him? a. You rvill honor his wish if he is the proxy. b. Youwill honor his wish and give the blood. c. You will givethe blood only if the patient is unconscious. d. You cannotgivethe blood. !tl Pt-l tt) l,,tcorCer
    • 7 r lO2 Practice euestions I J I t r E I I I MAI-PRACTICE I i l 49. A medical residcnt admits a patient overnight with uncontrolled blood prcssure. I He means to write an order for the angiotensin rcceptor blocker I)iov.rn at l0 mg olce a ! day. Becauseof his sloppy handwriting the nurses and pharnracy administer digoxin i at 10 mg a day. This is a drug that is rarely used at a dose .b.vc 0.5 mg a dav. Three i days later, the patient develops a hemodynamically unstable rl.rl.thrn disorder that the resident very sincerely tries to decipher but is unable to until thc patrent transfers10 the intcnsive care unit. At this point they discover the overdosc ofdigoxin. ,lhe patient and the family never discover the overdose. Which of the following most accuratelydescribes this situation? a. Therc is no riabirityfor the residentbecause the oyerdosewas unintentionar. b. There is no liability for the rcsident becausc thc pharmacy should have detected the crror. c. No liability exists becausethe error is unknown to thc patient. d. No liability exists becauseit was an accident. e. The resident and hospital are both liable for harm to the patient. f. No liability existsbecausethere was no per.manent harm to the patient. a. of the follorving most closeiy represents the role of risk managernent in the ITI nosprtala a. To ensure proper ethical management ofpatients b. To ensure proper clinical care ofpatients c. To act as a patient advocate d. To clari$. communications from the medical staff to the patient e. To minimize the legal risk to the hospital from litigationIiI $j!!p r.,lrorcarIt /
    • PracticeQuestions51, You explained the risks and bcnefits of bone marrow transplantation versus chen.ro- therapy to a woman with leukemia. This was part of an IRB-approved trial. you told her that the transplant has the highest chance of cure of the diseasebut also the high- est risk of immediate dcath. She understood what you said and signeclthe consent for transplantation, She dics as a result of the bone marrow transplantand her husband suesyou for wrongful death. Mrat will be the most likelv outconc? He losesthe lawsuit becauseBMT is the standard ofcare for this patients age and disease. b. He wins becausehe was not informed, c. He wins because chernotherapy has lessrisk of death. d. He losesit becausethe patient was fully infbn.ned about the risks and benefits of both alternatives. He loscs becausethc trial was IRB-approvcd.52. A 57-year old corporate executivc comes to the energency department with an ST segmentelcvation myocardial infarction. He rcceivesthrombol)rtics but has persistent chestpain, rvorsening lcft ventricular function, and a new 53 gallop. The patient asks ),ou about the risks and benefits of angioplastv. You tell him he could have a hena- toma or a coronary rupture as an adverse effcct of the angioplasty balloon. you tell him that the benefit will be that it stops the chest pain. He opts for further medical management without angioplasty bccause of fear of adverseeffects. He dies and his estate suesyou. ltrat rvill be the most likely outcome? a. You win because you fully informed him of the adyerse effects of the proce_ dure. b. You win trecausehe refused the treatment offered. You lose becausepaticnts cannot refuse lifesaving therapy. d. You lose becauseyou should have done the angioplastybefore the thrombolyt- ics. You losebecause you did r.rotinform the patient of the seriousconsequences of forgoin g angioplastl.
    • lo4 eractice Questions | 53, A 72-year-old woman is admitted to the hospitalwith gastroenteritis and dehydra- 55. tion. Thereare no indicationsin the chart of her havingdizziness. alsodoes She not directly inform the nursesof her dizziness. asksto be brought to the bathroorn, She Sheis lefl aloneon the toilet when shebecomes lightheaded,faints,and hits her head against wall sustaining laceration. a a The patientand her family subsequently suit file againstthe hospitalfor negligence. {rtratwill be the most likely outcome? a. Shewins secondary the negligence the nurses. to of b. Shewins secondary the negligence the physicians. to of c. Shewins if shehassustained significantbrain damage. d. Shelosesbecause therewasno significantinjury. e. Shelosesbecause did not inform the nursesshervasdizzyor lightheaded. she MEDICAT ERRORS 54. A 70-year-oldman is admitted to the hospitalwith endocarditis. sevendaysof At therapythe antibiotic order expiresand you forget to reorderthe medicationfor two daysin the middle of a four-weekcourseof intravenous antibiotics. Thereis no clini- cal deteriorationand the antibioticsare restarted. N What shouldyou tell the patient? 5t a. Tell the patient it wasa clericalerror. b. Because wasnot clinically significantyou do not haveto sayanlthing to the it patient. c. Apologizeand tell the patient that you forgot to reorderthe antibiotics,but that he will be all right. d. Inform your chief resident but not the patient. e. Ask the nurseto tell the patientabout the error.!tlpLlt.t) v r orcaL
    • eractice j Questions tosrydra 55. You are a resident managing a private patient with cellulitis. The patient has a his-snot tory of congestiveheart failure and a normal EKG. The patient is on digoxin, an ACEoom. inhibitor and a diuretic, but not a beta-blocker. You cannot find a contraindication head to the use of beta blockers either in the chart or in discussion with the patient. youe surt askthe private attending why there is no beta-blocker and he looks at you as if you "I had anoxic encephalopathy.He sa).s, have been in practice for 40 years. Don,t you think I know what I am doing? Ileta-blockers are dangerous in congestive failure., The patient looks proudly at the attending and says,"I have the smartest doctor in the rvorld." rhat should you do about this disagreenent? a, Wait for the attending to leave and give the patient a prescription for carvedilol. b. Suggestto the patient that he should find another doctor. c, Report the physician to the state licensing board. d. Do nothing; he is thc attending of record. Bring the disagreement to the chief of service. f. Help the patient find a good lawyer and volunteer to testii/.s of twoLini- MEDICAT RECORDS 56. A patient of yours has gone to the hospital to obtain a copy of her ntedical record for her own review. The hospital refuses to releasethem to her on the grounds that she must provide an adequate reason for wishing to seethe records. She has come to see you to ask if this is true and how can she get her records. What should vou tell her? a. You,asthe physician, get the recordsfor yourselfto view,but shecannot. can b. The hospitalwill giveher the recordsaslong asyou ask. c, Shehasthe right to haveher own recordsaslong asshehasa legitimatereason. d. Shehasthe right to her own recordsevenwithout giving a reason. Only anotherphysician, hospital,or insurancecompanycan havefree access to her records. Shecan havethe recordsaslong asshehasfully paid her hospitalbills. t(Apt-Arl M E D I C A LIIIi
    • Practice Questions 57. Which of the following most accuratel). describesthe ownership of the n-redical record? a. The record is entirely the property of the patient. b. Thc record is entirely the property ofthe health-care provider. c. The information is the property of the patient and the physical paper or elec- tronic record is the property of the health-care provider. d. The ir.rformation is thc property of the health-care provider and the physicaL paper or electronic record is thc property of the patient. 58. A man comes to the emergency department after a stab wound. Your notes document a 500-ml loss of blood. Later that night the patient developsasystoleand dies.You Und the loss of blood was originally really 3,000 rrl, which rvas not recorded by 1-ou. What shouJd you do to correct the documentation? a. Use correction fluid to eliminate the original note. b. Erasethe original note. c. l{emove the original note from the chart. d. Write a new note timing and dating it at the same time as the original note. e. Write a new note with the current date and time. MINORS 59. The neighbor of a l4-year-oldboy brings hin to the energencydepartmentafter sus- tair.rir.rg laceration to the scalp fron.r head traurna. You evaluate him and detcrmine a that suturing of the scalp will be necessary. Which of the following is the most accurate? a. He is an emancipated minori thc paticnt can give consent. b. The neighbor can give consent. c. Wait for the consent of at least one parent. d. Wait for the consent ofboth parcnts. e. Seeha court-appointcdlegal guardian. f, Conscnt is not necessary this case. in MTDICAL
    • Practice euestions to7 I medical 60. A 1s-year girl comes old to the clinic for dyspareunia speculum and a r.aginal clischargc. On examination find ,t. r,or..rui.ii;r. you infectionis modcst and there ii;;;;;;.; "" " negative. Tirc is no cmergency. {rhichof the follol,ing is the mosr appropriateaction to takc?or clec- a. Ceftria,rone/azithromycin now in a singJedose. b. Make at leasta.good tirith,,effortphysical to notifr her parentsand treat hcr. c. Wait to inforn at leastone parenr. d. Treat only if the patient agrees to infbrm her parents.rumer-tt e. Trcat her nol,and infornt the par_ents later.es.You,I )ou. 6l A 12 ycar ord boy ad his tlther are involvcd in a motor vehicle accident that results in a severe hemorrhage requirilg an Lrrgent Huna o"nri.,rion. clearll.alert ancl undcrstanc Both of therl are rvithouttl.reblood theymay die Iehovahs witnesse, "r.,1^1-lllr gh l r r o dl r . l t [ u i { , r ) Theyareboth ""a elu.ir on rcligious groundr. {hat should you do? a. Honor their nishes;no transfusions for either one b. Obtain a court order to transflsc tlre ch ilcl c. Give blood to the child bur not to the father d. Psychiatricevaluation e, Useintravenousiron in both ofthcn as a trlood sultstitutc I Explain the situation to the child and ask l.rim for consentsus- for the transfusiolrnine tt "crinic arter rissingpcriod. prcsnancv is a Her test i:i;[i:,?:*T:*iffi:: -tt^ roushc is adamant thepregnancy co,fio.,-;"i;;;;,1;:.;1t :i:: that voukcep What should tcllhcr? you a. "l u,ill give you the care Fou need ancl keep it confitlential.,, b, "l wiil not mention it to ),our parerts unlcsstbey ask.I can,t lic.,, c. "I am sorry, but I mLrst tell tl.rem.,, d...Irril]ntlttell,vottrparents,butInrrtstl.nfornrthefathcrofthebaby.,, t < l p t l r u ) l , l ro r c nr
    • Practice QuestionsI 63. A l2-year-old girl presentswith severeright lower-quadrantabdominal pain anrl narked tenderncss and is found to haveacuteappendicitis. The child is at a sleep- awaycamp.You arenot ableto locateher parents. They are not at homeand vou can- not reachthem on the cell phone.The camp counselorand thc clirectorof the camp bring in the child. What shoulcl do? you a. Do not do the surgery tvithout parental consent. b. Ask the camp counselor or director for consent. c. Ask the patient for consent. d. Perfbrm the appendectomy. e. Give intravenous antibiotics alone. 64. A 16-yearold female comesin for treatment of severe cystic acne with Accutane (isotretinoin).Shelivesaloneand is self-supporting with a job asa waitress. has She beenout of her parentshouse a yearand paysall her own bills.you havejust fin_ for isheclinformig her of the potentiallysevcre teratogenicitv isotretinoin.Her acne of is severeand shewould still like the isotrctinoin. What shouldyou tell her? a. "This medicationcant.tot takenby worlen of reproductive be age." "Use b. benzol4peroxidctopicallyinstead., c. "l will giveyou the isotretir.roin your parentsaccompany if you.,, d. "I will give you the isotretinoinasrequested., "I e. will treatyou with isotretinoinifyou havea consentsignedby your parents.,, MEDICAL
    • Practice euestions Jand PIIYSICIAN.ASSISTED SUICIDE EUTHANASIA AND 65, A 65-year old man comes to se:an- j:,",,i"ffi ,.i1::,11. ;;"..:"r[il::nHT[[li:ff J* r,..,"" ;.:;..;iigTHi;:ffimP :,ilHJ:iff Jil,"*,:: T-*l"r .oro.,o,.opy und deniesdepression seems have and mood. is asking o He ru o..r..r,l-,Tl or combination to a normai rPnon of medications hecantake to enci ,tft. ;;"r;;, ;: his that ;tu 5*J*ff ,il:ii.":1,:,*,_jr tTJ#";:::;ilr;,*il:"*x:Tjfi Whrch the follow ing of is mostapprop ate in this case? a. Providethe pain meclications I as toropriatebut not b. Providethe patien, the meansto end his ,n;;.;;;r, life c, "0*r u,r.i."r,;:::*il;::,o end riie his l"l" I d. Refer him to a specialist in this arca In-patient psychiatric evaluatjon f ot tuicidal ideation f. start antl.depressanr, {{l!!p rurorcar
    • eracticeQuestions] 66. A 79 ycar old man comes to see you for assistanccin ending his life. The patienl 6l fulll competer.rt has been suflering from progressively and worseningamyotroplir latcral sclerosis several for years.He is not imr.necliatcly preterminal.Despite ht thh, finds his clualityof life to treunacceptable. More inportant, he correctlypredictsthl his lcvcl of function will deteriorateover the next sevcralmonths and that hemav bccorncventilator dependent. is requesting He that ).ouadministera lethalinjection in his honc. IIc is not depressed. familyis arvare hisdesirc His of andthcyare wilLing to honor the paticr.rts wishes. Youhavediscussed appropriatepalliativcclrc issues. rhat should you tell him? a. You tell him that you will horror his l,ish bccausc he is competent and not depressed. b. You tell him that you will honor his ivish becausehis condition will rvorsenoru tl1l1e . You agree to his wish becausehe has a rigl.rt to a better quality of life. d. You tell hinr that you cannot help hinr because thete is no statelaw authorizing rt. You tell hin.r that under no circumstances can )ou participate in euthanasia. f. that it is okay as long as it happensin Orcgon. bu sa,v PHYSICIAN IMPAIRMENT 67. You are a fourth-year meciical stuclent on a subintcrnship in obstetrics. You trotice tlrat the resident has come in rvith alcohol on his brcath antl some abnormal behavior. (, rn( cxC(P()uiccrn lo nr)lica. l l.rat should ,vou clo? a. Nothing;,vou are subordinate to the resiclent. D. Talk to the residentdirectly alonc but dont mention it to the program ctrector Tcll thc dcan of students. d. Report hin.r to the state licerlsing boar-d. Report him to the chairpcrsonor program director of his department. f. inform his patients whorr you feel are at risk. In.rn.rediately MEDICAL
    • eractice Questions ttt ]nt ts 68. You are an attending physician at a university hospital. One of the attendings fromphic another division seemsto be having memory difficulty. You havc found hinr twice ins, hc the hallway having forgottcn where he was going. The residents tell you on the sidethat that they dont rely on him at all because"he forgets everl.thing we say an1.way." Thcmay chicf of service knows but doesnt have enough attendings to fiIl the yearly scheduletlon so he renrains in place supervising troth rcsident perforrnancc as lvell as patient cirre.ling What shoulcl vou do?3S. Nothing; the chief of service already knows. D. Talk to him directly. c. Tell your division head. Report him to the state licensing board. 69. Youarean attendingat a largeprograr.n NewYork.Youare out at a bar on Saturday in nightwhcn you noticeone ofyour residents the samebar.Sheis clearlydrunk. The in resident sitting behind 1ou,too intoxicatedto notice your presence. is kissing is She a man rvho you know is not her husband. You leavebe{oreshenoticesyou. Tl.refoJ- lowing you see at thehospital day her managing patients supervising ancl interns.Her behavior medical and management seem conpletely normal. What shouldvou do? Speak her dircctly about her behavior. to b. I)iscuss with her programdircctoror department it chair. c. Reporthel to the comn.rittee physicianimpairment, for d . Do nothing. I(APIAN MTOICAL
    • ll2 Practice Questions I RETATTONSH PHYS|CTAN/PAT|ENT tP 70. A physicianin a busy inner-city environrnenthas developed practiceover his years the point wherehe no longerneeds solicil new patients. doesnot to to He to expandhis hours ofwork so he decides limit his practice. instructshis to He staff to begin new patients. refusingto accept Which of the following most appropriatelydescribes action? his a. It is both legaland ethical. b. It is ethicallyacceptable, illegal. but He is within his legalrights to refusepatients, it is considered bu1 ethically ceptable. d. new patients. It is both illegaland unethicalto refuseto accept e. transferof careto anotherphysician. It is ethicalaslong ashe arranges 71. You have a patient who has recently been diagnosed with myeloma and he is ing treatment options with you. You are the full-time employee of an facilit1. 1g1 by a managed-care plan and you have recently received written i such as bone marrow transplantation in myeloma tions not to bring up sub.jects patients. The reasoning was that they are outrageously expensiveand do not cure disease,although it may extend survival. The data that they extend survival are entirely conclusive. ln addition, in a private meeting with the meclical director,lou have been told that the expenditures per prtient load of care of each of the would be examinedyearlyto determinewhich physicianwould be promoted. What do you do? Fully inform tl.repatient about the risks and benefits ofbone marrow transplan. tation. b. Refer your patient to an oncologist to have this discussion. lransfer c. the patient to another primary-care provider. d. Advise the patient to file suit against the managed care plan. Give the patient treatment with melphalan or thalidomide which both able therapy. f. Inform the patient about bone marrow transplantation if he asksyou aboutit.[APLAN) MTDTCAL
    • -t questions ru eractice I I 72. Youhavea patient who is a 57-year-old nan with a history of HIV who hasrecentlylhe beenfound to havesevere coronaryartery disease. hasthreevessels He with lessthanrnt 90 percentocclusionand left ventricular dysfunction.He is referredfor blpass sur_ice gery.The cardiothoracic surgeonat your hospitalrefuses operateon your patient to because is scared touchingHIV positivepatientsfor fear of seroconverslon. he of He is alreadyon a beta-blocker, ACE inhibitor, and aspirin. What shouldyou do? a. Add calciumchannelblocker.. b. Performangioplasty and stenting. c. Add clopidogrel. d. Havehis chief of servicecompelhim to do the procedure. e. Referthe patient to anothercardiothoracic surgeon.S- 73. A 60-year-old malephysician who is an internisthashad a fernalepatientfor the lastrt 20 years.Both lost their spouses several yearsago.They start spending time together:- outsidethe office.The femalepatient wants to begin a sexual/romantic relationshiph with the phvsician.e rtratshould he tell her?t "Iu a. can neverdo that with you, ever." b. "We can be social,but not sexual." c. "We needthe ethicsboardsapprovalfirst., "I d. cannot dateyou and be your doctor-maybe in the future we can date,after you get anotherdoctor." e. "Because this is your initiative we can begin dating.,,
    • l14 Practice Questions | i PUBTIC HEATTH REPORTING AND REQUIREMENTS 74. Vhich of the following does not need to be reported to the health departnent? a. Salmonella b. Gonorrhea c. Herpessimplex d. Tuberculosis e. Measles 75. A 38-year-old bus driver is seen in clinic for fever, cough, and sputum with an apical infiltrate as well as sputum positive for acid-fast bacilli. The patient is unwillingto take tuberculosis (TB) medications consistently and his sputum remains positivefor TB. Direcdy observed therapy while in his home has failed. You continue to cajole, discuss,encourage,threaten, educate,advise,and beg hin.r to take the medicationsbut he refuses. What should you do? a. Nothing, he has a right to autonomy. RE b. Arrest the patient and put him in prison. 77, c. Remove the family from the house. d. Remove the patient from his job as a bus driver and incarcerate him in a hospital to take medications. e. Physically restrain the patient and place a nasogastric tube to give the medica tions.I(A 9IA N MEDICAL
    • I I Practice Questions 5 I I i A 27 lrcar old man is seenby you after the diagnosis syphilis. you are adminis of As teringhis treatmentyou find he is quite promiscuous.You inform him that you nust notiE, the Departmentof Health and that his sexualcontactsneedto be treated.He is extremelyembarrassed askshorvthey will find out. and What shouldvou tell hin? v, You will notift them yourselfbut you will not give his name. b. You wiil notill. them and must let them know he was the contact. c, You will tell the Department of Hcalth but he himself must tell the contacts.al d. The Department of Health rvill send a letter or call the contacts and let themo know they have a serious health issue.They will test and treat the partners but)r will not reveal his name. He doesnt have a choice; he has to give the names.lt f. Their individual doctors will inform the contacts. REPRODUCTIVE RIGHTS 77. You are the general internist in a large, multispecialty physician group. The office- based pregnancy test on your patient has just become positive and you estimate the gestational age of the fetus at eight weeks.You are a very deeply religious person in a conservative,midwestern city and you are opposed to abortiolr becauseyou believe life begins at conception. After extensive discussior.r about the options, your patient asksto be referred fbr an abortion. Which of the following is the rnost appropriateaction? a. Inform the patient that you are morally opposed to abortion and you cannot make the referral. b. Terminateyour relationshipwith the patient as her phvsician. c, Propose social work/psychological evaluation ofthe patient. d. Tell hcr you will makc the referral aftcr a 30 day consideration period in which she may changcher mind. e. Refer the patient fbr the abortion. !l!!!!/ u:otc,rl
    • eraaice euestionsI 78, A 16-ycar-oldfemaleis in your officebecause has just found out sheis she Shediscusses optionsand asks her you to referher for an abortion.Shestates that parents do not know shc is prcgnant and she does not want thcnt to knolv. What should you do? a. Refcrher for the abortion without parentalnotitication. b. Make a "reasonable effort" to contactthe parents, still refer for theabortion but if you cannot contactthem. c. Do not refer for abortion without parcntal consent. d. Seek a court order declaring her emancipated. Strongly encourage her to discussthe issue with her parents. 79. A voung husband and rvife visit your office to discussrnethods of contraception, The wife decides that she wants a tubal ligation for sterilization. Her husband is shocked and strongly objects stating that thcy have no children. His wife is clcar that shenants the sterilization and that she wishes to be referred for the procedurc. What should you do? a. Reterfor the tubal ligation asrequested the wife. by b . Referafter a psychological evaluation. . c . Do not makethe referralbecause is youtg. she d. Do not makethe referralbecause may change mind. shc her Refcronly rvith the husbands consent. MEDICAL
    • PracticeQuestions I l7}nt. 80. A 35-year old married woman with four children is in your office seeking a termina-her tion of an unrvanted pregnancy in the first trimester. Later in the day after you give the patient the refcrral, her husband calls and is very distressedbecausehe does not want the abortion to occur. He very much wants to keep the baby and tells you that he even has a namc picked out. What should you tell him?ior-r a. You rvill try to talk his wife out of the abortion. b. You will cancel the procedure immediately. c. You say you cannot hold up the termination withoul a court order. d. You cannot prevent the abortion without paternity testing confirming that he is the father.he e. You sav you have an absolute duty to the nother to honor her wishes no matter what his personal feelings are.lednts 81. A 3O-yearold woman presents the clinic during her third trimester.The estimated to gestational agc of the fetus is 28 rceeksand she is seeking an abortion. The patient is generally hcalthy. An ultrasound of the fetus at 26 $/ecksand routine genetic testing showed no abnormalities. What should you tell the patient? a. Its okay; you will go ahead with the abortion. b. You will be happy to comply if she can get a court order. c. No way, third trimester abortions are prohibited. d. Legally 1ou can only do it if hcr life is at risk. e. No, you cant do it becausethe fetus is norn.ral. L ( AP L A N ) M T D T C A L
    • lt8 PracticeQuestions ABUSE SPOUSAT TO 82. A 42 year old man comes to seeyou for routine management whcn you inquire about 84. multiple scratches and contusions as well as a black eye. He says his wife routinelr "beating abuseshim and is me up pretty regularly, doc." He dcnics hitting his wife, You seehim a few weeks later and he has a new version of thc same injurics. You are very concerned about his injuries and you tell him that you are plalning to rcport the injuries. He very clearly statesthat he does not want these injuries rcported. What do you tell him? a, You have no choice but to report the injuries bccause you are a mandator,y rePorter. b. You will report the injury only with his consent. c. You will honor his wish but mlrst report it if there is another episode. d. I h e r ei s n o s p o u . a la b u . er e p o r t i n g . e. You will report it if you find evidence that the r,rifewas really the attacker. 85 SUICIDE 83. A 68 year-oldman attemptedsuicideby driving his car into a telephone polewith the inter.rtionalpurposeof ending his life. He wastbund sevcrely hemorrhagingandin the emergency departmenthe refuses givehis consent surgerynecessary stop to for to the bleeding.He states that he wants to die. He was recentlydiagnosed with cancer and refusedsurgeryto removeit. He states that his life had beencompleteand noli he wishes end it. to What shouldyou do about the surgeryto stop the bleedingnow? a. Follow his statedwish and withhold surgcry. b. Performthe surgery. c. Obtain a court order to forcethe surgery. d. Ask the family membersfor consent.I ( A PI A N MEDICAL
    • IORTUREtbout 84. you are a civilian physician and you have been asked to participate in the interroga.inely tion of a prisoner suspectedof carrying out a terrorist attack. Therc is very significantwife. eyidenceto prove his participation in planning subsequent attacks. you have been!l arc askedto monitor the patients oxJ.genlevel during a simulated ,,hanging,, ,.stran_ andt thc gulation" of the patient to determine if supplemental orJgen or intubation is neces sary. hat should you do?lory a. lt isethicrlll pcrmis.ihlc o pdrticipdtc. t b. Participation is permissible only if he has been convicted of tlre cnme. c. You can participate if there is a court order. d. You nust have a releasesigned by the military prior to your partrcrpation. e. You cannot participate in the purposeful torture of a prisoner. 85. A group of prisonersis brought to a rnilitary hospitalin which you work. They are to be screenedprior to transfercither to long-term inprisonments ot rn somecases, to bereleased. notice that several You ofthe patientshaveburns that look rike cigarettes wereput out on them aswell asseveral brokenbonesthat havestartedto heal.1eln hat shouldyou do?p a. Reportthe injuries assignsof possibletorture.:r b. Reportthe injuriesonly on the patients be releasecl. to c. If you are a military physician, you sl.rould report the injuries. d. If you are a civilian physician, you shouldreport thc injuries. e. Your only duty is to treat the injuries. t(A p tAlt ) M€DtCAl
    • Practice Questions I wtTHHOIDtNGn IflTHDRAWAI MEDtCAt OF TREATMENT 86. An elderlypatient with multiple medicalproblemshas been admitted to your care in the intensive-care unit. The patient is in a persistent vegetativestatesecondary to anoxic encephalopathy has now developed and sepsis,hypotension,gastrointestinal bleeding,and respiratory failure requiring intubation. There is no improvement expected the underlying severe in brain damage. Renalfailure develops the point to of needingdialysisbut you feelthe dialysiswould be completely futile. Which of the following is the most appropriatestepin management? a. Hemodialysis b, Peritoneal dialysis c. Renaltransplantation d. Give albumin e. Recommend that dialysisnot be performed 87. A 33-year-old femaleboxersustains cervicalspinefractureduring the welterweight a championship matchin LasVegas. hasa fractureofCl and C2 resultingin paraiy- She sisfrom the neckdown and is ventilatordependent. is fully alert and understands She her medicalcondition.Therehasbeenno improvementfor the lastthreemonthsand thereis no hope of recovery.Her manageris the health-care pror7. Sheis frustrated but not depressed is repeatedly and and clearlyrequesting removalfrom the ventila- tor. Sheunderstands that shewill not survivewithout the ventilator. What shouldyou do? a. Remove ventilatorassherequests. the b. Obtain a court order to continuethe ventilator. c. S e e ka m i l y o n i e n s u sn r e m o v i n gh ev e n t i l a t o r l c o t d. Seekapprovalofthe health careproxy. e. Sedate patient and continuethe ventilator. the5Aa!AN ) MrDrcAL
    • 88. A 48-year-oldwoman has developed stageIII non-Hodgkinslymphoma and needs combinationchemotherapy treatment.Without therapyshehas no hope of sur- forJ vival beyonda few weeksor months. With therapyshehas an 80 percentchanceofrl complete remission. understands entirelybut insiststhat shesimply doesnot She thist want the therapy.Thereis no evidence depression. oft Which of the following is the most appropriateaction? a. Psychiatricevaluation b . A : , kr h el a r n i l y o r t h c i ro p i n i o n f c. Seeka court appointedguardian d, Honor the patientswishes e. Offer radiotherapyinstead f. Risk management evaluatron 89. An elderly patient with progressive Parkinson diseasecones to see you becauseof fever,cough, shortness of breath, and sputum production consistent with pneumo- nia. The patients Parkinson disease has been worsening and he has become quite depressed. has insomnia, early morning rvaking, and weight loss as well as anhedo- He nia. He is refusing antibiotics and is asking for palliative care only to help him die. What should vou do? a. Psychiatric evaluation lt. Sedatethe patient c. Comply with the patients wishes d. Seekthe opinion of the family Ethics committee referral f. Comply with the patientt wishes as long as he is DNR !ll!!!/ vrotc,lL
    • 122 PracticeQuestions 90. A 55-year-oldman has been adnritted the hospital for worseningof his nentai to 92. status,poor nutrition anclinability to eatwhen fed.The patient hasCreutzfeld-Jakob disease u.ill not likelyimprove. and Overthe lastseveral monthsthe patienthas toLd you repeatedly "kept with artificial that he doesnot want to be alive as a vegetable" nutrition and hydrationby anymethod.fhe health-care proxy form specifically states "no placement there is to be of a nasogastric gastrictube for enteralfeeding." or The health-care proxyagentis a nurse. Theproxyinsiststhat you havea.lejunostorny (l tube)placecl tellingyou the prory tbrrn only exclucles NG and G-tubes. the What shouldyou do? a, Placethe J-tube. b. Tell the prory shcneeds get a court order for the J tube. to c. Tell the proxl sheneeds ethicscomrnittee an evaluation. d. Do not placeany forn oftube for artificial r.rutritionor hydration. 93 e. Transfer patients the careto anotl.rer physicianwho feelscomfortableplacir.rg the J tube. 9 1 . A 35-year-old homosexual man is a victirn of a motor vehicleaccident which in he sustainshead trauma resultingin a large sr.rbdural hematoma.His breathingis becoming worse and endotracheal intubation is being consideredfor mechanical ventilation. familyincludinghis motheraswell ashis maledonrestie His partnrris present. mother insistson the intubation beingperformed.The domesticpartncr His is the health-care agent.The agentstates unequivocally that the patient statedboth "breathir.rg verballyanciin writing that he rvisl.redneverto be placedon a machinefor any purpose." 4rat shouldyou do? a. Honor the proxyanddo not intubate b. Honor the nothers wishcsand intubirtethe patient c, Consultthe ethics committee d. Neurologyevaluation e, Try intubation for 24 48 hours to seeif he recovers f. Ask the opilfon of the restof the family!!l!!p urorcer
    • Practicental 92. A 75-.vear-old man is admitted for a myocardialinfarction and a strokethat leaveskob him in a persistentvegetative state.He is a rvidow,never designated hcalth care a.old proxy,and left no u.ritten evidence his u,ishes himself. of for His nephewand daugh-cial ter want to continrreall forms of therapyinclucring artificiarnutrition and hydration.ltes His son and the patientsbrother rvant to stop evcr).thing. Both partiesbelievetheyfhe L n o r v h c w i h c s f t h cp a t i e n t o(l- Whatshouldyou do? a. Encourage cliscussion arnongst famil1.. thc b. You,the physician, rnake decisior.r the bestinterest the the in of patient. c. Stop all fonr.rs therapy. of d. Obtaina court orderseeking court appointed a gr-rardian, 93 An 84-year-old noman with severeArzhcirners diseasc is admitted to your skiledhe nursing facility.She haslost the ability to conrmLrnicatc, is becl_bound, ar.rd unable to cat. she did not appoint a prorr and tbere is no rvritten or clear vcrbal advance direc tive of ,vhatshc uanted for hersell Multiple family members routinely visit her and:h 1ou are unable to achieve a clear consensusamongst the famil). of what the patieDt,s1S rvishesrvere.al What should you do in terms of hcr care?is3I a. Follow the wishes of the eldest child..h b. Follow what you think is best.)r Ask anotherattendingphysicians opinion. ) AsJ< hospitaladministratorfor consenr. the P u r . r r a n c l h i c :e o r n n r i t t e J l u d t i o t r . c (c
    • PracticeQuestions ] 94, A 72-ycar-old man cones to seeyou becauseof severepain from metastatic prostate cancer to the bones. His pain has become progressively more severe and has not responded to localized racliation, flutanritic, or goscrilin. ln addition, numerous pain medications have failed to achicve an acceptable level of analgesia.He needs more intense pain malta€iement with subcutaneous or intravenous opiates. He also has severeCOPI) and there has been concern about the effect of the opiate medications on the patients respiratory drive. In other words, the only way to achieve a sufficient anrount of pain relief is to use medications that may shorten his life, inadvertentlri becauseof respiratory depressiolr. The patient is fully alert and has the capacity to understancl the problem. Which of the follorving is the most cthical way to approach his pain managernert? a, It is all right as long as he is DNR. b. It is acceptableas long as the patient understands the risks. c. It is unacceptable to shorten life.with physician administered medications. d. Intubatc the paticnt then give the pain medications. e. Leavehim in pain as long as the respiratory drive is not impaired. f. Offer to cnd his life with pain medications. 95. A 77 year-old woman is admitted with a stroke that renders the patient dependent on endotracheal intubation and rechanical ventilation. There is no hope of rccoverv and the patient is unable to comntunicate. Thcre is no health-care prory and the patient lacks the capacity to understand her problems. Her husband produces a liv_ ing will signed by the patient on whicl.r is written the statement,,,I do not rvish to Lre maintained on a ventilator if there is no hope of recovery." He does not recall ever cliscussingthe subject with his wife. {hat shoulcl you do? a. Continue the ventilator b. Risk management evaluation c. Rcmove the tube and the vcntilator d. Seeka court order to remove the ventilator e. Ask the rest of the family rvhat they thinkITAPIAN M FDICAL
    • ate 96. An 84-yearold wonan is aclmittcd with abdominal pain. On the secondhospitallot day shebecomcs fcbrile, severelyhypotensive, and tachycardic from an intestinal perforalln tioo. The patient is disoriented rvith no capacity,re to understand hcr medical problen.rs. There is no response to antibiotics, fluids, and dopanine over the ncxt 4g hoursLaS and there arc signs of significant anoxic cnccphalopathy.ns Altho.gh th"r. i. ,r.ro health-care prorlz,the family is in uniform agreement on what the patient wourd have wanted fornt herselfhad she been able to speak for hersclf.rYlto rhich of the follorving cannot be stopped at the direction of the tamiJy? a. Ventilator b. Bloodtests c. Dopaminc d. Fluidand nutrition Nothing 97. A 73-year-old man has been brought to a chronic_care facility for long_tcrm ven_ tilator nanagement. The patient has advanced COpD and is unable to be weancd from the ventilator. A trachcostomy h-as been placed. A nasogastric tubc is in place to.deliver tube feeding. The patient is fully alcrt, and undcrstaids the situation. He is asking to have the nasogastric tube renroved becauseof discorfort. 4rat should you tell him? "I a. will get that tube out right away,sir.,, "l,ets b. seehow much you are atrle to eat first.,, c. "I will pull it out if you let me put in a gastric tube.,, "Let d, me talk to your family first.,, "Do e. you havc a health-care pror1,?,, f. "No way dude, we make the clecisiorrs arouncl here, not you.,, g. "Only if you promise not to sue me.,, Arc h. you crazv?Do you think I am going to let My patient starve to death?,,
    • PracticeQuestions 98. A 47 year old man r,vith cnd-stage renal failure has askedyou to stop his dialysis.The patient fi-rlly understands that he will die if he stops dialysis for nore than a few da,vs or wecks. Hc is not depressctland not encephalopathic. What should you tell hin? "I a. need a court order first." "l b. am sorry; I dont feel comfortable doing that." "I c. cant do that. Psician assisted suicideis not ethical." "I d. rvill stop when ye get you a kidney transplant." "You e. rvill feelbetter if I sedateyou so that you stop disagreeing rvith me." Although f. I disagrcewitl.r your decision, I will stop the dialysis." "I g. cannot do that. We already started dialysis. Now we have to continuc." "Not h. until you pay your bill." 99. A 92-year-old man with Alzheimers diseasehas been aclmittecl to the hospital with aspiration pneumonia. He is on a ventilator and has a nasogastric tube in place. He does not have the capacity to understand his meclial condition. You find a living will jn an old chart that says"No heroic measures," want to be DNR," and "I wish to be "l There is no proxy and there is no farnily available kept comfortable." with whom you can cliscussthe natter. He has no pr ivate physician with lvhom you can discussthe case. What should you do regardingthe ventilatorand tube feeding? a. Continuc both for now. b. Removethe ventilator and the tube feeding. c. I{emove the nasogastric tube but continue the ventilator. d. Seeka court appointcd guardran. e. Decide rvhat vor.rthink is best for the patient. MEDICAL
    • he 100.Which ofthc following best approximatcs the role ofthe health-care prox1,?lys a. To explain the physician,splan to the family b. To conrey the wishcs of the family to the meclical tcam c. To communicate and carry ou1 thc wishes ofthe patient d. To nake decisions based on what he or she genuinely belicvesrs the best interests of the patient e. To carry out the financial dccisionsofthe patient rvhenhe or shelosesthe capac_ Ity to speak 101A 34-year-old woman with three chilcrrenpresents pregnant at 20 weeksofgestational agewith anemia and severegastrointestinal bleeding requiring transtusron to saveher life. She is a JehovahsWitness and she is refusing biooj tr"r.rr-f.rrion. Vhat should you do?rh a. Honor her wishes, no transfision.Ie b. No transfusion now but the transfusion is mandatory after the second trinlesteri11 when thc fetus is a potentially viable baby.)e liansfuse c. the patient.LI d. Seek a court order mandating the transfusion.3 e. Get consent of the father of the babv I ( A PI A N ) M E D I C A L
    • -T_- f ! eractice Questions iJ I I I to2. Mr. Barberis a 58-year-old man who hasa cardiacarrestaftersurgery. suffe.sp., He ! manent brain damagefrom anoxicencephalopathy. is jn a permanentvegetative: He stateand ventilatordependent. wife and eightchildrenarepresent the hospitat His in ! and request writing for the ventilatorto be stopped. in After its removalhe continues I to breath. They are asking for the intravenous lines to be rernoved and all blood test- ing to be stopped. They agree that this was his wish for himself. He did not leavea written advance directive such as a living will but he clearly told his family,,.l don,t want to be a vegetable."He never designated a health-care pror7. What should you do? a. Refer the caseto the ethics comml[ee. b. Obtain a court order. c. Refuse;you cannot ethically do this. d. Transfer the care of the patient to another physician. e. Remove the IV lines and stop blood draws as they wish. f. You can withhold additional new treatments and tests,but you cannot stop those already started. MEDICAL i
    • I rzg.s per-ltative Answers Explanations and)spitaltrnuesI test-:ave a dont NoNeed Further for Studies When Brain Dead l, (a) Remove the ventilator.hose The patient meets the criteria for brain cleath.These are: negative corneal reflex, nvstagmus rn response to caloric stimulation no of the tympanic membranes, negative pupilary and oculocephalic reflexes, and the absence of ,ponon.o.,, respiration when the ventilator is held. Ifthere are no brainsten reflexesan.1the patient will not spontaneously breathe, then the patient is brain dead. There is no hope ol recovery this circumstance.An EEG is no in consistent deuth. with b,ai,, s.nitJffif ll,l..;fi H*:::1:::il",:T:;1,* States. Although the heart has contr.nuedto beat, it is the same as taking the heart of the chest and seeing it beat in a specimen out pan simply becauseof the automaticity of the hearti intrinsic conduction path*oy. Wh.n n pntient is brain dead, you n e e dt o s e e kc o u r t o r c t h i c sc o r l do not brain .",r"ilil; jt"t":il::il:HTiil:i:: :lifir#i: apatient dead, is patient.The brain-deadpatient is dead. Thisrvool.t b. "s illogi."l asplacinga naso_ gastricfeedingtube in a cadaver the on autopsytable. Remember, althoughyou havelegalright tnlurn off the ventilatorimmediatelyon a persor who is brain dead,you sh9yl4 talk to tl-re--family Ifthere is an answer first. says"discuss,""conference,, o, arriy iiiii that *"iJi ird"ti"g ,n", y.u lv"", to always achieveconsensus first, then that discuss -,,r,,r.,. the ma*er 0,,,",iifii:;,:,ffi:::tJ:J,jr,1T:i: jj:i]if.."l tube. -J t(A pt"AN M E D I C A L 1 I
    • Answersand Explanations Mandatory Reporting 2. (h) Report the family to child protectiveservices. Although, in general,it is better to address issuesdirectly with patientsand their families,this is not the casewhenyou stronglysuspect child abuse.Reportingofchiid abuseis manclatory evenbasedon suspicionalone.Although it is frighteningto be confrontationalwith the family,the caregiver legallyprotectedevenif thereturns is out to be no abuse long asthc report wasmadehonestlyand without malice. as You do not havethe authority to removethe child from the custodyof the parents. Only child protectiveservices the courts can do that. The policewould be appropriate or for an assault happeningat that exactmoment, but the policearenot appropriate to investigatechild abuse. When you havea suspicionof child abuse, doesntmatter it what the parentssay. That is why talking directlyto the mother or father is incorrect. When you suspect abuse,evenif the family deniesit, you must still report. Privacy Health-Care of Information theWorkplace in rl .,{r i - . ,r, | .,1,r, 3. (c) Inform him that you are not rc give details rggar<ling patient the {MV without the patientspermission. Confidentiality is a fundamental right of all patients. As part of maintaining the patients autonomy in revealing information only to those they wish to be informed of their condition you must refuse to releaseany specific information ofthe patients medical history or current medical problems without direct pern.rission from the patient. Respectthis right even if the person asking is, indeed, a cq-wo1kg1-ey sysn their superior. You have no idea if medical information may be used to discriminate against the patient. Scparate from this, third parties have no automatic right to a patients medical information unless they are directly involved in the care of the patient. This would hold true even if the person seeking information is a health-care worker if they are not directly involved in the care of the patient. Have the patient- not the person requesting the information-sign the consent form for release of information confirming that they are giving 1ou permission to releaseinformation.tl!!p urorcrl
    • Answers Explanations t 5 l and I 4. (d) Tell them you cannot show them the chart unlessthereis a signed the patient. release from You cannot releasea patients medical records unless thcre is a clear, signed from the patient or there is a court releaselelr order. This is true no mattcr who the federal agents have a court order rs asking. IfLild for the records ,h;; ,;;;;"r. a right to the information. A court order, warriberns tovjorateconndentiarityirir.;"ili,lii,llrj:]ilil:J;.":,*i[.JTil:"J;1"# medical recordasa physical objectis the p-p*ty "r trr" pifri.iu, o.bu r.,.nrth_.n.. tl t?.-ation is the_property thepatient. ofnly I;1:l,r.jr:^1"- house. rn a sense, information the is rrkca person5 No one has the right to enter yourate home without either your permission or a court order allowingto the investigation. This is also true people requesting it are law enforcement even il theter agcnts. We all have a constrtutional against illegal search and seizure rightct. of our property. Breaking Confidentialityprevent to lnjuryto Others 5. (e) Inform both the patients boss aswell aslaw enforcementof the threat.nt A patientt right to confidentiai n::tntt otrsons to safetv right begins Your to prote., t,* "rTlt^1111^Int-tt duty ,n. patientt inrormation ;:i ;ff :::Ti:::il medicar :::i::TiT duly warned.If larvenforcement info.-"d is ;:i::.:iTill::d urd th. pot.rr,lnlli.,r_ ir r.,o,irrfur-.a then you are held liable if thereis injuryrt to the victim:n Duty Inform patient Withholding to the First; Information from Patient the 6. (d) Youtell them that you are obligated to inform the patient of all the findings. Your first duty is to keep the patient fully informed about her health care. thereis significantevidence Unless of absorute r"*;*i::itf"T#fljl.j:iilffi :#*lljff; duty toth" psychological harm to a patientwould be an activelysuiciaut significantbad news. i..,on *fro wasgiven lll:!!p rure orcrr- -
    • r32 nnr*",, undExplanations I The motives of the family nembers are irrelevant. Whether they are kind and lov- ing or vindictive and evil makcs no difference. This is true rvhcther their requestto withhold infornation is in rvriting or is from the hospital ethics committee. In this case,the ethics comn.ritteeis not necessarybecausethere is no substantive question of the right action to inform the patient first. The health-carc proxTs opinion and participation are only mandated if the patient losesdecision-naking capacity. the lf patient has decision-making capacity,the health-care proxys opinion is not clifferent fron anyone elses. Breaking ConfidentialityInform to Others Genetic of Diseases 7. (e) Inforrn the patientsex-wife of the risk to the children, The patients right to confidentiality ends where it comes into conflict r,r,iththe safety of other people. The right to confidentiality is extren.relystrong, but it is not universal and absolute. In this case,the children of the patient have a right to knorv whether their lives will be cut short by the di.sease familial adenomatous polyposis (FAp) of and colon cancer The most important elemcnt is that sc,reelrjngfor polyps should begir.rat th_e_agggf with screening sigmoidoscopy evcry year. Colectomy needs to l2 be done if polyps are found. Hence, in FAP there is a very specific intervention that can prevent colon cancer and a very specific screening that can be clone. ln addition, the nother has a right to knorv whcther her children will become ill and how to plan for that. If a child falls and breaks his leg, ole parent cannot claim confidentiality asa reason to withhold this critical health information from the other parent. As a part of divorce, the stipulation that each parcnt nust inform the other parent of health care issuesfor the children as they arise is a standard part of the agreement. Although, in this case,the health care issue involves the private health of one parent, the issue is still pertinent to the other parent as the caregiver of the children. The right to one persons privacy is not asimportant asthe right ofanother person to to safety.This is establishedstandard and does not require a court order. you rvill have more liability from the mother of thc children if she is NOT jnforned than from violating the confidentiality of the patient to inform. She can successfullvpursue a legal action stating you, the physician, did not infornr her that her children were at "injury" risk of the of the genetic disease.I(APLAN MEDICAL
    • Answers and explanations tf5 I The health department does not do notification for ger.retic discases. The health department notifies partners thepopulation riskof transnr and at issible cliseases such astubercuiosis, STDs, HIV and food- or water-borne diseascs.lmmigration Confidential Status (a) "Donit worry, the Department of Health does not ask or report irnmigration status." As a physician or:r ethical duty is to provide medical care to patients. Neither physi_ cians nor the Department of Health act as information services to rcport peoples immigration status to thc government. Thcre is no mandatory reporting to the gov_ ernmcnt either before, during, or after the treatment of tuberculosis. Incarceration to take TB medications rnay occur for a noncompliant patient, but they do not spe_ cifically face deportation for health reasons.Actually, impaired health is one of the grantable reasons for asylunt. Mandatory reporting of immigration status would be a direct impairment of thc physician/patient relationship.Sperm/Egg/Embryo Donation9. (c) It is legal to sell both the sperm and eggs but not the embryos. The patient can sell and d!!3te unfertilized gametes such as sperm and eggs.Both spern and eggs are considered cqual. A fertilized gamete or embtyp can also be - { g 1 g t e J .H o w c v c r , t i ( u r r e n l l y i l l ( g , r lr o , r l l e m b r y o , . i I(API"AI{ ) MEDICAL
    • Answers Explanations and Who Asks Donation for Consent 10. (e) Organ-donor network The rules concerning organ donation are quite specific that the medical team taking care of the patient must not be the ones asking for the donation of organs. This is a conflict of interest. It pits the familys perception of the physician as caregiver against the impression that the medical staffjust wants the organs. There can also be signifi- cant amounts of irrational thinking associatedrvith grief such as the family thinking you only want to turn off the ventilator so you can harvest the organs. The medi cal team n.ruststay clearly in the role of the people trying to preserve the life of the patient. Thc other most practical reason for the organ-donor network to ask is that their chance of successfullyobtaining consent is far, far in excessof physicians who ask. The organ donor network doir.rgthe asking both preservesthe ethical integrity of the medical team in the eyesof the family as well as markedly increasing the supply of viable orsans available for donation. Payment Organ for DonationUnacceptable ls 11. (e) Reimbursementfor cost of travel and lodging for the donation is acceptable, but profiting from the donation is unacceptable. Thereis an enormousshortage acceptable of organsfor donation.As such,cashpay ment would favor the organsgoingto the personwho wasthe wealthiest, the per not sonwith the bestmatchor greatest needfor the organ.The organsmust be uniformly and fairly distributed.If sellingorgansis considered unethicalin the United States, then it is unethicalto participate a cash-for-organ in practiceanywhere. physicians As we cannothaveseparate domesticand internationalethicalsystems.!l!!!p urorcar
    • Answers explanations t 3 5 and I Family Refusal Overrule Organ-Donor Can the Card 12. (e) Honor the wishesof the family; no donation.taking Althoughthe organ_donor card indicates patient,s the wish to donatehis organs, istis is a still unacceptable harvestorgans it to against direct wish ofthc fbmily.If thegainst overruJe family,then therewould.be we wereto the no point in askingth"rn ,o .or,r"nt. Wtignifi- consent donation,if we would take y urk for the organs""y_;;nking ifthey said no?The organ-donorcard is an indication of the patient,swisi* i", ii^ not fully binding.nedi-rf the; that DNR NotLimit Does Other Forms Treatment of who.tyof 13. (c) Go aheadwith the dialysis;pPly ignore the DNR order. A "Do-Not-Resuscitate, (DNR) order is very specifically definedas refrainingfrom cardiopulmonaryresuscitative efforts..such ch.r, ;;";;,;.rr, as antiarrhythmic medications such as amiodarone lidocaine, or and electrical cardioversion thein event patient,s cardiopulmonaryarrest. ONn ora., ^of,the A in, nothing to do with any of the other forms of care thatble, the patient i, *..iil"g. ; L)NR order impact on the useof dialysis. has no you shouldpretend that th. oNn orae. aoes,ot exist whenevaluating dialysis. for Hyperkal.-iu i. lif. ,frr*i"i"S. i " inferior rherapysuch as kayexalate illogicalto usean for the long_term;;G";.", ot the hyperka_ay- lemia of renal failure if dialysisis indicated. This patient ;, ol_ut nt.rt, and able ", understand or her own medicalproblems. his to1ly ffr. p"i*,1 i"_lfy rs not relevantin *.Uior-making pathwayif the patientES, l::T: :1-,T t u, tt ..nfu.ity to understand nrsor her own medicalproblems.ns r(APLAN MEDICAL
    • 135 onr*"r, andExplanations I DNRDoes Preclude Management Not ICU 14. (c) Transfer to the ICU as needed; okav to be DNR in the ICU. "Do A Not Resuscitate" or DNR order means no cardiopulmonary resuscitative efforts in the event that the patient dies. There is to no other automatic limitation in therapy besidesthis. DNR orders are often confused with generalizedwithholding of care such as transfusion or ICU management. DNR orders are not the same as stop- ping the active management of the patient. DNR ordcrs do not automatically mean that the patient is immediately terminal or that there is an automatic assumption of palliative care only. 15. (e) DNR does not preclude surgery; proceed with the appendectomy. DNR is not meant to be a generalized limitation on all forms of therapy. You can still intubate patients even if they are DNR. No additional forms of consent are required ever.r they are DNR. DNRjust means you are taking death as the endpoint of giving if treatment. In the event of cardiopulmonary arrest do not give the additional therapy of cardiopulmonary resuscitation, defibrillation, and chest compressions.DNR is not a gencral equivalent for withholding any other forms of therapy except these.llajjl9 MEDTcAL
    • Answersand Explanations t57Reporting of Elder Abuse Mandatory16. (f) Report the grandson-in-lawt abuseto protectiveseryice. Elderabuse common and you havethe right to report the abuse is overthe objections ofthe patientin the majority ofstates. The reportingrequirements erderabuse for are like child abuseexceptthat they are not uniformly mandatoryin all states.Although thelegalrequirenentsarenot identicalin all states, ethicalrequirementof physi- the cians report abuse clearand uncompromising. to is The reportingofelder abuse does not dependon the wishes ofthe patient.With the elderlyyou often havea competent adultwho is simply frail or impaired in someother way.Although the patient may see lossof the careof the family asa worseproblcm than their injuries,you musr the actto protectthe patient from an environmentthat might kill her.you cannotspeak to the grandsonor notify the policewithout the patient,sapproval.Honrehealthaids aretherc to clean,cook, dress, and otherwisemaintain the patientsneeds, they but arenot securityDersonnel.Direct Physician Participation Ethical Not17,.Jd) "I am sorry; I cannot participate in the executionat all asa physician." Theethicalguidelineofthe AmericanMedicalAssociation and the Americancollege of Physicians expressly are clearthat a physiciancannot participatein.,any action whichwould directly cause deathof the condemned assist the or anotherindividual to directlycause dcath of the condemned." the This includesstartingthe intravenous line,mixing the medications, formulating the n.redications, administeringthe medi_ cation,and evengiving technicaladvice.In fact, it is unethicalevento be observing an execution your capacityas a physicianbecause givesthe suggestion your in it of acquiescence the procedure.It is not ethically permissibleto certifi the death to unless has alreadybeen determinedby another person.The primary role of the it physician terms of beneficence in (doing good to others)and nonmaleficence (not doingharm) arecompletely incompatiblewith participatingin executionl(!you are the physicianin a prison your physician/patient containboth the role of the caregiver relationshipcannotsimultaneoq,sly and the executioner,s facilitatoi dependingon Gi the day of the week)It is ethicallyperrnissible giveanxiolyticmedications to prior to - t h ed a yo I e x e c u t i o ln r e l i e r eh es u f f e r i no f t h ep e . s o n o n d e m n c d . o t g c !!l!!p vrorcnr
    • Answers Explanations and I Necessity Informed of Consent 18, (b) Informed consentis required to participate. All clinical trials require informed consent. Experimentalsubjects havean absolute right to know that they are participatingin a trial. This is true evenif the medica_ tron studiedhad only benefitand no adverse effect.you woulcl st l need informed consent. a principle of autonomy, As you do not havethe right to do somethinefor someone to someone or without her consent, evenif it helpsyou. ID thi, sense, I could not giveyou money as a gift without your consent. The designof the institu_ tional reviewboard (IRII) is to assure ethicalintegrity the of all clinical trials at an institution or facility.An IRB is an independentboard of reviewers who must not haveany direct gain or harm from the implementation of the trial in order to assure objectivity. human experiments All requirethe approvalof the IRB. Hence,if I designed trial comparingwhether me giving a you $50 or $100asa ta-{, freegift madeyou happier,I rvouldstill needto get IRB ap-prorrnl you _ould have urra to sign an informed consent. Prisoner ParticipationExperimentation in 19. (d) Their rights are identical to a nonprisoner. Prisoners havethe right to participatein clinicalresearch .l.hey trials. arealsoentitled to monetarycompensation their participation.participation for cannot be usedasa criterion for shorteningtheir prison sentence. Essentially, prisoners haveall the same rights in terms of their participation in clinical ..rear.h u, nonprisoners. This also includesthe right to refuseparticipation.It is not unethical for them to participate. The ethical difficultiesbegin wl.renthe porverof choice and informed consentare removedfrom the prisoner. Incarceration doesnot rcducethe prisonerto the subhu- man, animallike statusof unfair treatmentor not having the right to refusepartici, pation.Clinicaltrials that occurin a prison must undergo the samerevrewprocess by an institutionalreviewboard (IRB) asthoseoccurnng outsidcthe prison.you cannot force someoneinto research just because is u priron"r. you cannot he coercethem rnto participatingby suggesting will shortenthe prison it sentence.!ll!!p urorcar_
    • Answers Explanations t t 9 and i Disclosing Financial Affiliations Time publication atthe of 20. (d) There are no restrictions on your i authorship asIong asyou disclosethe finan_ cial affiliation.lutelca- Thereis no automaticethical difficulty with industry sponsorship clinical trials ofned and experimentation. Financialsupport from ".o_pui do., not eliminateyou asfor an author aslong asyou disclose of your all financialaf&liations with the company.e, I The absoluterequirementto revealfinancial or business affiliationsat the time oftu publicationis necessary all the authors. for This is true evenif the data are accurate an and unbiased. you must revealgrant support for your trial evenif the pagnentsnot madeto a third party suchasthe hospital are or medicalschoor. you may stil havebeenure influenced alterthe outcomeevenifyou to havenot personallfreccive<t payments the directlyinto you own bank account.The key issuein termsof research publica_ and tions is not whetherIou or your tnstitution took moneyfrom companies reveal_ butax ing the financialconnectionsbetweenthe authorsand ,ha .o_porry.lve Role thetRB of 21. (c) Ensurethe ethical and hr mane treatment of human subjectsin ex?erimenta_ uon Theinstitutionalreviewboard (IRB) reviews all experimentar trials to makesurethat thetreatmentof the subjects fair and humane.part is ofthis responsibility to make is; a surethereis adequate informed,consent and that the askedquestronis a valid ques_|le tion. In other words,the IRB will makesure that the placeboenJ of the trial doesnotSO withhold clearlybeneficialtherapysimply to co ect data.The IRB makessure that:e. all hunan subjects understand p,recisely what they areagreeing pa.trclpate There to in. IRB makessurethat thereis sufficientmonitoring of th! studi so that if a treatment is found definitelyharmful or helpful then trial ,iop, ir.,ord., to switch the subiects into the more beneficialarm of it, oncethe point LuaU".r, prou.n.ty)tn !l!!p r*aeorcnr,
    • t40 Answers Explanations and I lRBs developed out of the experience of the Nazi war crimes tribunal at Nuremburg in rvhich it becamc clear that experimentation was prcrftrrmeclon humans ^/tthor.tt thcir consent and without concern for safcty.The I RB ensuresthat tne paueDr neyel suffers purposeful harm simply to answer a scientific question. ln sltort, the function of the IRB is to ensLrrethat thc careof thc subjectiu the trial is more rmportant than the collcction of data. You cannot use an unethical n.rcans achicve an ethical to end. Employer Wants Mandatory Genetic Testing Workers of 22. (d) Ask the patient if she y/ants the test performed and the results reported. Employersdoot l.rave right tr thc confidentialhealth-carc a intbmation of patients. You may pcrforn and report certaiD tcsts to the enrployer at the request of thc patient. ln adclition, genetic testir.rg as of yet, of unproven valuc. It is not is, yet clear what to do with the resLrlts thesetestsin terms of their impact on the of standaril managementof patients.A positivetest for the ApC genedoes not mean the patient wil) get cancerof the colon. A negativetcst clocsnot mean that the patietrt will trot gct cancer.A negatiYetcst is insufficiently sensitive to rule out cancer. The nesative predictivevalue is insufficie.t to rule out c.ncer.lhe only thing that is clear abour the ethics of the genetic testing for cancer is that we wish to prevent discrimination and there can be no mandatory reportirg of geneticinformation. Cenetic privacy Information 23. (d) Refuse provide the information to the employer. to The enploycr has no right to the genetic information of a patient. Cancer is not tnnsmissiblc to fcllow cmployees. None of the geDetic tests have an impact on job perforn.ranceor job safety,which arc the only tbms of information that an emDloyer has a claim to.I(APLAN MDICAL
    • Answersand Explanations t4ls from Gifts lndustrv!tr 24, (c) Do not accept the rnoney, but the dinner and the lecture are ethically accept-I able.I Drug companies constantly surround physicians in an attempt to influence prcscril> ing patterns. It is ethically acceptableto participate in eclucational activities sponsored by the pharmaceutical industrl. Modest meals are also ethically acceptable.Although the speaker may accept a cash honorarium for preparing and giving the lecture, it is not ethically acccptable for members of the audience to accept direct monetary pay- ment for participating. Hence, it is ethically acccptableto attend the lecture and the meal,but not to accepta check for cashfor the participants. Honoraria Industrv from 25. (d) It is permissibleto take the money aslong as you discloseany other financial or businessconnectionwith this or any other company. Industry sponsorshipof the speakers medical educatior is acceptable long as in as there is no expectationof the conpany controlling or influencing thc content of thc presentation. ln other words, you are not allowed to simply be an advertisement for the companl pretending to be giving an objective presentation of ncdical data. Speakershave a mandatory responsibility to disclose all financial participation with ind ustrl. This allows the audience to judge for itself whether there is undue influencc from industry altering the content of the talk in thvor of a particular product. There is r.rorcquirement to clonate all speakersfeesto charity, Ihere is no requirement for prior review of a presentation to an independcnt monitoring board for content. Inappropriate fromPatients Gifts 26. (b) "Thank you very much, but I cannot accept." You cannot accept gifts from patients who are clearl).having cvidcnce of an acute psy- chiatric disturbance.Even if thc patient is not ill enough to qualify as incompetent, gifts frorn patients must be truly objcctive ancl clean in a way that there can be no qLrestion acute emotional durcssleadingto the gifi. of !!!!!, veotcer
    • onr*"r, andExplanations I Acceotable fromPatients Gifts 27. (b) Acceptthe gift. Smallgifts from patientsof limited valueare ethicallyacceptable. Food,plants,and Refusingsuch signs srnall articlesof clothing such as a scarf are all acceptable. of gratitudewould be hurtful to the doctor/patientrelationshipif they are a signofthe good relationshipwith you. Gifts can neverbe tied to a specificexpectation care of such asa particularprescriptionor the successful completionof paperworksuchas disability forms. There is no reporting or disclosure requirementfor small giftsof nominal value. Acceptable fromIndustry Gifts 28. (a) All the gifts are acceptable, Acceptable gifts from industry are nevertied to ParticularpracticePatterns, sPecific drug prescribinghabits,or any expectationof practicebehavior chanceparticular to a specificproduct. Industry may sponsoreducational experiences long asthey as are not restrictingthe contentin any way.Besides modestmeals, other forms of the acceptable gifts are thosewith direct educational medicalvaluethat enhance or the careof patients.Direct monetarypaymentsfor simpleparticipation are not accePt- able.In this case, gift of a stethoscope only enhance the will patient care.The gift certificate acceptable is because is to a medicalschoolbookstore. gift certificate it A to a departmentstorewould not be acceptable. valueof gifts shouldgenerally The be small,which is definedat present beinglessthan $100in value.Gifts shouldnot be as geared merelyto entertainment. Ticketsto concerts sportingevents not accept- or are able.Pens, notepads, smallpieces rnedicalequipmentsuchasa stethoscoPe and of or reflexhammer are acceptable.!l!!!p rurrorcrr-
    • Answers Explanations t 4 5 and I Pregnancy, to Refuse Right Testing 29. (a) No test;shehas the right to refuse.ts, and Patientscannot be testedfor HIV againstgns of their specificrefusal.This is true the case a pregnantwoman when of evenin the baby,sheaftf,t "t ,t"i.. In fhct,HIV tcsting of the requires additionallayerof consent anrf care eventhough it is only a blood test. nize,that.invasive, We recog_ potentiallycomplicaa.ap.o..ai..r ruJ nl roirch as need additionar because r,i riLr,r, jilffi c.nsent ",,rr"ifts of theseprocedures. general,blood In ,fii"T:.::,1il:ii testing f", ;;;;";;;.matotogy needa specific, doesnot additional consentbeyonJge,r..d .fhere h;iui-.;ent. is a low thresholdfor acceptingthat there is implied .orrrerrt on trr.-il.* presence the hospitalor office. in .r the patient,s This is not true in the c"r" "i if* no suchthing as an ,,implied,, ,ru ,"r,. Thcre is consentfor HIV testing.Er""ii"rgl, muchas a 30 percentrisk of getting the baby hasas the virus from ah;_;;.;;. -"rher cannotbe treatedagainst will. The reasoning her is the same. ffr" *.-u"lr.;gnt to choose the olh:r.own body outweighs the right of th" Ib;.;il li,nisem,enr rs not endowed undelivered fetus:cific with the powcr of an individj ia."ri f"r; ":i".ron,,in the legal:ular sense. This is the samereasonin caesarian,.ctio,.,.u.n havins rightto reruse the ath.y irtr,.i;i-.i:i?;::l:t-omanrsof the H|V-Positive Caregivers. Mandate lnform No to patientsgift:ate 30. (e) No one without his direct written consentbebe Patienhwith HIV havea right to privacyaslong asthey arenot puttmgPt- Youhaveno mandatoryobligation othersat risk. jris to inform the state, insurance,or Youand the patientdo not haye or his employer. a n.randatory obligatlontu i,riurlll fri. patients HtV. "l:* evenif he is a surgeon. of his This is becausle UIV_p"""r1y. "" n o s i g n i f i e arn . k o f r r u n , m i s : i o r ,r b r r ; a h , , . ; ^ - - , t " physicianposes it to ra patient universalprecautions t, to prevail in order to are supposed or".,."rrrtttott U1;ffi ilT,il*,",::1Tl::;:;J"Til;; L]*il":J*::ilT:ff ![!!p r,aeorcer_
    • 144 I Answers Explanations and There is no implied consent in terms of HIV. It must be expressed in writing. Health- care workers are at risk of HIV from accidental transmission from HlV_positive patients. Yet, there is no requirement that all patients be tested iorder to prel,ent transmission to the health-care worker. All patient blood and body fluids are to be treated as if they were HlV-positive. If the automatic right to know the HIV status 0f the patient does not exist, then the patient does not automatically have the right to know the HIV status of the physician. It works both wavs. Dentist RefusalTreat to patients H|V-positive 3l . (d) Refer your patient to another dentist outside of your group practice. It is unethical for a physician or other health_careworker to decline seeing any par_ ticular group of patients based only on a specific diseaseunless they are being asked to manage a diseasethat is beyond their area of expertise. Although refirsing to se€ HIV-positive patients is unethical, it is not illega.l. you cannot force the dentist to take on a patient without his consent. The medical director cannot do that either. The doctor/patient relationship must be entercd in a voluntary way on both sides.you cannot force a doctor to seea patient anymore than a patient can bc forcecl to seea particular physician. Oral antibiotics alone are insufficient for a patient who needs a surgical drainage. The boards often mix an ethical issue with a concrete medical alternative to see if you would pick an inadequate therapy rather than make a deci- sion in an ethical dilemma.L ( APL A N ) M E D t c A L
    • Answers Explanations t 4 5 and I:alth- Partner Notificationsitiverventlo be 32. (a) Encouragediscussionbetweenthe husband and wife and strongly suggest heus of disclosehis HIV statusto his wife.ht to You havea duty both to protect the privacy of your patient aswell asto protect the healthof innocentthird parties.Ifyour patientis practicingunprotected with his sex partner or is sharingneedles, shouldbe stronglyencouraged noti$. the partner. he to Ifthis doesnot happen,you are legallyprotected reveal HIV statusof a patient to the if you believethat person is endangering life of anotherperson.When partner the notification doesoccur,it is usuallythe responsibility the Departmentof Health. of It is the healthdepartmentthat shouldsendthe letter to the partnersnotilting them "urqent of the healthissue."Par-;kedtake 33. (a) Inform the partner now.TheYou You havefull legalprotection if you inform the partner.The safetyof an innocenteea personis always you arenot legallymandated inform more important that privacy. to:eds the partner directly but you are protectedif you do. you haveno liability in break-ical ing confidentialityfor this purpose.you definitelyare liable if the patient,spartner seroconverts and,voudid not tell him he wasat risk eventhough you knew This is a yersionof the Tarasofcase psychiatry(Tarasof Regents in v. of the State California, of l7 Cal3d424 [1976]). a mentally patientdiscloses you in confidence he If ill to that is planning to iniure someone, you have an absolutemandateto inform both larv enforcement well asthe personat risk. Ifyou know that harm may occur,but you as do notl.ring,then you are liabJe. partner notification is going to occur,you must If inform the patientthat you will inform her partner. ![!!p ueorcrr-
    • t46 Answersand Explanations Mandatory Reporting NotNational ls 34. (e) Discussthe issuewith the patient and encouragehim to find alternatemeth- ods of transportation The lawsconcerningthe impaireddriver are not universal betweenstatesexceptfor drunk driving. Thereis no nationallaw guiding physicianreporting of an impaired driver for reasons age,cognitiveimpaiment suchasAlzheimers, neurological of or diseases suchasmultiple sclerosis Parkinsondisease. few states or A requiremanda- tory reporting the to Department Motor Vehicles orderto restrict remove of in or a driverslicense.Most do not. Somestates offer protectionfor physicians case in the report is not honored.Most do not. The ratesof motor vehicleaccidents remained stablein older patientsuntil the ageof 70 when there is a slight rise.Howevet th€ highestrate of motor vehicleaccidents all agegroupsis in thoseabove85. This in gror.rp the very old exceeds of eventeenagers terms of the rate of motor vehicle in accidents. Because standards reportingof the impaireddriver variesbased the for on the state,therecanbe no questionwhercthe correctansweris eitherto report or not to report because this is a national examination. that can be universallyagreed All upon is that you should encourage potentiallyimpaired driver at any ageto seek a alternate forms of transportationor to havesomeone elsedrive. Misuse Beneficence of 35. (d) Your action is not appropriate becauseyou treated the patient without his consent. A patientmust giveconscntto any testor treatmentperformedupon him aslong as the patient has the capacityto dccide.Physicians not acting ethicallywhen they are treat a patientwithout his consentevenif it benefitsthe patient.lt is very difficult for somepeopleto acceptthat goodwill and sincerityare not sufficientto overridethe absolute necessity informed consent. for This is true evenifyou areright in the sense that the treatmentwill help the patient and that only the patient will benefitfrom the procedureor treatment,This is true evenif paymentis not received. Autonomy of the individual outweighsbeneficence, which is the desireto do good.This is the physicians desire treat the to patient.Another way of sayingit is: I havea right to be sick and miserable that is what I want. ifI(A PI.AN MED!CAL
    • Answers and Explanations /Decisions whileCompetent, when Made Valid Incompetent35. (a) Refuseto do surgery and follow the original advancedirective, The patient in this questiongavea clear advance directivewhile she still had deci sion-makingcapacity. This must be follorved. This caseis especially clearbecause it statesthereis both a clearverbalaswell aswritten advance directive.Cases which in thereis no clearadvance directiveare much harder,It doesnot matter if the familys request in writing. The casewould be considered straightfbrwardto warrant is too the interventionof an ethicscommittee.Evenif the ethicscommitteefor somerea- son recommended surgery, the you would still haveto refusebecause your duty is to follow the patientswishes,no one elses. You cannot refusea decisionmade while competent simply because patientlater becomes the incompetent. this werenot so, .[f then all wills would be invalid.A personswill is a form of advance directivefor their property afterthey becomeunableto speakfor themselves directly.Limitation DeterminationIncompetence on of37. (c) Honor his decision and do not do the colonoscopy, lust becausea patient may be incompetent in certain areasof his life does not mean that he is not able to consent for medical procedures. The patient describecl has a severeand perrnanent cognitive impairment; however, he is still able to refuse the procedure. A patient can be considered incompetent for financial issues but still havethe ability to make medical decisions. It would not be advisable to recommend routine medical procedures against the will of the patient. This would mean literally forcing him into the endoscopy through restraints or sedation. Incompetence in one areadoes not mean total incompetence. The court recognizesa much lower standard of cognitive ability to reliably consent or refuse procedures conpared with financial decisions.lt is easier to be declared inconpetent for financial decisions than it is for medicaldecisions. l!!l!!!2 urotcer
    • 148 nnswers Explanations and I Consent Specific Each ls to Individual Procedure 38. (b) Wakethe patient up and seekconsentfor a different procedure. Youmust obtain informed consentby specific procedure. Consentfor anotherproce dure or clearmedicalnecessity cannot infer consentfor anotherprocedure. Neither the medical necessity the procedure,the seriousness the condition, nor the of of assumptionthat any reasonable person would consentis sufficientto assume that consentis given.The patient is not awareof his surroundings and condition because of the sedation.You cannot have an "informed consent"without waking up and infbrming the patient.Another examplewould be a blood transfusionin a Jehovahs Witness. during a procedure, clearbut unexpected If, a necessity blood transfusion for arises, must wakethe patientup and askabout the patients you wishes haveor not to haveblood. The consentor refusalmust be informed.You cannotsaythat because of the necessity sedation, or that you should.justgivethe blood. On the other hand,just because patient is a Jehovahs a Witness,you cannot assume that he will refusethe blood.A refusalmust be informed aswell. The patient could,after all, be a Jehovahs Witnesswho doesnot agreewith that religionsteachingon blood. Eachprocedure must undergoan individual consentprocess. Invalid BecauseLanguage theWrong Consent of and Person lt Obtaining 39. (e) All ofthe above For consentto be valid, the personwho thoroughlyunderstands proceduremust the explainthe risks of it in a language patient understands. hospitalis required the The to provide translators acconplishthis end. toI{APLAN M EDICAL
    • Answers explanatlons and I t49 Consentlmplied Emergencies ls in I 40. (a) Give the blood.)ce- rn an emergency,unless the ls an extremely clearher consent to procedures. advance directive, there Th.rre is implie4 patient is not consciousthe be fully informed to make to make a decision. He cannot choice There is no advancehat or limily available there directive, proxy, living will, ,a "substitute"usc make decision ,n" o.r, ]-ll lnt a for his judgment.Hence, must we ,, of thepatient. shirtis not and directive.you aon,o, A sufficient advance dn.uo,rr".ests n:Y.I,/s the risksof deferringhs rn this case, death. therapS which, is Even,:r"ll ll:l a r:f:v.ihs witnesson wouldrefuse o,oro."o.j-ll--1is vou cannot certain be ,n" "w-ell herot utona *ooti t.,",il";Ii::i::::av everv otherlehovaht witnessrefuses oof specincariy say d;;J;;T;:lilH::i#ff::ft he i"aiuiau pnti",,t, *u,trst T.:he restauranr aI the where residents order arways ptzza.ls :jjT:,il1J,lT::i:ffi"re :i,Tii*;m**i;{l mll.m*?,yit::iiffi:;:i:ffi ,1.:! jiilii::::;T::ht:ff ;fmuli::*:",.mi*, and maybehe will .r. o refusalmaybethe patient will consent, ,ntr::1::nsent.or t rs not sufficientevidence transfusion. ofa chorceoffood or bloo<i {{!!P neorcrr-
    • r50 nnr*"r, undExplanations I Emergency Procedure anAdultLacking in Capacity 4I . (a) Sedate the patient with lorazepam and perform the lumbar puncture The patient described is not unable to give either an informed consent for the pro_ cedure nor is he able to make an infornted refusal of the proce<Jure either, He does not have the capacity to understand his medical condition and the consequences of deferring the lumbar puncture or the antibiotics. There is no prorlr or family member available to give consent for the procedure and to substitute for his own judgment. In other words, what would the patient want for himself should he be able to make decjsions for himself The co-worker does not count as a person who can give con_ sent. A blood culture alone or an MRI is insufficient as a diagnostic test ro manage meningitis adequately.You cannot wait for the family in a caselike this. If a patient has an urgent, life-threatening, dangerous, or even severclypainful medi_ cal condition, and the patient is not competent and has no family or prory available, then the medical staffcan do what they feel is necessaryto protect the patient without a specific signed consent. You would be more at fault for withholding therapy in this patient than you would to do the lumbar puncture. Acting in his best interests ou! weighs a formal consent that you cannot immediatelv obtain.r ( A p r - A NM T D I C A L
    • Answersand Explanations t5l Substituted When proxy Judgment the Disagrees thepatient with 42. (d) He should not give consentfor the transfusion.r Pro- The purposeof a health,careprolT is to cauy: does out the rvishes the patient in the of cventthat the patient becomes unableto make decisions himsell The key for issuecesot hereis "the wishesof the patient.,, The prory is not a personwho is just to give hismber own opinion ofwhat he (the proxy) thinks is bestment. for the patient,if rhe patient,sclear wishes knorvn.Thc prory or health_care are proxy,,agent,;or ,durablemake powerofattor neyfor healthcare"is like a mail carrier.He is to con- carrf the patient,smessages whenthe patientcannot deliverthem himsell your maillnage carrier is not supposed be writing to lettersfor you. He is just supposcd transmit yours to ._t.he accuratcly. only differencc is that if the patientdid not put his wishes writing in the prory is authorizedto makc decisions based what he wastold by the patient or when onnedi- nothing elseis availablc rvhatis in the bestinterests the patient. oflable,:hout In this case,the proxl is a brother who veryr this strongly disagrees with the patient,s wishes againsttransfusion. The patientdoesnot want bloo.l. The prorT _ust notout give consentfor the transfusionbecause that is the wish of the patient.The prorT is not thereto wait for a patient to losc capacityand then take over It this werethe case, then no lastwill and testament would be valid.The last will and resrament conveys a personswishes their property for whenthey havedied. for Deathrs the ultimateform of lossof decision-making capacity. The executorof the will is to obey the will, not decide what he thinks should havebeendone. I(APtAN MEDICAL -
    • Answers Explanations and Never-Competent Best Person, Interests Standard 43. (d) Ask the guardian what is in the best interestsof the patient This patient has neverbeencompetentso there is no possibilityof trying to deter- nine what he had wantedfor himself.Thereis no family to act in his bestinterests. You cannotsubstitute judgment for a personthat hasneverhad judgment.This case involvesdecision making on the least accurateof the decision-makingstandard, which is to determinewhat would be in the bestinterests the patient.The reason of this is the leastaccuratemethod of giving or withholding consentis that thereis no way to be surewhat the patient would havewantedfor himself.With a bestinterests standardwe havethe difficult problem of determiningwhetherthe guardianis bas ing their decisionon what the patient would need,or the guardians own subjective standardof what they would want for themselves. this case, burden of therapy In the for no chance cure is worsethan the option of simply deferringtherapy. thereis of If "expert a court-appointed guardian,then there is no point of an panel."The question hereis not one of what the bestmedicaltherapyis, but what is in the bestinterestsof a patienttoo mentallyimpairedto makehis own decisions. Pregnant Woman Refusing C-section 44. (a) Honor her wishesand do not perform the C-section A competent adult hasthe right to do what shewantswith her own body.This is true evenif the decisionseems foolish or unwise.This is also true evenif the patient is pregnantand the fetus is potentiallyviable.Until the baby is born, a fetus doesnot havethe rights of a "person." undelivered An fetusis .judged a part of the womans as body; henceshehasthe entire right to choose what will go on. Psychiatryevaluation and a court order areinappropriate because is fully competent per the descrip- she as tion in this case. The fatherdoesnot havethe right to decidewhat to do anymore than he hasa right to consent an appendectomy the mother.The mothersright to refusea C-section to for is the sameasa mothersright to choose abortion.The fatherhasno say.llg:39 MEDTcAL
    • Answersand ExplanationsNecessity of Informing Patient Other the of Treatment Options45. (d) He will win because you did not inform him of the risks and benefitsof alter- native therapy to surgery. Patientshavethe right to be fully informed about the risks and benefitsof therapy and alsoabout alternativetherapies. cannotmakean informed decisionif he has He not beeninformed about the alternative the main coursein therapy.The absence to of adverseeffectsdoesnot eliminatethe needto tell him the risks of theraovaswell asthe benefits.oral Consent lsValid46, (e) Take consent for the blpass over the phone and have a second person confirm the consent. An oral consent is equal to a writtcn consent if it is valid and provable. The validity of oral consent has nothing to do with the severity of the procedure. If you improperly take consent for a minor procedure you are liable for damages.If you take a proper consent for major surgery it is valid even if it is oral. It is important to have as much documentation of the consent as possible. The second person speaking to the proxy on the phone is a valid way of confirming the consent. A second person should even lvitness consent in person. There is no limit on what can be consented to by oral consent. lt is simply a matter of establishing proof of the consent so no one can deny it later if there is an adverseeffect of the procedure.
    • anrlvurcund Explanations J Onlya Competent Patient Refuse Can Emergency procedures Lifesaving +2. (b) Give the blood. only a fully conscious patient can refusea lifesavingblood transfusion.you do not havedirect evidence ofthe patients wishes himserf. for you cannotassume that what the parentsaresayingis what he would havewantedfor himself.If he were awake he may very well sayhe thinks his parentsreligiousbeliefsare crazyand he wantsthe blood. He may sayhe agrees with then. Because haveno clearidea of what the you patientwantedfor hirnself,you must givethe bJood.Consentis implied in an emer_ gencyprocedureunlessthere is a contemporaryrefusalby a conscious patient.you cannotwait for a court hearing.The patientwill die in the meantime. Refusals When Made Competent Valid Are When Capacity Lost ls 48. (d) You cannot give the blood. The patient has given you a clear advance directive both orally and in writing. you I n u s t h o n o r h e r w i s h c s r e n i f s h el o e sc a p d c i t yl.f t h i s w e r en o t e true no onc i,ould have to honor a persons last w I and testament when he or she died. rf this were her will and she was designating what she wanted done with her property after death you cannot reassignher property based on what the husband wanted. The most intimate property a person has rsher own life and body.I(API"AN MFDICAL
    • Answers Explanations r 5 5 and I Harm: NotRelevant Intent 49. (e) The residentand hospital are both liable for harm to the Datient. Harm exists evcnifit is unknown to the personactedupon. The tntentlonofthe per_ sonmakingthe error doesnot actuallymatter in termsof assessing malpractice both aswell asharm to the patient.In this case, both the residentand hospitalareguilty of harm and potentiallyliable for damages resulting for in an injury to the patientthat wereavoidable. The nursesand the pharmacistcan alsobe held liable. If a manufac_ turer sellsyou a car that is unsafeand you sustaininjury they are still liable for dam_ ages because is their responsibility ensure safeqr it to the of the productstheysellyou. If I own a restaurant and you get food poisoningaccidentally from unsalefood or an employee who did not washhis hands,then I am liabre.I am not absorved ofliability for the harm just because did not intendharm I and am in,,goodwill,,towardyou. I still harmedyou. The sameis true of a medication error.Role Risk of Management50. (e) To minimize the legal risk to the hospital from litigation Riskmanagement the term appriedto the portion is of the hosprtaladministration that evaluates potentiallegalliability to the institution. The role of risk management rs to try to intervenein acutecarein a way that protects primarily the hospitalfrom lawsuits. Risk management may leadto bettercareand communtcationin the service of reducingthe chance that a patientor their family will engage legalaction in against theinstitution. !l!!p veorcer
    • onr*"r, andExplanations I lnformed Consent Protects Against Liability 5 1 . (d) He losesit because patient wasfully informed about the risks and benefits the of both alternatives. The key issuein termsof liability for adverseeffects patientsis whetherthe patient to was fully informed of the risks of the therapybeforethe treatmentwas given.If a major adverse effector evendeath occurred,but the patient knew and understood this and still chose proceed, to then thereis no liability.The patientwasfully informed of what could happen.If a minor adverse effectoccurredsuch as hair lossand the patientwasnot fully informed that this could occur,then thereis wrongdoing. Again, the issueis whetheror not the patientgaveconsentor had the opportunity to make anotherchoice. The patientsfamily doesnot need to be informed. The patient must be informed. IRts approvalalone doesnot shieldyou from liability. The key issueis whetherthe patientwasgiv€nthe opportunity to makea freechoice. A man is buying a car.The one in the store he chooses a cup holder he likes. has They delivera car with a much better engine,but without a cup holder.The dealer is liable because customermust be given a choice.Maybebe will only buy a car the with a cup holderhe likes.Youcannotsay,"This car without the cup holderis a much bettercar." It depends being informed,not on what occurs. onI(API.AN MEDICAL
    • Answers txplanations and t57 I Necessity of Knowing of Deferring Risks Therapyits (e) You lose becauseyou did not inform the patient of the serious consequencesof forgoing angioplasty.:nt In order for a patient to make an informed consent for a procedure, he must knowIa the risk of not having the procedure done. In this caseyou did not document thatod you told the patient that a person with an acute ST segment elevation myocardialed infarction who fails to reperfuse with thrombolytics has a markedly increased risk ofne death without angioplasty.You only informed him of the risks (hematoma, coronary.n, rupture) but not the benefit (decreasedmortality) of the procedure. He was not fullyke informed and therefore you are liable. ln the sane way that failing to inform a patient of the risk of harm from doing thed. procedure is mandatory, you must also inform of the risk of harm when you dontle do the orocedure.s. Duty Patients Inform Staff Medical of to the of Problemslr 53. (e) She loses because she did not inform the nurses she was dizzy or lightheaded.h Malpractice occurs if the physician, hospital, or other staff deviated from the stan- dard of care and the patient sustained harm. lt is not a deviation from the standard of care to leave a patient unescorted on the toilet if she does not offer a complaint. There would have been malpractice and liability if the patient had informed the nurses that she was dizzy and in need of assistanceand they did not provide it. The patient has a responsibility to inform staff of medical conditions that would have an imnact on her care. t(A p tA tt MEDICAL
    • onr*"r, and Explanations / Revealing a Medication Error 54, (c) Apologize and tell the patient that you forgot to reorder the antibiotics, but that he will be all right, Medical errors are one of the most difficult issuesin the ethical management of patients. Therearefew absolute rulesin terms of disclosure and it is one ofthe most embarrassing issues deal with. There is very little acceptance evenan honest to of error on the part of the patient,the physician, our physicianpeers. or Nevertheless, the ethical direction is clear that you should revealthe error to the patient. The patient has an absoluteright to be fully informed about his own care.This means it is his right to knorv and your duty to inform about any error in careevenif there is no demonstrated harm. The patientsright to know is more important than your embarrassment over the error.The greatest obstacle informing the patient is fear to of lossof credibilityand the potentiallossof confidence the patientin your com of petence. The patient may choose sever relationshipand sometimes engage to the to in litigation if thereis potentialharm.You must still tell him the details; is his right it to know. If you bring your car for repair and the mechanicmakesa n.ristake the repair,you in are entitledto klow. The car is your property and no one has a right to mismanage your propertywithout 1ourknowledge. The most personalform of property is your own bodv. Disagreements Residents Attendings Between and 55. (e) Bring the disagreement the chief of service. to Your first duty is to the patient;however, you cannot damage physician/patient the relationshipbetweenthe privateattendingand the patient.You cannotjust change therapyon someones patient without his knowledge. would be inappropriateto It go outsideyour local hierarchywithout first appealing privatelyto the chief of ser- vice. The chief of servicehasthe authority in an institution to intervenein quality of careissues.I(API.AN MEDICAL
    • Answers explanations and / ts9 Absolute of patients View Right to Their OwnRecordscs,but 56. (d) She has the right to her own records even without giving a reason. The patient does not haveent ofr most rh" ro. ."n.*,i.;;;;;;". to L:;:."XJTili* J.lliHlili:,::iiJ.::i:::H,,i: withheldfrom the patientfo any reasonincludingnonpaymentronest health-care ofbills. The patient,s information car-reless, strons,i,u..,ary,ffi,ll"*,:"i::fffi,.i:.iT.#j: thatr,:. The seekthe parient,sapprovalin_orderfr. th.;;;.;-"*rT ;i:T,:neans You,as a physician,require ,n" parient,srecords. rthere a or r..-j, ,.",il,lllnTlll,r:,1,1*the get copv the paticnt order vou in for to yours fearcom- Ownership of Medical Recordsrgageright 57. (c) The information is the propertyofrhepatient and the physicalpaper or elec_ tronic record is (he property of ,f," f,.utit _.*" p.olil,, Younage The health-care provider can copiesof the medicalrecord other hcalth-care p.ouro.rr, o,ototto" to the patient orFour is the propertv ofthe phvsician, clinic, or hospital.H.".., ,1r"o::l:-1fll:" 1:- orrgtnal recordalwaysremains care..l.he information in the re with the provider of the property of the patientis entitled ,. "...r, Patientand that is why the .f ;:tisientnge3tOter-lity I(API.AN MEOICAL
    • Answersand Explanations Inaccuracies Record Changing in the 58. (e) Write a new note with the current date and time. The two methodsof correctingerrors in documentationare to placea singleline through the original error,write in the new information, and add your initials or to placean entirelynew note with the currentdateand time. Usethe first methodifyou find the error immediatelyand the timing is the same.The reasonnot to remove, erase, use correctionfluid on the error is to maintain credibiliry lf you alterthe or note in an unacceptable then the thought process-including the mistake-can- way, not be followed,Youmust neverbackdate/postdatenote.Youcannotrewritehistory a by trying to makeit look likc a note written todaywasreallywritten yesterday. Always usethe current dateand time for what you write in the chart. Informed Mandatory Sututring Consent for 59. (c) Wait for the consent of at least one parent. Proceduresthat are emergenciesdo not need any infomed consent from a parent in order to begin the treatment. We do not want a childs health to suffer just because no one is present to give consent at that moment an emergency occured. Neighbors cannot give consent. Only parents or legal guardians can give consent for procedures for minorsj however you do not need both parents to sign consent. You would only seek a court-appointed guardian if there were no identifiable parents. This Patient cannot give consent becausc he is a minor, which in rnost states is defined as being under age 18. Ily definition, minors are considered incomPetent except on areasof oral contraceptives,STDs, prenatal care,and rehabilitation or detoxification for sub- stance abuse, ) METTCAL[APLAN
    • Answers Explanations and STD a Minor in 60. (a) Ceftriaxone/azithromycinnowin a singledose. Parental consentis not requiredto treat a minor for illnesses suchassexuallytrans_ mitted diseases (STDs),prenatal care,contraception, HIV or substanceabuse.A minor is definedasa personunder the ageof 1g.parentalconsentis requiredfor all fbrms of treatmentother than th j.::ffi thiscase,arthoughcervicitisis";::",1 :11H|.T,::-::"";T:T:|J.:l eventrying to noti4, the parents. want We to lower the barriersto the careof these diseases. other words,we preventmore STDs In and unwantedpregnancies grant_ by ing a minor full access this form of care. to The ..q.,ir"_"rr, for"parentalconsent makesthe minor lesslikely to come in for care.LessSTD treatmentmeansmore transmission. Lesscontraceptive management meansmore unwantedpregnancies. Thereis no consensus nationallyon parentalnotification for aborhon. some states requireit and somedont.Urgent Blood TransfusiontheChild a Jehovah,s in of Witness61. (c) Give blood to the child but not to the father Any competentadult may refusetherapyof any kind, including the lifesavingones. The sameis not true for a minor. Minors cannot refuseurgent lifesavingtherapy. That is why the father may refi:sefor himself, but not for the child. This question doesnot address whether the child wants the blood or not. The child,swishesin a matterof urgent,lifesaving therapyarenot relevant the properethicaltreatment to of the child. A 12-year_old child, by definition, is treatedas iou would an incompetent adult That is,you are happyif they areagreeable, but you will still do what you think is right anpvay.In a legalsense, minor child a is like your dog. you are happy if he doesnt bark during the treatment, you will not but change your methodof treatment based his opinion.you do not needa court on order in this case because direction the is clearand well worked out. you save life the of the child; don,t wait. rA PlAll MEOtCAT
    • Answers explanations t6l and I STD a Minor in 60, (a) Ceftriaxone/azithromycin now in a single dose.rgle Iine Parental consent is not required to treat a minor for illnessessuch as sexually trans-als or to mitted diseases(STDs), prenatal care, contraception, HIV, or substance abuse. Ard if you minor is defined as a person under the age of 18. Parental consent is required for allremove, forms of treatment other than these with the exception of emergency treatment. Inalter the this case,although cervicitis is not an emergency,she can receive treatment without.e--can- even trying to notiry the parents. We want to lower the barriers to the care of these: history diseases. other words, we prevent more STI)s and unwanted pregnanciesby grant- ln: Always ing a minor full accessto this form of care. The requirement for parental consent makes the minor less likely to come in for care. Less STD treatment means more transmission. Less contraceptive management means more unwanted pregnancies. There is no consensusnationally on parental notification for abortion. Some states require it and some dont. Bood Urgent TranslusiontheChild a )ehovahs in of NitnessItent 11-l 61. (c) Give blood to the child but not to the father)ecauseighbors:edures Any competentadult may refusetherapyof any kind, including the lifesavingones.ld only The sameis not true for a minor. Minors cannot refuseurgent lifesavingtherapy.patient That is why the father may refusefor himseli but not for the child. This questions being doesnot address whetherthe child wants the blood or not. The childswishesin areasof matter of urgent,lifesaving therapyarenot relevant the properethicaltreatmentof torr sub- the child. A 12-year-old child, by definition, is treatedasyou would an incompetent adult.That is, you arehappyif they areagreeable, you will still do what you think but is right an1way. a legalsense, minor child is like your dog.You are happy if he In a doesnt bark during the treatment,but you will not change your method oftreatment based his opinion.You do not needa court order in this case on because direction the is clearand well worked out. You save life of the child; dont wait. the I(API.AN) MEDICAL
    • r52 nn.*urs und Explanations I Thereis no needfor a psychiatric evaluationbecause fatherwasclearlycompetent the and it doesntmatter what the child says. Intravenous iron will not work fastenough. The cases must be clear and unequivocal. Occasionally, 17 year_oldchild with a leukemiathat will likely be fatal anl.way allowedto is refusea transfusionor chemo- therapy. This sort of case far,far different.A 17_year_old is is closeto a legaladult, the disease not sudden, is and the treatmentwill likely not change outcome. The bottom line is that parentscannotrefuselifesaving therapytbr a child. Prenatal in a Minor Care 62. (a) "I will give you the care you need and keep it conffdential.,, Prenatal care is one of the exceptions to the general rule of parental notification and consent for the treatmcnt of minors. you do not have to inform either the parents of the patient or the father of the baby. This conficlentiality also extends to protecting the patielrt even if the parents were to ask. The patient has a right to privacy for her prenatal care. Emergency Treatment a Minor of 63. (d) Perform the appendectomy. The patier.rtdescribed in this casehas acute appendicitis and needs an urgent proce_ dure, Allltappendectom). must be perfor-.d u, ,oon u, possible rn acute appendicitis. You cannot allow harm to thc patient because you are momentarily unable to contact the parents. Intravenous antibiotics alone are insufficient to treat acute appendicitis. Agamr you cannot harm the child becausethe parents are not able to be locatedat this moment. Only a parent or legal guardian can consent to a proceclureon a patient. Neighbors, aunt and unclcs, grandparents, and babysitters aurrnu, gru. consentfor a child that is not their own. Minor children cannot consent to an appendectomy.!!l!!p ueorcar-
    • Answers Explanations t 6 5 and ]cmpetentt enough. Emancipated Minorrild withr chemo- 64, (d) "I will give you the isotretinoin as requested,,,rdult,the This patient, although a minol is a special exemption known as an..emancipated minor." This category appries to persons who are under the age of rg but who are independent of their parents. An emancipated minor is one rJho rs either self-sup_ portrng, married, in the military, or who has children that they are supporting through their own independent means such as their own job. A large portion of the definition of an emancipated minor has to do with the patient being self-supporting and living independently. There is no definite age .utoff fo, _h.r., someone may be considered an emancipated minor The age varies by state but is usually at either age l5 or 16. An emancipated minor is capable of consenting to any medical procedure.on and All minors can consent to prenatal, contraception, HIV:STD, and substance abuseents of care.An emancipated minor is one that can consent to any form oi care or proceduretecting as if he or shewas an adult..or her 65. (a) Provide the pain medications as appropriate but not the means to end his life Physician-assisted suicide is always considered unacceptable. The patient is not acutely depressedso antidepressantsare unnecessary.This form of reasoning does not need an inpatjent psychiatric evaluation. Try never to refer patients on board questions for anything. There is no ,,specialist,, that can certii/ a patient as a goodIOCe- candidatefor assisted suicide.There is an cthical imperativefor the physician to pre_icitis. serve life. Consequently there are no acceptable circumstancesin which a patient canntact act as an assistant in suicide- There is significant concern that putting the power tocitis. end lit-ein the hands of the physician is an uncontrollable power that woulcl easily berd at subject to abuse and indiscrirrent. persons ort,"at,.,,..,tnil:"rT,::::*;t:";"1,:,il:1,H.-J"irff[:::: in,.,..dbra suicide demand. on Rementber theboards not testing that are yourpersonal opinions about what you think ought to be acceptable. fhey are testlig tne bestconsensusof the law and practiceguidelines. 5{!!P ueorcnr
    • nnr*"r, undExplanations I Youmay personally agreewith physician-assistedsuicideor disagree firsttrimes_ that ter abortionsare acceptable. do not choose Just theseasthe answers the test to ques- tions. Forty nine or 50 stateshavelawsthat make phvsician-assisted suicide illegal. The experimentin the statcof Oregonwherephysician-assisted suicideis legal does not hold true for any other placein the United States.Hence,on a nationalexami- nation, you must go wjth what would be true in the majority of cases. addition, In despitewhatever lawsthereare currently,all physicianprofessionalgroupsconsider assistedsuicideunethical. Lethal Injection Always Unacceptable 66. (e) You tell hirn tirat under no circumstances you participate in euthanasia. can Under no circumstances it ethicalfor a physiciar to participatein euthanasia. is The difference betweeneuthanasia and physician-assisted suicideis that euthanasia a is meansof death administered the patient by another.physicians not ethically to are permittedto destroylife. This is true evenif thereis a law authorizingit. The higher ethicalduty of the physician preserve supersedes law.Euthanasia unac- to life state is ceptable evenif a competent patientrequests physician-assistcd it. suicideis clifferent from euthanasia that the physicianprovidcs the patient I,ith the meansto end in their own lives.In physician-assisted suicide,the patient administersthe means of ending their life. In euthanasia, physicianadministers meansof death.Both the the of theseare unacceptable. This is markedlydifferent from giving pain medications or other therapythat inadvertently endsthe patient,s life. If the only way to controt a persons pain and sufferingcompletely to givemedications is that inadvertently oI unintentionallyshortenthe patients this is acceptable. is sor:netimes life, This referred to asterminal sedation. The primary issue one ofintent. In euthanasia, primary is the intent is to end life. In terminal sedation, primary intent is to relievesuffering. the!APLAN) MEDtCAT
    • Answers exptanations r6t and Imes- Substance Abusing-Residentues-egal.loes 67. (e) Report him to the chairpersonor program director of his department.mt-ion, The reporting of a potentially impaired physicianis an ethicalder duty that cannot be bypassed.Although you havean absolute duty to protect the patientsunder his care, you should first go to the personin the tableof organization to whom the resident reports.Tellingyour deanof studentsis inappropriate because deanof students the doesnot supervise resident. the Tellingthe deanof students would be appropriateif the rmpairedpersonwasanotberstudent.For physicians_in_training the first stop is their program director or departmentchair.For attendingphysicians it can be the departmentchairor the medicaldirectorofthe hospital.For attendingphysicians not reportrngor working for local authorities, makethe report at the higherlevelof thele statelicensingboard or the mechanisms placefor impaired in physicians. is fruit_ Ita lessto go straightto the impairedperson.It is like reporting child abuse. Ifthe personly who is impaired admits it to you, you must still report centrally to makesureof the:r follow-up and resolution.If they denythe problemyou must still do the same.t If you noticc the impairment and do not report it, then you becomeliable for anyI harm that might happento a patient.t Dementia Attending in 68. (d) Report him to the statelicensins board. Reportsof physicianimpairment should go first to the local supervisory personnel. If this is eitherunsuccessful not applicable or then report it to a higher levelsuchas a statelicensingboard.Tcllingyour own division headis inapproprrate becausethat personsupervrses not the potentiallyimpairedphysician. you, !(d p LAr) MEDTCAL
    • t65 onr*"r, andExplanations I Behavior Abnormalities Affecting Not Patient Care 69. (d) Do nothing. Your responsibilityfor reporting physician impairment restsonly with reporting abnormalities that may affectpatientcare.If thereareno abnormalities her ability in to makemedicaldecisions and supervisejunior houseofficersthen to report details of a physicianspersonallife would only be potential slander.Lossof reputationis a seriousissuefor a physician. Other physicians patientswill not want to usea phy and sicianwhom they think is of low moral character evenif her rnedicalcareis fine.You do not haveto agree with, condone, approve or ofthe behavioryou witness. However, therehasto be evidence medicalimpropriety in order for it to be worthy of being of reported.The Committeeon Physician Impairment helpsphysicians with substance problem.This is beforethey drive or mar.ragepatientswhile intoxicated. a ph,vsician If is impairedand takescareof patientswhile intoxicated, then the physician shouldbe reportedto the local chief of service Departmentof Health. or Right to Accept Not Patients 70. (a) It is both legal and ethical. Thereis no legalor ethicalmandateto carefor anypatientwho comes see to you. The physician/patient relationship must be enteredinto voluntarily on both parts.Hence, if the physicians practiceis full, thereis no obligationto acceptnew patients. would It be unethicalifthe physician wereto accept somepatientsbased arbitrary personal on preferences and reject others for the sane reason,although this is not illegal. For example, would be unethicalto accept rejectpatientssirnplyon the basisof race, it or gender, religion unlessit had to do with a specificareaof expertise or such asbeing a gynecologist rejectingmale patients. Although it is courteousto nake a referralto anothcr physicianthere is no obligationto arrangefor carefrom anothcr physician. This is entirelydifferentfrom a case which a patientwasalreadyunder the careof in a physician. this case, physician In a must arrange appropriatetransferto another for physicians careashe endsthe relationship. Oncehavingaccepted responsibility a for patientthereis far less freedon on the part ofthe physician breakthat relationship. to To cease from providing careto an ill patient rvithout appropriatetransferof carcis both an unethicaland illegalaction characterized patient abandonment. as ) MEDTcALfA?LAN
    • Answers explanations 167 and IDuty thePatient, Orders Valid, to Gag Not HMO71. (a) Fully inform the patient about the risks and benefitsof bone marrow trans- plantation, Your primary duty is always the patient.One of the unique elements to of the physi_ cian/patientrelationship that its ethicalboundaries is transcend ordinary rulesof the workplaceand institutional rules.As such,you cannot withhord information from a patient if that information may lead to benefit for the patient.ln order "informed to make an consent," patient must be fully informed.The patrentcannot be fully the informed ifhe hasnot heardofthe options.It is not appropriate for lou to backaway from educating your patientby transferringcareunless is for an areaoutsidevour it expertise. Thereis no needto encourage litigation under any circumstances. It is not ethicalto tell a patient about a potential therapyonly if he asks about it. It is our duty to inform him. "Gag orders,preventingthe educationof patients about treatmentoptions are alwayswrong. The patientscannot hayeautonomy over the choiceof treatmentof their body if they arenot aware the options.Beneficence of to the patientalways outweighsinstitutional directives.
    • 16l I Ansuersand Explanations Physicial Refusing Treat Patients a Procedure to HIV for 72. (e) Referthe patient to another cardiothoracicsurgeon. The patienthasa very clearneedfor coronarybypass surgery with three-vesseldisease and left ventricular firnction. The bottom line point to this questionis aboutwhat you do for patientswho needa particularprocedurewhen the physicianis refusing to do the right thing. Ar.rswers c, and d involve switchingthe patient to another b, form of therapy,which is inadequate, comparedwith surgery. This is unacceptable. You cannot forcethe surgeonto operateagainst will. Although it is unethical his for a physician refusecareon the basis race,gender, to of ethnic origin, and diseases such asHI4 you cannotlegallyforcea physician takecareofsomeonethey do not want to to. The physician/patient relationshipthat must be enteredinto voluntarily on both parts;hence,it is unethicalto refuseto treat a patient solelybasedon you dislike or discomfort with HlV-positive persons, it is not illegal.The chief of service but may havethe power to removeor suspendhospital privilegesand to fire someone for unethicalbehavior, the chief of service but doesnot havethe ability to forcea physi- cian to perform a procedure. When a patientneeds procedurethat your consultant a will not do, then the right action is to find the patient a doctor who will do the right thing. Although this casewas framed in terms of HIV, the answerof referringto anotherphysicianwould be the sameno matter what reasonthe physicianhad for refusingto do the procedure. Sexual Relations between Physician Patient and 73. (d) "I cannot dateyou and be your doctor-maybe in the future we can date,after you get another doctor." Sexual relationsbetween physicianand a currentpatient areneverethicallyaccept, a able.At the very least,the physician/patient relationship must stop. The patient must transferher care to anotherphysician.This is to avoid an abuseof power in the relationshipand to keepclearboundaries. Relationships betweena psychiatrist and a patientaregenerally neveracceptable evenafterthe physician/patient relation- ship hasstopped. doesnot matter who initiatesthe relationship. It Thereis no ethics board in placeto act asa dating service physicians. for I(APTAN) MEDICALE!-
    • Answers Explanations 1 6 9 and ] 74 (c) Herpes simplex The primary purpose of reportir.rgdiseases the Department of Health is to be able to to interrupt a cycle of transmission. hr addition, we wish to know the epidemiol ogy of diseases order to assess in resource allocation and the successof interventionlisease programs. Finally, for infectious diseaseswe report seltsitivity patterns in order tot what guide appropriate ernpiric therapy in the future. For instance,we track the sensitivityfusing of gonorrhea resistanceto quinolones in order to assess whether we can continue torother use quinolones en.rpirically to treat patients into the future. We report salmonella sortable. that we can identify and eliminate the source of the infection such as a resta[rant:al for closed or contaminated food discarded. We report tuberculosis so that the contacts; such can be PPD skin-testedand the sourcepatient isolateduntil noninfectious.Measleswant notification is important so that we can assess who needsvaccincs in order to Drevent both further spread. Herpes does not need any ofthese intervcntions. Herpes spreadsonlyke or through intimate contact. It cannot spread through contaminated food ar.rd water like maF salmonella. Herpes cannot be effectively eraclicatedfrom the entire bod1..In betweene for outbreaks, herpes is dormant in the body ancl the outbreaks only shorten rvith abor-hysi- tive therapy such as acyclovir. People ofien harbor asymptomatic gonorrhea, whichitant-ight can be detected and eradicated. There is no isolation for hcrpes and there is n. effcc tive vaccine.8toI for Tuberculosis andIncarceration lsolation 75. (d) Remove the patient from his job as a bus driver and incarcerate him in a hos- pital to take medications.ter lhe patients right to privacy and autonomy ends when the public,s right to safcty is at risk. The patient does not have the right to be atJarge.with persistently posi_ trve sputum stains for acid fast bacilli. you do not have the right to forcc feed the medications through a nasogastric tube, but you do have the right to rcmove thent patient from hisjob and put him in a hospitalwhere he cannot infect othersuntil hisin sputum is free of acid fast bacilli. This is not just bccausehc has a job as a bus driver,ist rvhich has a lot of contactwith the public. TB incarcerationis not the samc as beingt- arrested. is part of the Department of Health, not the crimial justice systenr. It yocs go to a hospital where the only rvay to get out is to take the medications antl have clean sputum. You do r.rotgo to a jail. MDICAL
    • onr*"r, andExplanations I Partner Notification Syphilis for 76, (d) The Department of Health will send a letter or call the contacts and let them know they have a serious health issue. They will test and treat the partners but will not reveal his name. The need to keep the population free from diseaselimits the patients ri€lht to privacy. You have a duty to the other contacts he may have infected. However, in order to respect the patients privacy, the Department of Health has never revealed the name of the source patient, no matter how rnr.rchthey are asked. They make the original notification by phone or mail but only reveal the specific diseasein person. If the patient wont reveal the names of his contacts, you have no means to force him to do so. You cannot incarcerate or arrest a patient becausehe will not reveal the namcsof his contacts. Physician 0bjecting Performing to Abortions 77. (e) Refer the patient for the abortion, Patients have the legal right to safe and effective abortions. This right is universal within the first trimester and no hrrther evaluation or rsaiting period is required. The right to abortion after the first trimester (12 weeks) is less cleat and extenuating cir cumstancessuch as a risk to the life ofthe mother from the pregnancy or whether the conceptiolr is a product of sexual assault are also considered. The criteria for ready access abortion becomeslessclear after the first trimester as the fetus progresses to in i L .d e v e l o p m e nlto w a r db c c o m i n ga v i a h l ei n l a n t .I(A P LA I.I M E D I C A I
    • Answers Explanations l 7 l and I Although you may object to abortion, the patient still has a legal right to obtain one. You are not under an obligation to perform the abortion yourself. your objection can cover your refusal to do the procedure personally but you do not have the right to refuse to refer her to the care she neeclsas your patient. Although a physician has the right to refuse to enter into the physician/patient relationship before it has begun, once you have entered into the relationship you are obligated to provide the care the patient needs. Hence, you cannot just terminate the physician/patient relationship at the moment the patient needs a form of care you disagree with. you cannot ask for a four-week waiting period especially when the patient presents at eight weeks of pregnancy and this wait will bring her past the first trimester Ifthe patient has clear decision_making capacity,there is no need to obtain a psycho l o g i c a le v a l u a l i o n .Parental NotificationAbortion for78. (e) Strongly encourage to discussthe issuewith her parents. her Although competent adurtshavean unfetterecr legalright to abortion within the first trimester,this right is not universalfor a minor. A minor is generally defined as a personbelow the ageof 18.The necessity parentalconsentor of at leastnotification is a mired issueacross states nationally. Somestates requireparentalnotification and somestates not. Hence, a board examination, do as which is givennationally,thereis no singleclearanswerUnlike the bar examinationfor lawyers, physicians takevirtu_ ally no statespecificexamination.4ren you passUSMLE or the Board of Internal Medicine,it is valid in everystate. The only thing that is alwaysclearis that we should stronglyencourage the patient herselfto havethe discussion with her parents.Many of the boardswill want an answerindicatingdiscussion beforeaction so you will be trainedinto trying to build consensus. Evcnif you are within your rights to walk up to a brain_dead patientand removethe ventilatorwithout consentof the family,the boardswiI alwavswant vou to answer"cliscusswith the famiiy,first if that is one of the options. I(APLAN MEDICAL
    • 172 nnr*"r, undExplanations I Sterilization-Husband Disagrees 79. (a) Referfor the tubal ligation asrequested the wife. by Although it is preferable haveconsensus, to there is absolutely spousalconsent no requiredfor sterilization procedures eitherpartner.The fallopiantubesarelocated of within the body of the woman; henceit is a matter of her right to autonomyover her own body that shehasthe right to the sterilizationprocedureif that is what she desires.The number of children that a patient has bearsno impact on the accept- ability of the sterilizationprocedure.If this were true, it would be equivalent to legallymandatingthat everywoman must reproduce. other words,"We will tie In your tubes,only aslong asyou haveput them to good use.First fulfill your biological potential,and then we will sterilizeyou." This is unacceptable reasoning. woman A has a right to choosewhat to do with her own body. If a man buys a new car but chooses neverto drive it, that is his right. If he chooses throw out the car,that is to his right. Youcannotmandatethat he drivethe carbecause car is new.Youcannot the tell him he must keepthe car because "you might change your mind later,and want to go for a drive." As long asthereis no evidence ofpsychiatricdisturbance incapacity understand or to her medicalissues, psychological a evaluation not necessary. is Paternal Consent Abortion Necessarv for Not 80. (e) You say you have an absolute duty to the mother to honor her wishes no matter what his personal feelings are. A woman has a right to choose what to do with her own body. Undelivered babies or fetusesdo not have legal standing as an independent person to bring a suit to prevent its termination. Until the moment of delivery, the embryo is considered an extension of the womans body. She does not need consent from the father of the child or any member of the family. Her ability to consent to the termination is equal to her con- s c n t f o r a b r e . r " b i o p s yo r a l e ga m p u t a t i o n , t!?r-,yD reorca.
    • Answers explanations t7t and I Although a fetusmay geneticay contain half the geneticerements both parents, of it is the femalethat must go through the delivern i"".., ,fr. *o_an has ownership, a,,right of over any undeliveredchild because inhabl,, i". nra" itThird Trimester Abortion8I. (d) Legallyyou can only do it if her life is at risk. Abortion during the third trimester is the nost controversial areaof reproductive rights. There is no automati( Duringthird the trimeste.,tierriil,tsl:;::J:1ffi,fil.TiJi:,",,r;, tational age (six months) can potentially ;::i:1:::: survive intact with a deliveryalthough would havea greaterrisk of complications it ,..onau.y to p.._"rr.u, The Supreme Court has consistently exceptions Ieft for the possibilityof uior,_n ln later of pregnancyif the life of the mother stages is at risk. you ."nrroa"rH.ully freely potentially viable fetus unlessthere abort a is a very significan;";;;r",r", suchasrisk to the mother or a fetus crrcumstance so d.""1;p;.;ll; "0""r_, ,n", fetal demise is certain. As for a court ordet the court can caryp orroression"i,;;;;;.;r-,#r.i::#li:l?11*1.,f.T,#::;T,;"i,1: it legal to perform euthanasia on unethi do even " .;;f :.d:;;l : :H,,r*:tr;.1,1"1 car so _,,h to jl jj.lrl: *,1 ont:t:tanparticipating an execulion. in lfltllt Thecondemnej is undera court order to die and it is legal. However, it is unethical for a physician to physician, in an execution. partrcipate, as a I(API.AN) MEDICAI
    • 174 Answersand Explanations VictimObjects Reporting to 82. (b) You will report the injury only with his consent. The rules on the reporting of domestic violence are much less strict than those on reporting child abuse are. This is becausea competent adult has the voluntary choice of reporting the injury themselvesin the vast majority of cases. additiolt, you can- In not violate the patients right to autonomy by specifically doing sonething that has expressively been refused. For children there is mandatory reporting because chil- dren do not have the abilily to defend themselves.Minors, by definition, are deemed incompetent except for a few exceptions like sexually transmitted diseases(STDs). Children are not, therefore, considered to have autonomy that can be violated. This patient is being physically abused. As an adult Patient with the capacity to understand his medical problems, he has the right to refuse care and protection from reporting the injury if that is what he wants. Attempted for Procedure Suicide-Need Emergency 83. (b) Perform the surgery. This patientsinjury is, in a sense, sameasa Purposeful the drug overdose, jumping offa bridge,or trying to shoothimself.In this case, caris a largegun.Althoughan the adult patient with the capacityto understand medicalcarecan refusetreatnent his this is not the sameas allowingPatientsto kill themselves. Peopleactivelytrying to kill themselves by definition, not considered are, competent.The right to autonoml endsjust short of condoningactivesuicide. is assumed, this case, lt in that the suicide attemptwasperformedwhileunderthe intolerable emotionalburdenofrecentlyhav- ing found he had cancer. assumption madethat when acutelife stressors a An is lead patient to attempt suicidethat they are temPorarilyincompetentand Psychotherapy or psychopharmacology help him. lf you reviewthe questionyou will seethat may the case neverstatedthat the cancer wasincurable,progressive, evenfatal. orl!!!!!) ueotcrt-
    • Answersand Explanations You cannot let a patient kill himself rvhile under acute psychological distress such as depression.You cannot wait for a court order tbr energency surgerv in a henorrhag- ing patient. The familys consent is not necessary. is nice to have, but does not alter It the reasoning stated above. If I was trying to commit suicide, it would rot matter if my family comes by and says,"Its okay, lct him die." You still have to intervene to prevent the active suicide.NotEthicalto ParticipatePhysical in Torture84. (e) You cannot participate in the purposeful torture of a prisoner. Physicians are never ethically allowed to participate in the torture of anyone. This is true even if there is a court order directing you to do so. It would not be ethical to assault someone or murder someone even if there is a court order. The physicians duty to the patient transcends duty to ordinary institutional structure. This is true even if the prisoner has been convicted of the crime. We cannot have our duty to patients flexible based on urhether they have been accused,arrested,charged,on trial, or convicted. It is always unethical to participate in the purposcful injury whether physical or psychological of a prisoner. There is no releaseyou can obtain from a superior or an institution that makes unethical behavior ethical. The physician cannot later justifu participation in torturc under the rubric, "I was only follorving orders."Duty Report to Prisoners to Inlury85. (a) Report the injuries assignsofpossible torture. You havea duty to protect the rvelfare all patientsunder your care.This includes of prisoners.Failing to report the injury makesyou an acconplice or in some sense participatoryto the injury because you did nothing to preventthe next injury. This duty transcends your presence eitherin or out ofthe military. It would be the sameas finding evidence child abuse. area mandated of You reporter.Youareliableif you fail to report an injury to a child that you suspect beingabuse. thereis a subsequent of If injury to the child, thosewho fail to report the first injury are liable for helping to cause subsequent the injury by failing to report the first.The sameis true for evidence of torture to prisoners. havean ethicalduty to report evenifthe injury turns out You not to havebeensecondary rorture. to
    • Answersand Explanations Hence, in terms of torture and child abuse,the physiciansethicalduty is to report possible episodes.Thereis no obligationto only reportepisodes are that orovento be episodes abuse torture. of or Futile Treatment 86. (e) Recornmend that dialysisnot be performed You are not required to administer any form of therapy that you feelwouldbe You do not havcto perform the dialysis it will not leadto anysignificant if the patient.This is true evenif the family is requesting youperform that the Although, in practice,it is extremelydifficult not to honor a familys wishesto form any therapy, there is no legal or ethical requirement to do so.In this cas€, the pcrsistent vegetative state, there is multiorgan failure associated with no chance of survival. Hence, dialysis woulcl not be prolonging this patients would only be prolongingthe dying process. this case, In doingdialysis would kidneytransplantation. callybe the sane asthe family requesting Adult withCapacity Withdrawal Ventilator Requesting of 87. (a) Removethe ventilator as sherequests. Any adult patient with the capacity to understand her mcdical problems has right to do what shewishesvrith her own body.Althoughtheren.ray an be distinction on the part of the caregiversand familv betweenrvithholdingofcare withdrawal of care,there is no ethical or legal distincrion.This prtient shewill die and it is her legalright to havethe ventilatorremoved she if wishes. court order is not necessary because type of case beenlegally this has worked out the past in other cases.The consentof the family and the prory arenot becausethe patient is alert and able to communicate her own wishes. The careprory only becomes responsible decisionmakingwhenthepatient for loses capacityto speakfor herself. You should not evenconsultthe proxyandthe when the patient is alert unlessit is at the requestof the patient.Sedation is propriate. We cannot just sedatepeople when we do not like their decisions. You patient. not havethe right to force any form of therapyon a competent This be diff-erent only if thc personwereacutelysuicidal.!!l!!p rueorcar
    • Answers Explanations and 177 Iect and Adult Capacity with Refusing Lifesaving Chemotherapyalwavs 88. (d) Honor the patientswishes The patient is an adult who hasthe capacityto understandthe risks and benefitsof therapy.Consequently has the right to refuseor accepttherapy she or alrl part of the therapythat shesees psychiatricevaluation fit. would only be necessary there if wereevidence depression of and possiblesuicidalideation.psychiatryevaluationisfutile. also usefulsometimes the patientscapacityto understandher medical if conditionfit for is unclear.If the patient clearlyunderstands issues is crearly her or unableto under-alysis. stand then a psychiatricevaluationis unnecessary. court has no The standins to) Per appoint a guardianto overrulean adult with the capacityto understand her issues.:sides Radiotherapy not adequate is therapyfor stage lymphoma.In addition,you can_ IIIrtially not substitute anothertherapywithout the patient,s consent.Risk management an isife.;r institutior.ral agentwhoserole is to minimize the risk of litigation for the institution.ethi- They would not be necessary here as long as you haveadequately documentedthe patientsmental capacityand the refusalof therapy. Depressed Patient Refusing Therapy 89. (a) Psychiatricevaluation the This patient is severely depressedwith vegetative signsof depression suchas weightrnal change,anhedonia,and sleep disturbance.It is important to evaluate and treatand depression, which n.raybe a temporary condition, prior to withholding therapynds without which the patient will likely die. In atldition, the shortness ot breath mav;.A indicatehypoxia,which may be interferingwith the patient,s capacity understand tolrn their medicalcondition.yorr do not want to sedate patient who needs a to speaktoary a psychiatrist. addition, simply sedating patientwho is refusingtherapy In a may beth- construedassimply making him unableto refusetherapy. The family,sopinion doeslhe not change primary duty to the patientto assure the that the reason the refusalof forilv potentially lifesavingtherapy is not simply untreateddepression. Ethics committeeLP- evaluationis most usefulwhena patientdoesnot havethe capacity understand to hisdo medicalcondition and the family membersare in disagreement. DNR A order doesLld not absolve you of the needto treat the patient,s other conditions. ! ( A p t A N) M a D r c A r
    • 178 nns*ersand Explanations | Refusal Atificial of Nutrition; Disagreement theProxy with P 90. (d) Do not placeany form of tube for artificial nutrition or hydration. Your primary duty is to the patient rvho specifically told you not to place any of tube for artificial nutrition. Although the proxy has the abilitv to ovettr{e in the famlly in tems of decistonmaking,shecannotoverrulethe patien.Is$. the paper documentationdid not specifically mention J-tube,the patientgave a lou clear oral adrzancedirectire and that tr the abnJute ruJe )ou mut stitk bf tlno nal. ter what cout or theclhjcs a connjtlcend// tal Hkough X j,f loal ighl /0xrttff to accept patrent, a you cannotethicallytransferthe careof a patientto someone who will go against patientswishes the just because feeluncomfortable. you Oral advance directives harderto provebut they arestill valid.This is true evenwhenthepatient are loses capacity makedecisions. the to Ifwe did not honor a patientswishesafterlosing competence, onewould be ableto makea lastwill and testament. persons no A willis, in essence,proxy directingthe financialand property wishes a ofthe patient.Death is the ultimatewayoflosing capacity makedecisions. person,s to A advance directive a is tbrm of will directingwhat he wishesdonewith the most personal propertya patient can have:his own life and bodv. MEDICAL
    • Answers explanations 179 and I Proxy Ultimate as Decision Maker 91. (a) Honor the prory and do not intutratem Thehealth careprorT is the ultimateciecision makerin all mattersofhealth care. Thele prorTis the designee the patient to by deternine and implementthe patient,sh in the eventthat a patient becomes wishes unableto make decisions. doesnot lta every matter if singlepersonin the univ accurateryknowsthe*,,h.,,;T;"T;,:"::ffi :#:T:Jjlj5:Xil:.i:.jLT trmebecause the prory is the persondesignated byihe patientto makejudgmentsfor thepatientt care. The prory is like the .r..uto. ofu will. Atit: ol,gi ..,,n."nru, ugr".- ment with the family is not necessary sometimes questionscontain an answer the choicethat says"encouragediscussions,, amongst the family and proxy or,,seek agreement."When that answer better consensus ro seek "J;J:"H::1,il,ili:,liH:T,.ili!1, i*,*LiJi evaluation not necessary is ifeither there is a pro-xy who t"o_, ,i. a"nni,. wishesof the patient or, when there is no pror:7, when thereis agreement amongstthe family, Neurology consultationis not necessary the same for reason. It is like voting.Ifyou havea letter from a personwith their prorl, ballot for an eiec_ tion, it doesnot matter what otherpeople think, you castth" ]rot. th. pnt,.rrt wanted. Not the vote that his mother thinks is best for him. Wh.r, u purr..r, Oo.u_ents clear wishes, proxy is like a mail carrier delivering the the .e.or.l of th. patientt plan for himself. I(API-AN MTDICAL
    • l80 onr*urc andExplanations ] NoProxy, Disagreement amongst Family 92. (a) Encouragediscussionamongstthe family. When there is no clearevidence a patientswishesfor himsell we must seek of th€ bestevidence can find ofwhat judgmentthe patientwould makefor himselfwere we he awakeand communicative. practicethis is not a problem aslong asthe famil,v ln membersall agree. addition, when there is disagreement, In particularlywhenthe family membersare considered haveequal"weight" then we must first try to seek to consensus encouraging by discussion.Only if this is not fruitful should an outside third party suchasthe courtsbe sought.All necessary therapyshouldcontinuewhile the evidence the patients of wishesis collected. NoProxy, Disagreement amongst Family, Consensus No 93. (e) Pursue an ethics committee evaluation. When there is no clear evidence of the patients wishes, then you must seek the best "substituted judgment." The physician mLrst seek out what the patient would hare wished for herself and you "substitute" the judgment of the caregiversor family for what the patient would have wanted for herself had she been awake. When a reach- able consensusby discussion is not possible then an evaluation by the ethics com mittee is appropriate to seek consensus.This is the weakest form of decision making because it carries the least precision. If a clear agreement still is unreachable then referral to the courts nay be necessaryto achieve clarity and objectively weight the evidence that the different family members bring forth. This is what happened in the Terry Schiavo casein which the patients husband was judged by the courts asbrining the best evidence that he and others had the most accurate knowledee of what the patient wanted for herself. If there is no family available then the ethics committee and physicians would make decisions based on the judgment of what would be in the best interests of the Parrent.t(Aat-AN MEDICAL
    • Answers explanations t 8 l and I Terminal Palliative "Double-Effect, Sedation, Care, 94. (b) It is acceptable long as the patient understandsthe risks. aseek the Your primary duty to a patient with a terminal condition and intractablepain isllf were to relievesuffering.lt is unacceptable unethicarto leavehim to suffer.As and rons family ashe understands that the pain medicationsmay havethe ,double_eftect.. both ofIen the relievinghis pain and possible shorteninghis life and he agrees then it is acceptable.to seek It is the sameasperforming a riskTsurgicalprocedure which the patientconsents inrutside to a lifesavingsurgeryknowing there is a risk of possibledeath.This is the same as: while cardiacbypass grafting in which the surgerywill prolong life if successful, has but a risk of deathfrom the procedure. This is the sameas a bone marrow transplanta_ tion ir.rwhich the patient hasa very significantrisk of death,but must do it in order to preventdeath from leukemia. DNR order alone is not a way of avoicling A risk. Physician-assisted suicideis illegalin virtualy all jurisdictions. you cannotpurposely e n dt h ep a t i e ns l i f e . t The primary issueis the intent of the physician givilrgthe pain nedications.If the in prirnary aim is to relievesufferingand there is an inadvertentshorteningof life: best as an adverse effect,then it is acceptable. the primary intent is to end his Iife with the If have medications then it is unacceptable.y forach-:om- The direct statementof the rJ-S.supremecourt is "the statepermits physiciansto administermedicationto patientsin terminal conditionswherethe primary intentking is to relicvepain,een whenthe medicationis so powerfulasto hastendeathand theihen patientchooses receive with that understandins., to it the thelrng theuldlhe I ( A . P L A N M E DI C A L
    • r82 nnr*"r, undExplanations I Validity theLiving of Will 95, (c) Remove the tube and the ventilator All adults of sound mind have the right to do what they want with their own bodv. The patient has left a clear advance directive of what she wanted clearly stating she does not want ventilator managemcnt if there is no hope of recovery. It does not matter what the risk manager, the rest of the family, or even the husband wants. All that matters is what the patient wanted. To treat a patient for anything without her consent is legally equivalent to assault and battery. In this case,ifyou leave the venti- "mugging" lator in place you are the patient. This caseis extremely clear becausethe advance directive is in writing and specifies the precise medical intervention that is being refused by name. A court order is unnecessarybecausethe courts do not have the authority to treat a patient against her will. The vast ma.jority of stateshave actual statutes saying that a living will is a valid form of advancedirective that absolutely must be honored. All 50 stateshave laws declaring the validity of advance directives. ln the three statesthat do not have specific living will statues,there is caselaw and legal precedent showing that the living will must be honored. lt is clearer if we take the word "living" out of the reasoning and view the patients body as a house in which the husband brings in a will directing what she wants done with her house. It the document is valid then you must honor it no matter what the rest of the family or the courts say.!!!!p rurorcrr
    • Answers Explanations and t85 I NoCapacity. Proxy. Limitation What No No on Can Withdrawn Be by FamilyConsensus in 96. (e) Norhing body.rgshe Thereis no limitation on what familys not can withdraw that is uniteclin agreeing wishesof the patient.Thc difficulties on thes. All arisewhen th" f"_ify ,piir, ,r, their to what the patient lyanted.The best opinion ast her form of advance ,ti;*i;; " a prorT with an agentthat has the patient.s wishesfor herselfwritten o,,, n,rdend- a"r.r,O"a by specific proccdure. other words,ir.rstead ln: the ofsaying,,noh.roi. ,rraurur.ri,i,e pror:7 .,no mechanical says ventilation,no nasogastric tube placement,at is and no artificial nutrition.,, This is thc patient speakingfor hersel|lave It is c]ear"rJP...rr". i ** are no on what can be withdrawn or withheld. ]imits When this i, ;.;;;;*,, then the family or frienclsmust describewhar the patient would have-;; ;. herserfhad she beenableto speak. this case family In rherrm actsasa subs,irri. i"i,fr. luag_ent of the substitutedjudgment notas is a,rng i,lljll_T:::1"::. creardocumentation. sood up.oltir,.*,,. ,here no is The fanily is statingwhat they believeare the patient,si.g for themselves. is the case this wishes This in <lueition. Be.""r. ri.1. "r. ," "greement, be is no problem.Theycan do anything there incrudingpulling or, ii" .ra.rr_n*rhe stopping tube and nasogastric fceding. tubeheet The pivotal point is that the family is conveying what they understandthe patient would wish for herself,not what they think is i*,,, ,., ,i. of decisionmaking fbr a patient without O"l*nt. The last form d..irio; _aki;;:ip".,r1, ""0 withour proxy rs prople making a judgment a of what they thint ll; ii tt i U..t i,rterests patient.This form of decisionmaking of the of the ,,best res,iironiura i, ."L* inte no documentationof the patient,s thereis wishes(liing ,ill), ""d ll; ;;;;y T h eo r d e ro f d i r e c t i v e s r a n g e f r o n tr t r o n g e r t ar d t o w e a k e srl : i 1. Adult wirh capacity_No limit on what can be withdrawn/withheld 2. No capacity, with pro{, that states but in writing the patient,s wishes_No limita_ tion 3. No capacitSno prory, but written wishesfrom the patient_No limitations (ll!!P rureorcnr
    • t84 j onr*"r, and Explanations 4. No capacity, no proT, no written wishes, but family united in knowing the patients wishes (essentially a verbal advance directive)-No limitation c When there is no proxy and no living will and the family is not in agrecment,thenan arbitration processshould occur starting with an institutional ethics committeeand sometimes ending in the courts. Adult withCapacity Wants Stop to Artificial Nutrition 97. (a) "I will get that tube out right away, sir." An adult patient with the capacity to understand his mcdical problems has the right to stop any form of therapy he wants to. This patient gives the reason that he is uncomfortable, however, the patient does not have to give you any reason. He can just say,"I do not want it," and you must stop. There is no evidence of psychosisor depression described in the caseso there is no reason to doubt the decision making capacity of the patient. 4hen the patient has the capacity to understand, the wishes of the faniily, the courts, or the pro)!l. are not relevant to what you have to comply with in terms of the patients care. There is a big difference between not complying with a patients wishes for himself and not agreeing with the decision. You do not have to agree with a conpetent persons wishes for himsell but you do have to comply with them. Removing tube feeding in a person who needs the nutrition has a different emotional feeling for many caregiversbecauseit seemslike denying basic comfort. Nevertheless, there is no legal or ethical distinction. Tube feedings are a medical intervention that can stop like any other at the discretion ofthe patient. You cannot force-feed a patient asainsttheir will. I(APLAN MEDICALIIE I
    • Answers rxplanations and t85 Ithe Competent Wants Stop Adult to Dialysisan 98. (f) "Although I disagree with your decision, I will stop the dialysis."Lnd An adult with the capacityto undcrstand the effcctsof his decisions(rn st()p ry forn of therapy even if it rvill lead to his death. Stopping dialysis is not a form of phy- sician assisted suicideor euthanasia. Eutltanasia mcans giving a medication that will kill the patient. The primary clifferenceis one ofintent. Passivedying from stopping a medical treatment is cntirely at the discretion of the patient provided that the person is not acutelyclepressed suicidal.By dcfinition, a suicidalpatient is decmed not ancl to be competent.This casespecifically statesthat the patient is not depressed.ht Although there may bc an emotiolal difference betwcen stopping therapy and everis starting in the first placc, there is no legal difference. Therc is no ethical or lcgal dif-.n ference betrveen withholding and withrlrawing a treatmcnt. All that matters is rhat)r you are adhering to a competent adults clcar wishes for his own cire. lf I am painting your house blue and halfivaythrough the job you insist that I paint the house red, I must comply rvith your wishes.I cant tell you, "Sorry, once I start to paint, I dont stop urtil thejob is clone. Your wishesare lessimportant than mine." It is your housc. You can do what you want $ith it. Adult without Capactity a Vague and Living Will 99. (a) Continue both for now. fhe major difficulty with the living rcill is that it is often rot clear and specific in terms of what it means.The phrase"no heroic measures" not sufficientlyclear as is an advance directive to stop a ventilator that thc persons life is dependcnt upon, You also do not larow if the patients wishes have changcclsince the last visit. As far as you know, the paticr.rtsfamiJy may appear any minutc and say the patient wants to be on lhey "no a ventilatoras long as it is not permanent. may say heroic measurcs" neant dialysisand organ transplantationin the mind ofthe paticnt.A DNR order docs not frean ren]ovea ventilator.DNI{ just meansno cardiopulmonaryresuscitation efforts in the event of the patientsdeath. I(AIIAN MEDICAL
    • 185 onr*"r, and Explanations ] If the advance directive is not clear, particularly concerning basic nutrition, then 1ou should continue therapy until it becomes clear If you think that what is best for the patient is to rernove the ventilator and he dies, what happens when you find out that "no the Alzheimers diseaseis mild memory impairment and heroic measures"in the patients nind meant no chenothcrapy or surgery?Continue therapy until the situ- ation is clear. In absenceof a spccific directive to stop, you should continue. Definition Health-Care of Proxy 100. (c) To communicate and carry out the wishes of the patient Thc health care proxy is the agent of the patient to carry out the patients wishes for their mcdical treatmcnt in the event that she losesthe capacity to make decisions for herscll The prori:yis not an agent of the physician. The proxy should be the primary person to be the substitute for the judgment of the patient. ln other words, what would the patient want if she were able to speak?The reason it is called a health-care lhe proll. is to distinguish it from a financial executor. power of the health care prorT has no impact on the finarces of the patient. They do not pay the bills for the patient. The most important issue is that the primary role of the health-care agent or proxv is not there to state what the prorT thinks is best for the patient, but what the patient wanted. The prory is like a mail carrier. lf the patients wishes are like a letter to the physician, the prory is there to deliver it.I(APLAN MTDICAL
    • Answers Explanations 187 and In you Pregnant withCapacity Adult)r thet thatn the l0l. (a) Honor her wishes;no transfusion. situ- The pregnancyhas no impact on the ability of a competentadult,sright to refuse therapv. long asthe fetusis insideher As body,the fetusdoesnot havethe indepen- dent rights of a person.The fetus is considered the sameas her body. personhood for the fetus is only a considerationafter the delivery.The sameanswerwould be true evenifshe werein her third trimester ofpregnancy. The consentofthe father is irrelevant.The father is not the one receiying th.-t.nnrfurinn. Do not seekhis opin_ ion. The courtscannotorde a comPetent r personto receive medicaltherapysheis afor refusing.forrry Oral Advance Directives Binding ArelatLrere I 02, (e) Remove the IV lines and stop blood draws as they wish.le There is no limitation on what can be withdrawn from a patient,s care based on a clear advance directive. In this case the advance directive is oral. A written advancev directive is preferable becauseit is easier to prove. fhis is especiattyimportant whenrt there is disagreement amongst the family members. In this case,the wife and eight children are in uniform agreement on what the patient stated he wantecl for himself. There is no ethical or legal distinction between withholding and withdrawing care. An_ethics committee is important when there is disagreement on what the patient,s wishes were judicial interventionrvould be necessaryifthe physrciansdisagreedwith the prognosis of the patient. In other words, ifthe fu-ily _u.rt"a "u.rything stopped because they believed there would be no recovery but the physicians believed the rmpairment was temporary, then judicial jnrervendon for a court order might be necessaty. !f!!p r,,|eorcrr
    • tsBN-13: 978-1-4195-4209-1 10: 1-4195209-5 4 fl[ilfl[i