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

    • OTHERBOOKSBYKAPLANMEDICALUSMT.ETrStcp1Qbook,Third EditionUSMLETrStcp2 CK Qbook,ThirclEditionUSMI-EnStep2 ClinicalSkills,Third EditionLrSN{l.F.rNrStcp3 Qbook,Third ldition
    • USMLE"MedicalThe100YouAreMoston theConradFischer,M.D.AssociateChiefof Medicinefor EducationSUNYDownstateSchoolof MedicineCaterinaOneto,M.D.P U B L I S H I N GNew York . ChicogoCasesLikelyto SeeExamEthics:I ( A P t A N
    • USMLE" isa registeredtrademarkof theFederationof StateMedicalBoards(FSMI3)ofthe United States,Inc.,andtheNationalBoardof MedicalExaniners@(NBMEo),neitherof whichsponsorsor endorsesthisproduct.This publicationis designedto provideaccurateand authoritativeinformation in regardto the sub.iectmattercovered.It is soldrvith the understandingthat the publisheris notengagedin renderinglegal,accounting,or otherprofessionalservice.Iflegal adviceor otherexpertassistanceis required,the serviccsof a competentprofessionalshouldbesought.EditorialDirector:fenniferFarthingEditor:CynthiaC.YazbekProductionEditor:LeahStraussProductionArtist: EllenGurakCoverl)esigner:CarlySchnurO 2006by ConradFischerPublishedby KaplanPublishing,a divisionof Kaplan,Inc.888SeventhAvenueNewYork,NY 10106AIl rightsreserved.Thetextofthis publication,or anypart thereol maynot bereproducedin anymannerwhatsoeverwithout written permissionfrom thepublisher.Printcdin theUnitedtareof AmericaSeptember200610 9 8 7 6 5 4 3 2 |I 3-ISBN:978-I -4195-4209-|l0-ISBN: l-4195-4209-5KaplanPublishingbooksareavailableat specialquantitydiscountsto usefor salespro-motions, employeepremiums, or educationalpurposes.Pleasecall our SpecialSalesDepartmentto orderor for moreinformationat 800-6219621,ext.4444,ernailkaplan-pubsales@kaplan.com,or writeto KaplanPublishing,30SouthWackerDrive,Suite2500,Chicago,IL 606067481.
    • ) o fther;ardnother:.To:Antonio OnetoLawyer,Politician, Humanist, Fatheq and Loyal FrienilA man of honor and integrityc.o.To:TruthC.F.:d:s),
    • ContentsINTRODUCTIONANDHOWTOUSETHISBOOK ........xiiiABOUTTHEAUTHOR. .......xvCHAPTERI AutonomyCHAPTER2 CompetenceandtheCapacitytoMakeDecisions.......5Definitions............ .................5Minors................... .................5PsychiatricPatients................. .............................8Capacityto RefuseProceduresin anC)therwiseMentallyl)isabledPatient..................9C H A P T E R 5 l n f o r m e d C o n s e n t . . . . . . . . . . . 1 1A1lOptionsMustBeDescribed........ ................I IAll MajorAdverseEffectsMustBeDescribed.............. ...................l2ConsentIsRequiredfor EachSpecificProcedure ...........................13BeneficenceIsNot Sufficientto EliminatetheNeedfor Consent................................13DecisionsMadeWhenCompetentAreValidWhenCapacityIs Lost..........................14ConsentIsImpliedin anEmergency.................... ...........................15ThePersonPerforrningtheProcedureShouldObtainConsent..................................l5TelephoneConsentlsValid.............. ................16PregnantWomenCanRefuseTherapy........................... ................17InformedConsentfor a Never-CompetentPerson..................................................,.....17CHAPTER4 ConfidentialityandMedicalRecords. ......... 19Confidentiality..... ................t9Releaseof lnformation....................... ...............20GiveMedicallnformation to the Patientliirst,Not the Family....................................21Releaseof Information to Governnental Organizationsand the Courts........,.,,........2lBreakingConfidentialityto PreventHann to Others....... ..---.........22MedicalRecords.. ......---.......22CorrectinsMedical RecordErrors..... ...............23
    • CHAPTER6 Reproductivelssues. ........ 41CHAPTERTOrganandTissueDonation ..........45CHAPTERSReportablelllnesses .........47CHAPTERl0 SexuallyTransmittedDiseases(STD$. ....... 5iCHAPTERll Malpractice ........ 55Definition ............................55Deviationsfrom LocalStandardsof Care...................... .................56Informed ConsentProtectionagainstLiability.... ...........................57Informed Refusalls asImportant asInformed Consent. ...............58PatientsMust Fully lnform the Physicianof Their MedicalProblems.........................59RiskManagement ................59MedicalErrors..... ................59
    • . t J...25...27...33...35...37..37..37..38..384l. 4 ......... 6lCHAPTERt4Doctor/DoctorRelationship ......... 7tCHAPTERf5Experimentation.. .........75PRACTTCEQUESTTONS ..........7sANSWERSANDEXPLANATIONS... .....12947t9495052i25;5o78999
    • 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 wishesrvith his own health care.The concept of autonorny is fundamental to the entirety of theU.S.legal system and has complete acceptanceas an operating principle of day_to_daydecisionmaking. Justice cardozo set this as a clear legar precedent in 1914, in the caseSchloendorffv. Societyof New york Hospital, 105 N.E. 92 (1914). JusticeCardozo wrote,"Everyhuman being of adult yearsand a sound .rind hasthe right to determine what shallbedone with his own body and a surgeonwho performs an operation without his patientsconsentcommits an assault,for which he is liable in damages,exceptin casesof emergencyrvherethe patient is unconscious and where it is necessaryto operate before consent canbeobtained."lustice cardozo waswriting concerning the need for informed consentwhena person undergoes surgery, ln this caseit was made clear that to perform surgery on apatientwithout his direct consent was equivalent to assaultand battery.Patient autonomy is a concept derived fron the property rights issuesthat led to theDeclaration of Independence, the U.S. Constitution, and the Bill of Rights. Autonomyoveronesown medical careis seenin the samelight asfreedom of religior, freedom fron.rillegalsearchand seizure,freedom of speech,and freedom of assembly.Theserights are soinlri,icto our cullurethlt theyrrr conideredaxiomalic.Vithin the l.rrt30 yearrtheyhavebeen legally extended to cover the freedon to chooseones own form of health care.Ior example,patients have the right to refuseundesired therapy,and they havethe right tochoosewhether or not they will participate in experimentation. Each patient has the rightto havehis wishescarried out even in the event that he losesconsciousnessor the caoacitvto make dccisions for himsellChapterl. AutonomyI(APTAN MEDICAL
    • IChapterOneln part becausetrcatments such as mechanical ventilation and artificial nutrition didntexist in the past,re need nervlar^sto delineatepreciselythe ethicsof health care.our ability to devclop new forns of therapy hasoutpaccd our ability to createethical svstemsthatdetcrmine whethcr or not thesesvstemsr,villbe used in a specific case.. Doesthe developmelltand existenceof a treatnent_such asplacementon a ventila_tor-mean we should alwaysuseit?. Docsthe fact that we canplacea nasogastrictube in a con.tatosepatient and admin_ister artificial nutrition that cankecpthat patient alivealmost indefinitely rneanweshoulddo so?Each patient should decidc the aswers to tlresequestions for hinrsell rhis is autonomy:I havethe right to do what I choosewith my own body aslong asI understand the conscquencesofmy decisions.There is no form ofproperty more personal than one,sown bodyiso each patient hasthe right to deternire what is done to his body. Theseprinciples mayseemobvious, but they are fundamental in medical ethics.This work is an examination ofthe various cthical situations faced clailyby ph,vsicians.Autonomy representsa patients right to deter.rine his or her own health-care decisions.No form of a treatment can be pursuedrvithout his or lter agreerrent,even if the proposed therapy is"forher own good." Although beneficence-or doing rvhat is good forpeoplc-is a high ain and ethical principle, autonomy is considereclmore important andtakesprecedence.Eachpatient hasthe right to refusea treatment even ifthat treatment hasno adverseeffectsad will heip her.You cannot trcat him or her aqainsthis or her wil] evenif the treatment is for her benefit.Think of your body as a piece of property such as your house or your car.fhepolice donot have the right to searchyour house at their *him. They m.st obtain a warrant. Theycannot even do something benign, such as step inside vour honc, without your expressagreenent. 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, eventhough thesearemild and uncomplicatedprocedures.Along the same lines, a painter cannot repaint your house without your consent even ifhe does it for free, the existing house color is ugly, anclthe servicewill only benefit you. Aphysician cannot treat your pneumonia or remove a cancer even though the procedure ortreatment is benign and it will only benefit you.A doctor can violate this autonomy if you are doing something potentially dangerous,such asbuilding a bomb, becausethis activity can harm others.A doctor can violate yourMEDICAL
    • cn didntfur abil-€ms that/entila-lmin-n w ecnomy: conse-n body;es maytion of:isions.e Pro-od forrt andnt hasI evence doTheypresslsent.theseen if,u.Ae orous,ouronlyifyouhaveHIV,tuberculosis,or asexuallytransmitteddiseasebecauseconditionscanharm an innocent third party. Your right to autonomy is only limiterlthereispotentialharm to an innocent third party. Even in thesecases,the violationof@nfidentialityislinited andtightlycontrolled.Theconceptofpatientautonomyissimilarto thatofvoting.Ballotcounterscannotmakepresumptionsbasedon rvhomtheythink you rvill vote for. They must definitelyknowwhomyouintendedtovotefor whenyou werecastingyour vote.This must bebasedonwhomyouspecificallyvotedfor Another personcannotbring your proxy ballot to theelectionbasedonwhichcandidatehethinks you shouldvotefor or which candidatewillbelpyouthemost.Youmustcastyourvotein amannerbasedonyour clearlystatedwishes.Youhavearight tovotefortherveakestcandidate.Youhavethe right to makethe"wrong"choice.In thesameway,adoctorcanonlyrendercarefor you basedon rvhatyou tell heryou want.Patientautonoml givesyou the right to make the wrong choice about your health care.Evenif youareunableto make or expressyour health-care choices,the physician cannotsimplymakedecisionsfor,vou that go againstyour wishes.lhisstandseven if your choiceswouldbeharmfulto you. This is one of tlre most difficult things for a physician to under-standandacton. l)octors are trained to act in the Lrestinterest of their patients, but thepatientsright to act againsthis orvn best interest comes first. Patients havethe autonomyoffreewill.AutonomyI!!!!p ueorcer-il
    • Chapter2: CompetenceandtheCapacityto MakeDecisionsDEFINITIONSCompetenceis a legal term. Competency decisions transpire within the judicial s1steni.Onlya court can determine that a patient is incompetent. All adult patients are consideredconpetent unlessspecifically proven otherwise. Physicianscan determine whether or notapatient hasthe capacity to understand bis medical condition.The physician makes a determination of the capacity of a patient to comprehend herrnedicalproblems basedon whether there is an organic delirium due to a medical condi-tjon such as a sodium problem, hypoxia, drug intoxication, meningitis, encephalitis, or apsychiatricdisorder.Thesedetcnninations arebasedin large part on a neurological exami-nationtesting memory, comprehension, reasoning,and judgment. Any physician can makethis determination. The physician does not have to be a psychiatrist. A psychiatrist maybeusefulin 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 ageof 18.With some exceptions,minors aregenerallynot considered competent to n.raketheir own decisions.Only a parent or a legalguardiancan give consent for a minor. Neighbors, aunts, uncles,and grandparents cannotgiveconsentfor treatment of a minor. This rule doesnot cover life-threateningor seri-ousemergencies.Consent is alwaysimplied for emergencytrcatment. A physician shouldnot withhold blood or surgery in a life-threatening accident just becausethe parent is notPresent.I(APLAN MEOICAL
    • I chapterrwoFor example, a 10-year_oldboy accider.rtallyruns through a glasswidou, at schooland 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 neeclexpressrrritten consent. parental consentis implied. saying that you had .o ask aother p".ror, ru.h as the tcacher, thc principal,the school nurse, the babysitter,or the granclparentsfor consent belore givir.rgcmergencytreatment would be the wrong answer.Seekinga court ordcr i, olrn u tv.,,,.rglhoi."l,., ur.,emergency becauseit delaysthe treatment and becausein an emergencyit is implicd thatthe parents rvould consent if they were there,PartialEmancipationAlthough only a parent or guardian can give consent for procccluresand therapies for aminor there are some exception_sto this rulc in thc areasof prenatal care,coutraception,sexuallytransmitteddiscases(STDs),and substanceabusc.The mature minor is generayone.abovethe ageof I5, although this raries by state.USMLE wilt not make hairsplittingdistinctions like giving you a r4-year-old the day before her r5th birlhday. Thc caseon theexam will be clearFor example, a l6-year-old girl comes to seeyou in clinic to discusscontracep_tion. She is generally healthy but is not accompanied bv a parent. What should,voudo?h all caseslike this involving prenatal care,STDs,contraccption, Hrv anclsubstanceabusethe answer should bc to trcat rhe patient. Saying thut 1.ou_urt notily thc parents, get acourt order)seeklegalcounser,refusetherapy,or to go to the ethicscorr[]rttee areaI incor_rect answers.These interventionsuwantecrpregnan.y,,.i,i,.,,,ij:::i:: ffiI :;::XlTr:Xil.::,:"T,rj;;::,,,:,fthan it is to take the risk that a teenagcrwill get pregnant and necclan abortion laterAboftioninaMinorThe rules on parental notification for abortion are lesscrearbecarse there is no nationalstandard.Somestatesrequireparentalnotificationand somedon,t.I(AI.AN MEDICAL
    • rolrt-)r-)nsentrcipal,gencyin and thatforation,rallyrungrtheuSe3 t a:or-ingIOnnalCompetenceand the Capacityto MakeDecisionsForexample,a 16-year-oldgirl comcsto seeyou in her first trimesterof preg-nancy.Sheisseekinganabortion.Whatshouldyou do?Inthiscase,thereisno clearansweraboutwhetheror not thephysiciansl.rouldnotif, theparents.Thereisno clearnationalstandardandit dependsupon the stateyou arein. Themostlikelyrightansrverwill indicatethenceclto encouragethc child to notify the parcntsherself,whichwouldbebest.Sothe corrcctanswerchoicewill saysomethir.rglike,,encour-agediscussion,""counselher to tell the parentsherself,"or"suggesta fan.rilymeeting.,Ontheethicsquestionsfor USMLE,if thereis a choiccthat savsto discuss,confer,meet,orhavevoluntarynotification,thisrvill generallvbethe right thirg to do first.EmancipatedMinorA smallnumber of minors, particularlyat older agessuchas l6 or 17,may bc consideredemancipatedor freed of the necd to haveparental consent fbr any medical care.The critcria arethat the minor is married, self-st4rporting and living indepenclently,in the military,or theparcntofa child that they themselvessupport.The criteriafor beingan emancipatedn]inor relateto being no longer dependent on ones parentsfor support, In other words, iftheminor does not livc with his parents,has a.job, ar.rdis self-supporting financially, thelrtheminor no longeris dependentupon parentalconsentfor his actions,An emancipatedminor is free to make health caredecisionsin all areas,not onh, just STDs.prenatalcare,contraception,or substanceabuse.Seriousmedicalconditionsor proceduressuchas organ donation, surgery, or abortion may require a specific court order to allotvthe legal standing of enancipation to be fully valid. Only answer"courtorder,,.,judicialintervention,""courttrial," or"seeklegal resolution" if the caserepresentsdisagreementoralackof consensusin the stem.LimitationsonParentalRightofRefusalforMinorsAlthough a competent adult can refuse any medical care she wishes,the same right doesnot 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 thenclfareof the child that exceedsthe parental righr to den1.therapy for the child if the childmisht die.t ( A p tA N-MEDICAL
    • r I cnupt",r*oFor example,a child is in a motor vehicleacciclentand sustainsheadtraumarequiringsurgeryto drain a hematomathat,if leftuntreated,will befatal.Aspartof the surgerythe child will needa blood transfusion.The parentsareJchovahsWitnessesand refuseto giveconsentfor the transfusion.Ihe parentsstatedreligiousbeliefsarethat acceptingblood for their child would be a fateworsethandeath.4rat shouldyou do?If the child needsblood to savehis life you must givetheblood evenoverthe objectionof the parents.It may seemcontradictoryto seekparentalconsentfor a procedurethatyou will perform evenif they refuse,but in this case,you shouldattemptto obtain theirpermissionnonetheless.Withholding lifesavingtherapyfor a child is consideredcomparableto child abuse.Theparentsright to practicetheir religionin termsof healthcarewould covertheir abilitytorefusea transfusionfor themselves,but not for their child.Thisethicalconcepthasonly expanded.Parentscannotrefusetherapyfor childreneveniftheyareseverelybrain damagedor otherwisedevelopmentallydisabled.Societydoesnotdistinguishbetweenindividualsbasedon theirrelativeworth.Inotherwords,parentscan-not refusetracheo-esophagealfistularepairon apatientwith Down syndromejustbecausethementalcapacityandfunctionalabilityof thechildwill bemuchlessthanthat of achildwithout this disease.From this point of view,treatmentagainstparentswishesin a life-threateningsituationisequallyvalidfor both afuturegeniusandachildwith cerebralpalsywho will not achievea mentalageabove2.One of the only timesparentsareallowedto refusecarefor their child is when the childis soill or deformedthat deathis inevitable.This is not a true refusalon the part of theparent.This is reallyjust sayingthat parentscanrefuseonly the futile carethat thedoctorshouldntbegivingany.way.PSYCHIATRICPATIENTSA patientspsychiatrichistoryisintrinsicto theconceptof competenceandto thepatientscapacityto understandher medicalproblems.A patientwith the clearcapacityto under-standor onewho clearlydoesnot havecapacitydoesnot needa psychiatricevaluation.However,a psychiatricevaluationcanbe usefulto help makea determinationof capacityin ecuivocalor questionablecases.l (nIsct$:."9MrDicAL
    • :tionthat:heiratThey t o:nifnot?n-rts)n,ityruserildife-nl,IrildthetorCompetenceand the Capacityto MakeDecisionsAll suicidalpatients are considered to lack capacity to understand becar.rseactive suicidalideationis deemedto be a sign of impaircd jr.rdgment.In addition, thc level of compctencenecessaryto make financial decisions is different fron.r that necessaryfor an informedrefusal.In other words, a patient rnay have a history of bipolar disorder making it impos-siblefor him to manage his financial decisions. Howevel the same person might still beconsideredto have capacity to refuserrearment. There is rvirylimitiil iteiriiril liliced onp,ricnlto estJblih(dp.tcilylo rcfuetrcdtntet.CAPACITYTOREFUSEPROCEDURESINANOTHERWISEMENTAIIYDISABTEDPATIENTA patientwith mental illness or mental retardation that might be consideredincompetentfor other areasof life may still retain the right to refuse medical procedures. The criteriato determineconlpetencein areasof finance are at a higher standard than those for refus-ing nedical procedures. Your patient might have schizophrenia, mental retardation, orautismto the point of needing to live in a group home, but that does not mean they areincapableof understanding medical procedures.This means that an adult with a mcntalageof 8 or l0 nay still be allowed to refuse medical procedures.Our society is reluctantto strapa patient to his bed and perform procedures that would be painful or uncomfortablefor the patient without his consent. For irlstance,certain court casesin the past haveallorveda patient with mental illness to refuse diagnostic procedures even though twoout of three of the reasonsfor the refusal were delusional. This is an affirn.ration of howdeepthe principle of autonony goesin the managenent of patients. In addition, it showsthat beneficence-trying to do the right thing for patients is considered lessimportantthan autonomy. Autonomy is given more wcight in decision making than beneficience.Autonomy haspriority.A personmay meet the legalstandard of competenceto refuseor acceptmedical careevenif sheis not consideredcompetent in other arcasof life, such asfinancial matters.MEDICAL
    • I r rAtt OPTIONSMUSTBEDESCRIBEDbu nrust full,vinforrn the patient of the risksanclbenefitsof eachprocedureprior toundergoingthc procedure.Thc explanationmustbe in languagethatthe paticntunder-standsandincludefull infbrnation regardingalternativetreatments.Ihepaticntcannotmakean informcd choicefor onetreatmentif shecloesnot latow of the existenccof oth-For example, you inform a patient about the risks iurd benefits of bone marrowtransplantationfcrrchronic myelogenousleukemia.You fully inform the patientabout the risk of transplantation,including the possibility of deveJopinggraftversushost disease.Afier the transplantationthe patientdevelopsgraftversushostdisease,which is hard to control. The patient learnsthat there is an alternativetreatmentcalledimitanib (gleevec),rvhichtloesnot includc the risk of graftversushost disease,but which rvill not cure the lcukemia.The patient filessuit againstyou. What rvill be the most likely outcomc of the suit?In this casethe patient rvill probablywin the suit becausehe wasnot fully intbrned aboutthe alternativesto the therapics mentioned. The physician has an ethical duty to ir.rfbrmthc patient about all the treirtmcnt options and then allorvthc patient to decidcamongthcm. Although the phvsicianspref-erenceof procedure or treatment may differ from whatthc patient chooses,the patient has the option to choosetherapy that may not be ^rltatthedoctordeemsis bestfor hin.Chapter3: InformedConsentliI(APLAN M E D I C A L
    • ChapterThree!13!9 MEDTcALAtLMAJORADVERSEEFFECTSMUSTBEDESCRIBEDAdvcrse effectsanclinjury lrorn rnerlicalcaredo not necessarilyrepresenta mistakc or failurc of therapy. In the casedescribcd in the previous exantple,the error was not that graftversushost cliseasedeveloped.Thc patient wasfully informed that this could occur and hechose the bone marrow triursplantation anyway.The error rasnot informing thc patientof an alternatir.eoption in treatmcnt. At the same time, a patient could potentially die asan adverseeffect of treatment. This is only an ethical and legalproblen if the adverseeventhappcns and the patient was not told that it could have happened.The patient n.ight say,"Doctor,I would never havc taken digoxin if ,youhad told me it night causea rhythm disturbanceor visualproblenr"or"I rvoulclneverhavehad surgeryifyou had told mc I mightnccd a bloocl transfusion." Thc m.rin point is tt rcpcct 3utonolly. The patieitt must beir.rforn.redof the therapeutic options, the adverseeff-ectsof the procedure, and the harm ofnot undergoingthe procedurc.If thcy havethe capacityto understandand thcy choosetodo it ar.rvr,vay,they havemade an autonomous tlrerapelrtic choice,and therefore,thc patientbearsthe burclenof any adversccffect,not the physician.For example, a man underploescoronary angioplasty. He is inforned that tl.rearterymay rupturc and that thereis a srnallchancehe couldbleedto dcathduringthe surgery to repair thc danaged vessel.He knorvs he could havebypasssurgeryinstead.He understandsand choosesthe angioplasty.He dies from a rupturedblood vessel.The fanily files suit against you. What will be the n.rostlikcly outcome?Although it is unfortunatethal the patientdied in this case,thereis no liability with regardto informed conscnt or ethical error.lhepatielt was intbrmed of his trcatment optionsancithe possiblecomplications,anclhe chosethe treatment.The patient mlrst undcrstand the risks of a procedure just as a drivcr rrust understandthe risks before getting behind the wheel of a car. Why cant you sLlca car manufacturerif you die in a car accidcnt?Predominantlybecauseyou are an adult with the capacitytour.rderstandthe risks of driving anclyou choseto drive an1.way.Tl.reliccnsing processis aneducation processthat both tries to make you a safedriver, while alsoproperly informingyou of the risks of driving. Each time you get in a car,there is i.r.npliedconsent that you arechoosing the risk of driving. Evcn if you €letinto a car accident and arreinjured or killecl,the manufacturer has no liability, aslong asthe car is well ntade,trecauseasa compctentadult you choseto put yourselfat risk.
    • tnformedconsentItr;raftl h ei€[te a srentsay,A t .Lghtt b er o fe t oientard)ns.ndrertoann8lre",]rntIn addition to understanding the risks of the procedurc, you must inforrn the patient ofwhatcould happen if shedoes not choosethcrapy that you offer.For example, a patient comcs to the emergencydcpartnent with appendicitis. Heis inforrned of the risks of surgery,and refusesthc procedurc both verbally and inrvriting.lhepatient dies.Vhat was done rvrong here?Thepatientsmust be informcd both of the risk of thc treatmentasrvellasu,hatwill happcniftheydontundcrgothe procedure.In this casethe physicianis liablein court becauseheneverdocunented that he infornred the patient of the possibility of appendiceal rupturcanddcathif the patient did NOT havethc procedurc.CONSENTISREQUIREDFOREACHSPECIFICPROCEDUREIf the patient signs a consent form for an opcration on hcr left knee, you cannot, in theoperatingroom, decide to operate on her right knee and assumethat you have conscnt. Ifapatientsignsa consent for an appcnclectomy,but when you open her up you find coloncancetyou cannotjust do the colectomvwithout first informing the patient of the acldi-tionalprocedureand obtainingher consent.Thcre can be no presumptionfor conscntforanythingbeyond what the patient specifically saiclsheconsenteclto. lither the paticnt hasto signconsentin advancefor the other procedures or shehasto regain consciousnessandhavethe additional proccdure explained to her.BTNEFICENCEISNOTSUFFICIENTTOETIMINATETHENEEDFORCONSENTTrving to bc sincere anrl to do good is very important and takes primacy; howeter, thepatientsright to control what happcns r.vithhis own body is more irnportant.For example, a 40 year-old man is undergoing a nasalpolypectomy. In the opcrat-ingroom you seea lesionon thc nasalturbinatethat the frozenscctiondeterminesto be a cancer,You have found the cancer early but will need to rcsect the nasalturbinate to cure it. What should you do?M E D I C A LI ( A P I A N
    • t 4I chapterrhreeYou cannot rcmoe tlre cancerousresior.rrvithout the patients approval. This is true evcnif the physicianis sincere,taleted, accurate,and helpful.fhis is truc eve if the procedurewill savethe patientslife, unlessthe illnessis an emergencyrnan unconscrotrspatrelt.Beneficcncedoes not elirninate the need for informed consent. lf you live in a very messyapartlnentyour neighborcannot breakinto your apartmentto cleanit el,enif he doesn,tstealanvthil.lg.You must col]sent to the cleaning. His good intcntions are not asimportantasyour right to do what you wanl nith your otvn property.DECISIONSMADEWHENCOMPETENTAREVATIDWHENCAPACITYISTOSTWe must respectthe lastknown wishesof a patient if shelosesthe capacttyto con]munlcateand state those rrishes.Although it is preferable to have thc patients last kown wishesdocunented in writing, following verbally expressedwishesis perfectly valid. oral cosentis valid for arrylevelofproceclure if the orar consert can be proen. The basisfor varidit). oforal or written conscntis not whctrrerthe procedureis largeor small.Ir.rother words,it isnot thc casetltat oral conscnt is valid for a stgmoicloscopybut a brain biopsy requireswrit_tcn consent.A patient cal.tgive oral consent tbr ir heart transplant if the patient is unableto *rite.lheonlv diffrculty is that if challenged,orally exprcssedwishes for treatnrent aremore difficult to prove than lvritten ones.For example, a 42-ycar-old nran with leukemia repeatcdly refuseschenrotherapy.He losesconsciousless and his rnother tclls you to givc the chentotherapy.Whatshould you tell l.rer?You must rcspectthe l.st kntxvn rvishcsof thc patient. If the paticr.rtcloesnot wat a treat-ment, you cannotiust $iritfor him to loseconsciousnessand then perfornt the treatmcnt.If this rverepermissible,ther no one courdhavean estatewiI. The ultimate form of rossof decisitur naking capacitv is death. ,Veurarkeout a will so that when rve lose the capac_ity to speukfor ourselr.es,our wishes for rvhat to do with our property are respectedaftercleath.For example, a 64-ycar-old roman accontpanied by her husband comes to theemergency room seeking treatment for chest pain. The patient clearJytells youthat shewants to haveher aorta repaired and shesignsconsent for the procedure.Shelater becomeshypoter.rsiveand losesconsciousness.Her l.rusbandis now thedecision maker and says,"Lether die.,,What do you tell him?tabaTpPntlTsTsoY(OIaII(A9IAN MEDICAL
    • InformedconsentI tse eyell:edurertient.messyoesnt)rtantLlCatelshesrsenttyof, t t l surit-Lablet areApatientt family member cannot wait for her to lose consciousnessand then go againstthepatientsprevrous expressedwishes regarding treatments and procedures.In the caseabove,becausethe patient exprcssedthat shewoulcr riketo haveher aorta repaired her hus-bandcannotgo againstthis aftershclosesconsciousness.The samereasoningholds true ifapatientrefusesa procedure or treatnent and then losescolrsciousDess.CONSENTISIMPTIEDINANEMERGENCYFor example, a sO-yearold construction worker arrives at the emergency roomby ambulance after an accident lacerating his arm. He has lost so much blood hersunconscious.There is no family member availableto sign consent.What shouldyoudo?Thcmanagementof an emergency is different. Consent is implied rn an emergencyfor apatientwithout the capacity to speakfor himsell This would not apply to a terminally illpatientwith a pre existing DNR order Neither a court order, nor a hospital administrator,nor the ethics committee is re<luired to give permission before the doctor can administerroerap.m an emergency,THEPERSONPERFORMINGTHEPROCEDURESHOUTDOBTAINCONSENTThepersonwho is mostknowleclgeableabouttheprocedurcshouldobtaininformedconsent.Becauscwe must inform the patientabout all the optionsof treatment,risksof theoptions,and risksof not performingthe procedurein a languagethe patientcanunder-stand,theconsentmustbeobtainedby a personqualificdto maketheexDlanation.Forexemple,you arean intern who hasconsultedsurgeryto placea subclaviancentralvenousline,Youonlyknow accessmustbeobtained.you do not knorvwhvtheinternaljugularapproachisr.rotbeingused.On thephonethesurgicalresidentsays,"Can).ougo getthe consentrvhileI am comingup?,What shouldyou do?Youmustnot bein a position to explainthe risksof proceduresthat you did not decideon.Ifthe patientdevelopsa pneumothoraxandyou do not knowwhy theinternaljugularapproachisnot beingused,you cannotadequatelyinform thepatient.you arenot certaineat-ent.loss,ac-fterjI(APIAN MDICAL
    • 16|chapterrhree!(A9rAN) MEDTCALwhy central accessis being obtained at all. You must, at the risk of seeming difficult, tellthe surgical residentthat he must obtain the consenthimsell If a complication occurs,youcannot say,"lwasjust gettinga papersigned;I didnt know what it meant."The sameis true for a patient who signsconsent.If you tell the patient that he could haveapneumothorax and might need a chesttube and document this, and the patient still signsconsent, then you are not at risk. The patient also cannot say latel"lrvasjust signing apiece of paper.I didnt know rvhat it meant."TETEPHONECONSENTISVATIDConsent obtained by a family member, health-care proxy, or other valid surrogatedecisionmaker is valid even if obtained over the phone. This is a legitimate form of consent by anauthorized surrogate decision maker.Forexample, a 65 year-old r.nanis admitted to the hospital for a seizure.The headCT shows a ring or contrast-enhancingi lesion consistent with a brain abscess.The patient remains persistently confused, but is not deteriorating. You need toperform a brain biopsy but there is no family member or health-care proxy whocomes to visit hini. His wife is housebound from multiple sclerosisand cannotget to the hospital. You have hcr on the phone but the nurse is refusing to be thewitness for the consent, saying that telephone consent is not valid. What shouldyou do?As with all forms of verbal communication, oral advancedirectives,and telePhoneconsentare more difficult to prove if contested.However, they are equally valid. If a health-careworker is uncomfortable taking the telephone consent,useanother member of the health-care team to act asyour witness for the consent.You can educatethe nurse later.You cantake consent tbr cardiothoracic surgery over the phone if that is the only way to speaktothe surrogate.The real questions about telephone consent are these:1. Is the personyou arespeakingto reallythe surrogate?2. Doesthe personknow the paticntswishes?3. Did you get the oral/telephoneconsentwitnessedby another Personso that the persongiving consentcannot later deny havjnggivenconsent?PT]wlScfr,molHc?Hs€FroCnc(llTnacbh1nchctT
    • tnformedconsentItzIt,tells,IouuYeasignsringaPREGNANTWOMENCANREFUSETHERAPYTheprevailing consensusholds that a fetus is not apersonuntil birth. Hence, no matterwhatyour personal feeling may be, the fetus doesnot haveany intrinsicrightsasa person.So,even though a 34-week-old fetus would be a viable child if the fetus were removedfrom the uterus, all health-care decision making and ethics are basedon the choicesof themotherand her interests.Ifparents havea child born at 34 weeksof gestationalagein needof a blood transfusion to saveits life, they cannot refuse lifesaving therapy for the childevenifthey are JehovahsWitnesses.The statewould intervene in the interestsof the child.However,if the same child at 34 weeks of gestational ageis still in the uterus, the mothercanreluse or accept whatever therapy she wishes without specific regard for the fetus.Hence,a pregnant woman may refusea lifesaving transfusion. Shemay refusea Caesariansectionto remove the child even if this will put the life of the fetus at risk.Foran1.question concerning reproductive rights, decisionsare basedentirely on maternalwishes.The father has no legal right to make an informed consent fbr any pregnancy-relatedissuebecausethe questions concern the body of the mother. A mothers autonomyoverher own body is felt to be more important than the rights of the fetus or of the father.Onlythe mother can sign informed consent for any procedure or treatment during preg-nancy.Any answerchoice that hasAskthe father. .."in it will alwaysbe wrong in terms ofconsentissuesduring pregnancy.INFORMEDCONSENTFORA NEVER-COMPETENTPERSONThis is one of the most difficult subjects in ethics becausethe standard of this manage-menthassignificantly evolvedover the last severalyears.Ifthe patient hasDown syndromeandhasa family member to make decisions for her then the question will be straightfor-ward-ask for the consent of the parent or guardian. If there is no parent or guardian, thecircumstanceis much more difficult. A third party court designeemust make a decision1,basedon the bestinterestsof the patient even though the patient may neverhur,. ."p..rr.d pher feelingsbefore.The bestway to obtain consent for a person who has lost the capacity to make decisionsfor him/herself is a health-care prorT or durable power of attorney. This is an advancedirective(written or formal). An advancedirective cannot even be given by a patient whohasnever had capacity.The same is true of a living will. The next best method of givingconsentis"substituted judgment." In this casea person who knows the patient well triesto determine what decision shewould make for herself if shewere awake.This is also notpossiblefor a person who hasnever been competent. The weakestform of consentis to act:nl0nbyands,00tednsentFCAIE:alth-ucanaktot(APt-Al{ M E D I C A L
    • 18|chapterrhreein the"bestinterests"of the patient. Tl.risis the weakestmethod of grvrng consent becauseit is filled with subjectivity and inprccision. However, it is thc best method of obtaininsconsent for doctors treating a person who has never had capacity.A legalguar.lian whicicould be a fan.ri11.member must make the decision on behaif of the patient. In the absenceof a family member the guardian is either appointed by the courts or is the administratorof the health carefacility, such asthe medical director.
    • I rgauseninghichenceatorChapter4: ConfidentialityandMedicalRecordsCONFIDENTIATITYPhysicianshave a strong professional mandate to maintain the confidentiality of patients.Communications betseen paticnt and physician are highly privileged and this confidentialit,vcar.ronly be violated when there is potential harm to a third party or if thcre is acourt order demanding the information. Medical information cannot be passedto anyonel ithout thc direct consent of thc patient. Confidentiality also includes keeping a patientsmedicalinformation priyate even from his friends and family unless the patient expresslysaISit is okay to releasethe information. The fact that a patient may have a good rclationshipwith his familv and fiiends is absolutely no excuseto assumethat the patient wants hismedicalinformation passedon to them. I have an exccllent relationship with my mother;honever,even though I am a doctor (or mavbe becauseofit) shedoesnot want me to knowherlist of medications. Shehasno obligation to give me a reasonrvhyshedoesnot want rneto know which mcdications she is taklng. If I call her doctor and sa1"l just want to helpmom vvith hcr mecls.What is she on?" Her physician is supposedto respond,"Imsorry,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 isarake and alert. His wife comesto you demanding inforn.ration about the patient,saying that she is his wife. She shorvsher identification card verilying this. Whatshouldyou tcll her?bu cannot releasemedical information to anyone about a patient unlessthe patient givesyou pernission to do so.Although it may seem rude and unreasonable,you must tell theMEDICAL
    • 20]ChapterFourpatients fan.rilymembers that you must ask your patient for permission befbre youreleasehis medicalinfornation.For example, the wife becontesinfuriatcd and storms off the floor, threatening tosueyou. You apologize to the patient for upsetting his wife by not speaking.withher about his private medical problens. The patient responds"Onthe contrary,Doctor, you did great.Although she is still my wife, we arc finalizing our divorceand we do not live together. I expect to be clivorced and rcmarriecl lvithin thenext few months. Sheonly wanted information about me to useagainstme in thcdivorce proceeding. Thanks for protecting my confidentiality."REI.EASEOFINFORMATIONInformation transfer between physicians involved in the care of patietts is a commonoccurrence. However, the information can only be transferred if the patient has signed aconsent or releaseform requesting the transfer of information. It is the patient who mustsign the consent to releasethe infornation, not the health,care provider. This is how thesystem guarantees that the patients medically privileged inforrnation only transfers tothose people to whom the patient rvants it to go.For example, yott receivea phone call from another physician who is rvell knownto you in your local community. The physician saysthat one of your formerpatients has transferred his careto him and he is asking for a copy of the patient$meclicalrecord. What do you tcll him?You should tell another physician requesting information to send you the patients signedreleaseform befbre you send him the infonration.!!l!!p rreorcnr
    • 00n: d arustthei t oGIVEMEDICALINFORMATIONTOTHEPATIENTFIRST,NOTTHEFAMITYFor example, your patient is awaiting the resr.rltsof a biopsy to tell whether or notshehascancer.Her soncallsyou anclasksyou to givehim the infornation bccauscthe family is concerned that the bad news will depresshis mothcr. He is sincercand genuine in his concern. r{hat do you tell hin?trledicalinformation such asthe result of a biopsy must go to the patient first. There isno basisfor informing the family and not the patient.It is exactlythe oppositc:withoutdirectinstruction from the patient, the family shoulcinot receivethe patients confidentialnedicalinformation. Maybethe patient wantsher family to know and maybeshedoesnt.It is alwaysthe patients decision. There is a rare exception in the caseof a patient with apsychiatricdisturbancein rchom to inform if a meclicalcondition might induce a suicideattel1lpt.RETEASEOFINFORMATIONTOGOVERNMENTALORGANIZATIONSANDTHECOURTSFor example, an investigator from a local law enforcement a€lencycomes 1(]:your office. He shows )ou proper identification stating that he is a governmentemployee.He is looking for your patients immigration statusand for his medicalcondition. What do you tell the investigator?If a n.remberof a larv enforcel.rent agencycomes to you with a subpoena or a court orderthat constitutes a searchwarrant then you must lurnish him with the information that herequests.Ifthe investigator doesnot havea searchwarrant, then you must refusehim accessto the files.You are not under any obJigation to make immigration statusinvestigations ofvour patients nor to provide this information to third parties unless it is at the request ofthepatient. This right of privacy also coversgeneticinformation. You must keepthe medicalinformation private from a patients co-workers aswell.confidentialityandMedicalRecordsI21I(APLAI MEDICAL
    • IChapterFourBREAKINGCONFIDENTIAI.ITYTOPREVENTHARMTOOTHERSThe^right of a patient to privacy is not absolute. .fhereare sonle exceptronsas to whenconfidentialitycanbe brokcn in order to protectothc.s.The Tarasofcasc(1976),in whicha mentally ill paticnt toid thc psychiatristof his intent to harn sonreoDe,is a famousexample of this ln this type of case,thc physician must inform larvenlorcement asrvell asthe potential victim. Confidentialitl. 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 forsexuallytransmitteddiseasessuchas syphilisand HtV fne patienfs right to confidential_ity in such cascsis lessirr.rportantthan anorher p.rr.r,, ,ish, ;; r;;.ty. Horvever,all effortsmust first bc made to enlist the patient to inform tr.reintiiriate partrer. No lawsuit agaista physicia for brenkingc.nfidcntiality in order to nolify an ir_o..nt,f,la purty that hishealth may be at risk hasbeen successful.MEDICATRECORDSThe 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 record as ap,hysicaloblect rcnrains al.waysin the hands of ih" h"ultl,_.ar".fir.lfit1,, tt . parient has anabsoluteright to free accessto the information it contar.ns.it "-rrr.o.n,onon containeduithin a patientt nedicar rccord is cnveredby a the same rures of confidentiarity asanyother privilcged meticar information. you cannot relcascthe mecricalrecrrd without theconsent of the patient No one exceptthosc directry involved in th. .ur" ot the patiert hasa right to accessto the record. paticnts cirnuot tJkc sulc *rr""rr.,r, ., ,n" O^ysicalnteclicalrecord but they havea rigltt to acccssor copy thc information.For example, you have a new patient with a complex history r,ho hasbecn tryingto get a copy of her record from her previous doctor. .fheother practice said shemust provide them rvith a valicl reason for u.hy she needs thc chart. lbu call theother doctors office trying to get the chart. The practice administrator infornsyou that thc paticnt is extremely unpreasantand aim.utt. rr.,uiJrt,un, becausethepatient hasnot paid hcr bill thc prior practicefcelsno obligationto provide youwith the chart. The patient rcturns to seeyou thc tbllowing iav anclasksr.vhathasbecome of her record. What tlo ),ou tell her?I(AP!AN MFDICAL
    • Con{identialityandMedicalRecordsIvhenhichlous:llasfortialbrtsinsthisna-N AaltredThepatienthas a right to her medical records.No one has a right to interfere with this foranyreason.You should tell her that she should be allowed a copy of the chart. A patientdoesnot have to give her doctor a reason for requesting hcr own property, and she isentitledto this information whether or not she is"pleasant."Furthermore, the mcdicalrecordshouldnot be"heldhostage"to compela patientto payher medicalbills.The needfor information to take care of patients outweighs the physiciansright to payment.CORRECTINGMEDICATRECORDERRORShen an error in a chart needs correcting the doctor should draw a line through it andtheninitial the correction. This allows anyone reading the chart to seewhat was originallythereand it ensuresthat medical errors are not being covereclup. you cannot just removepagesfrom the chart or cover them over with correction fluid if there are mistakes.Thismakesit look asif you arehiding medical errors. If you forget to put in a note or documentsomcthingand want to add it the next day,you cannot put a note in the chart with the olddate.If you forgot to put a note in the chart documenting a patients condition yesterday,,youcannot write a note today with yesterdaysdate on it. In other words, you canl]ot,back-datenotes.Your notes must alwaysbear the current date and time.rnythe!ascalI(AP:-AN MEDICAL
    • WITHHOTDINGANDWITHDRAWATOFMEDICATTREATMENTEverycompetent adult l.ith the capacity to understand his own medical problems hastherightto determine what treatments he does or doesnot wish to receive.There is no ethicalor legaldistinction between withholding and withdrawal of medical treatrnent.For example, a 60-year-old man with diabetes and hl.pertension develops renalinsufficiency to the point of needing dialysis.He is equivocal about spending therestof his life on dialysis,but he agreesto start. The patient is not depressedand isfully alert. Six months after starting dialysis,he comesto realizevery clearly that heabsolutelydoes not wish to continue. You have no doubt that the patient has fullcapacityto understand the implications of this decision. What should _voudo?Although there may be an enotional distinction between withholding dialysis and stop-pingit after it has started,there is no ethical distinction between the two. lf I don,t like toplaybasketballthcre is no legal distinction between my never starting to play basketballor playing a few gamesand 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 havethe right to refise to allorvyouto work on my house and the right to tell you to stop after you started.The patient hastheright to stop treatment.For example, an elderly man with COPD progressesto the point of needingmechanical 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?Chapter5: End-of-LifelssuesM F D I C A L
    • 26Youmusthorrorhiswi.he.I hj r).rti.nri. a- ,,r,.r, .:,L-lmcdicalproblems,sohehas,n.:,:l:t::t ltan adultrvith the capacityto understan<lhistator.r.he*oon*.un,*.,,,n.il:riliil:,,.i:.iT::::;:"l,",,_TJasking the family for consent.For example, a 42_year_oldreavinshimp-"ry,;;;;;,il1;,iJ.,i,"iTlll[Tl.#il.1],:,i.":*;upbcatand cheerful.He sayshc will gerbetter"r;;;;;; to-tb.n.,orntorrr"dp".manentlyon the ventilator.yo clearlyinform him .h;; ;; ;r*r."g and irewillneverinrpror.c.He sayshewantsthe ventirarorrn."*r n..rr.,,irnerscured.whatdo youtcllhim?()nceagain,you must honor hisunderstandhis meclical.on.litio,lwishes This is an adult patient with the capacitytotherikerhoodorhi;;:;;;;:i":"T-,HX; :.:iil::JillHi,:1:J::*ifjequivalent of incompetencc. Overall, this caservill be ,h" ";;i.:;,.,, agree wirh, becausemost ethicaldilemmas do not inrrather inolve patients ,.,ho have ,;l-ttu t:nttt:t. patient wishing to continue care,butdrirw treatment.rst capacrtyand the dilemma of whether or not to with_For example, a woman withArterarbw_"",r,,,r,"r,..",,1:iil::?"ill :i."?:::;i:,Til:.::ilj:r::sions.Shehasthecapacityto understandthatshewill ai.,.rriifrcr*,fr" ar"nsfusion,althoughshcisnot suicidal.Vhatdoyou tellher?Youmusthonorherwishes.Sheproblcms.rhe consequences.r r]l,lt]-^Yl th,thecapacityto unclcrstandircrmedical;::.,i":.:;*j.,]:H.{*iirFFHil"lr;i::il::il;an cthicsconrnrilteeevaluation.;::l::-i:t lltto ruthorize the proccdurcor to askfoicapacirytounderstancr,,";:;,;,:l:i;l;:;:T]11,::.J,"il:J:::nT.:ji:.i:Tpsyihi.rtricevaluarioni nccc.rr).For example, an HlV-positive,lehovah,s Witness who is now pregnant needs atransfusion to live and haye adeprcssedandisfuuyalert.{hf::t;:1:i, ;|,"..atcsoricauvrcfuses.sheis ot1tccTtlr(IIttlPucrDhcltlrlft:Aatlcbi!!!!p Meorcar_
    • .dhis:y toboutt theausebutdth-lbu must honor her wishes.Yon cannot transfuse!t competeDtadult againsther tvill. Thesituatior.rwould be different if thc patient rvcre a n-rinor.in u,hich cascthe doctor rvouldbecompclledto transfuse.The fact that the patient is pregnantdoesno1alter the ansrver.Theprevailingconsensusis that personhoodbeginsaftcr birth. Until delivered,the fetusisconsidcredanother part of thc mothers boclv.Ihervrong ansrverswill includc getting acourtordcr or askingthe father of the child for consent.Another wrong ansrverwould beuaitinguntil the paticnt is no longer consciousand then transfusingher.Theanslversto all of the examplesdescribedin this scctionare clearbecausein eachcasethepatientis an adult rvith the capacitl,to understandhis or her nredicalproblems.If thecasedescritresdeprcssionin the patientthenyou shouldchoosepsychiatricconsultation,orchoosea trial of cither belravjoral therapv or antidepressantntedication asthe ansrvcr.Patientshavethc right to try therapyfor a while ald thcn stop it if it doesnot suit then].This is true even if it means they will clie from stopping dialysis, mechanical vcntilation, HIV medications,or blood transfusions.The typc of treatnlent does not changethe answer.A CBC or cardiac bypass is ethically antl lcgally indistinguishable. Ticatin€!apalient wjthout consent is legally ecluivalent to assaultand battery or any other form ofunwantedtouching.Therefore,in a scnsc,treatinga paticr.rtagainsthis wi)l and without hisconsentis like mugging the patient or beatinghirn up.Thereis no distinction betweenwithholding anclwithdrarving care.If you are doing soncthing the patient does not ant,you cannot sa,v,"We11,sorry, but I already started, and Ircallvhaveto continuc."ADVANCEDIRECTIVESDefinitionAn advancerlircctive is the tncthod by rvhich a Daticnt conmunicates his wishes for hishealthcarein advanceof becoming unable to make dccisionsfor hirrself. The aclvancedirectiveis a by procluct of the successof nredical thcrapies such as the mechanical vcntilator that can kccp a patient alive when in the past he would have cliecl.Becauseof thcsetherapies,doctorsarenorv in the position of trying 1qictcmine u,hateachpatientwantcdfor himself in terms of his health carc.Thc advancedirectivcis part of the conceptofautonomy.The advancedirectiyetellsthc physicianrvhatthe paticnlswishesaresothat thelcssaccurateforms of dccisionmcLking,suchassubstitutedjudgn.rcntor making a decisioubasedon irnotherpersonsideaof the bcstinterestsof the paticnt,bccomeavoidable.End-of-LifelssuesJ27icall b eLingtornttno!!l!!p vrorcnr
    • FHealth-CareProxvThe ttvo most comnon forms of aclvancedirectives are the living will and the health carcpror:7 Thc health-careprorrr orir.redicalpower of attorney" is thc durabre power of attorneyfor health-caredecisionsor medicalproxy.The conceptof a,durablc,,powerofattorDeyis critical becausethe word"durabre"means it remains in effect evenafter the patient rosesdecision-making capacity becauseof medical illness.Other forms of legal proxics, such asa finar.rcialproxy, bccome ineffective after the patient losescorsciousness.The health carcprorT is a person chosenspecificallyby the patient to lake health-caredecisionsfor her inthe evcnt that she cannot make decisions for hcrseH Thesedecisions are limited to healthcare,not finance.Advance directive docunents ntay also have written instructions to giveboundariesto care.For cxample,.rpatient rnay want to receivcantibiotics,but not wantto receivechenotherapy or diall.sis.However, the main focus of the proxy is to designatea person of"agent"who speaksto the physician regarding consent issuesfor aI treatmentsand tests,aswell asdiscussesissuesof withdrawing and withholding treatment.The proTspeaksfor the patient. Becausethe patient chooses the prorT as her representative,theproxy overrules all other decision ntakers. Therc is a strong presumption that the proxyknows the patients wishes.The proxy is not there to give his personal opinion as to whathe thinks should be done for tl.repatient. The proxy is there to communicate the patient,soriginalwishcsin order to ensurethat they arecarriedout.The pror:y is like a messenger.Ihe patient writcs thc message-hcr wisrresfor her ownhealth care-and the pror:1,delivers the nessage.you woulcl not want your prorT to alteryour 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 toeat (what kind of medicines and testshe rvants).The proxT praccsthc order ir.rthe kitchen.The prory is not there to alter ).our expressedrvishcs.you would not want to order chickenand havethe wartertell the kitchen you want fish. your waiter tries to understand what youwant to eat.lhewaiter doesn,twalk up acl tell you,,,you look weak and anemic. you arehaving a rare steaktoniglrt, which is what is bcst for you.,Now the main diffbrence is thatthis is a"restaurant"in which thc custon.rcris unconscious and can,t tell you exactly whathe wants.The proxy makcs dccisionsbasedon rwo paranteters:l. 1he patient.sdirectly expressedhealth carewishes2. 4rat thc patient woulti havewanteclif he/shchad capacitvI crapterriveM F D I C A LI(A PI"AN
    • h-careattor-torneyt losesuch ash-careher inhealtho give- wantignatementsproxye, theProxFwhat:ientslIs to;hen.cken.youI arethatryhatThesearethetrvo overriding principles:t. Thehealthcarepror.y must carry out the written and verbal wishesexpressedto himregardingthepatientshealth care;the basisforwhich is sornetimesjusthis understanding0fwhatthepatientwould rvantif shewereavaketo makethe decision.2. Theprox,voutweighsall othcr potcntjal dccisionmakcrs,including thc family.For example, a 75-year-old nar arrives at the emergency department febrile,shortof breath, and confused. Many family men.rbersaccornpany the patient,includinghis wife, his siblings, his children, and his grandchildren. The physicianlvantsto perform an emergency lumbar puncture, which the patients wife andsiblingsare refusing. His 25-year-old granddaughter r,valksup rvith a health-careprorylbrm signedby the patient designating her asthe proq. Sheinsiststhat youdotheiumtrar puncture stating that washer understanding ofthe patients wishes.Therestof the family, including the wife, refusesthe lumbar puncture stating thattheyknorv the patients wishesbetter.What do 1oudo?[egai,youshould honor the health-care prory aboveall other decision makers,regardlessofthelevelof closenessin biological relationship or frequency of contact. You cannot tellivhoin a family knows the paticnts wishesbest unlessthe patient is awaketo tell 1ou.Theprox,vdesignationis thc patients wa). of telling ).ou who he feelswill representhis rvishes.In the absenceof an advancc directive there is a list of relative importance in terms ofsurrogatedecisionnakcrs. You should start first with the spouse,then parents,then adultchildren,then siblings,tl.renfriends. This is an approximation only. lf the farnily is split initsrvishesthcreis no easysolution. When the family is split and there is no proxy, you nrustreterto lhcclhic.eommittecor thccorrrt for a iudsmerrl.LivingWillA living will is a written form of advance directive that outlines the care that a patientl,ould want for herself if she were to lose the ability to communicate or the capacity toundcrstandher medicalproblen.rs.The etiologyof the lossof decision-makingcapacityisirrelevant.A living will can range from being an extremely precise document outlining the exacttypesof care that a patient wants or does not want all the way to being a vague, uselessdocumentthat makesnonspecificstatementssuchas"noheroic care."The nain problemEnd-of-Lifelssues|2sMEDICAL
    • with the living will is trratmost of the tinrc it lacksprecisionbccausethe patientdoesnotexplicitly statewhich testsaud treatmcntsshewants for herself,A clocumentsaying..noextraortlinary cilre" is virtua[y rvortrrless.wrr.t croes"extraordinarycarc" nrean?I)oes thatmean a yentilatoror chemothcrapy,or dialysis,or bloocitcsts,or all of thcnr, or none ofthenr?If the living l is cxpricitin listing thc prccisenanes of the tcstsand lreatmentsthat thc patient *ould rike to receive(or not to receivc),then it is uselul.For instance,aliving will that says"Nointubatior, no cardiopulmonaryrcsuscitatron,no dialysis,and noblood transfusions" is vcry Lrsefuland allotvs fbr easyfollowinq.For example, a 78-year-old woman ts admitted with metastatic cancer Jeaclingtoa changein mcntal status secondaryto hypercalcenria.Shehas a lir.ing will in herrecordthat states,"Inthe cventthat I becomeunableto speakfor mvselffor anyreasonI rvish to expressmy r,r,ishthat I not be intubated or placed on a ventilatorunder any circumst.ruces.I alsodo not wish to reccivedialysis.Blood tcstingandantibioticsareacceptable.,,What shouldyou do?Thc Iiving will is nost valid antr usabrc*.hcn specific tcstsand treatmerts are outrined. Inthe cascabove follon the directio of the living will ancrcarry out the patients wishes.Alivig rvill woulcl overrurethe wishesof the fanrily beca,sctrrc riving will conmunicatesthe patieDtso.wn wishes.As a nlatter of autonon),, the patient! clearly expressedrvishesalrvavstakeprecedenceoverthc n ishesof other decisionmakers,suchastamily mentbers.Thc rnajorissueith the useof a living will is that it is very difficult, ur advanceof trrer-ness,to be celtain which medical treatmer.ttsand tcstswill be necessary.It is very difficuitfor a layperson to sa1,"Ido not tvant an albumin infusion with ny large volume paracen_tesis,"orAbiopsytbr diagnosticpLrrposesby interventior.ralradi.logy is acceptablc,but Ido not want an opcn biopsvil the operatir.rgroorn,,,or.,l agreeto antibiotics,but not toamphotcricin." A hcalth-care proxy allows for far greatcr tt.*it itity. Hor.vevcl if a patientreally does vvritcout the specific nantes of the nlost colftmon treatments and the param_etersfor their use,ther.rthe living rvill can bc a vcry usefui documelr.NoCapacityandNoAdvanceDirectivesHere is uhat is vcry ciear atrout withholding and withclrarval of caredecisions: An adult with capacitycandecideto acceptor refuseanv therapyoflered.. An adult Iithout capacitycanbe managedr,vitha health_careproxy or a living will ifthe Iiving lill is sufficientlyclearand specificenough.ttpftpnbcl(ll!!p v:orcer
    • End-of-LifeIssuesI5 lot-loatoftSaIOLlnfortunately,the ast majority of patients, een at oldcr age ad with life-threateningillnesses,do not havea formal advancedirective. Decision making ca be rmLchmo.. diffilcultin this circumstance.Ifthe family is united and in agreement,then there is o difficultyllith making decisions for the patient. The main issueagain comes to clemonstratjng tltebestevidenccof lctowing the patier.rtswishes.Forexample, a 64 year-old man suff-ersa severeiltracrallial bleed leavir]s himconatoseand paralyzed.His wife, sister,and four chjldren arc in the horpital.Theycome to seeyou bccausethey are unanimously asking that you remove theendotrachealtube and lcavethe patient to die. The patient repcatedlymadc thisrvishknown to his family. What shoulclyou do?Forapatient without the capacitr to understand his redical problens and no hcarth carepror-vor livirg will, the path of rnanagement is clear asrong asa[ of the familv menrbersar€in agreenlent.You can rcmovc the cnclotrachealtubc and let thc patrcnt dic if everv_.ne savsthat is what the patient has saitrhe wanted.rhe endotrach.artube is r medi.altherapylikc any other. The patient has the right to refuseit. The patientt fanrily or otrrerswhoknow the patient well can provicle the patients previously expressedwishes_an oraladvanceddirective.For example, a 78-year old wouran has been aclmitted to a nursing homc withadyanceddementia. Shehasdifficulty maintaining oral intake sufficient to survive.Thenursinghome wantsto placea nasogastrictutrefor-fecding.The husbandandthe son expresslystatethat the patient slid she.,never*lnted to be ntaintainedlike a vegetable"ar.rd"Idont want to be put on a ventilator or have a feedins tubedorvn my throat." What should you do?Arethe family members passinplon information about what the patient said, or are thevtellingyou to do what the1,think is bcst fbr the patient? you can do virtually anything inthecareof a patient, even without an aclvancedirectie, aslong as the family is united inpassingon what the patient said she wanted for her own care. problems arise when thefamilyis in disagreementabout what the patient said or rvhcn.rnsteadof expressingthepatientswishes, they are representing what they u.ant for the patient. Having a fan]ilymemberexpressa patients wishes is equivalent to having him cast a vote on the patient,sbehall If a person cannot speak,another person can mail in her vote for her if she hasclearlytold this person which candidate shervants to vote for. If she told her brother thatlvantedto vote republican and he sendsin her ballot stating this, then he is acting on her
    • r wishesasheragent.on the otherhand,if heberievesshewould preferto votedemocratifshewereawakeor hebelicvesonecandidateis betterfor her thentl.risrepresentsa muchlowerlevelof evidencefor hervote.Likewise,if hekows what shewantsbecauseshetorrlhim, then he canstopthe ventilator,the blood tcsting,the .h.tno,t "rupy,the dialysis,oranyothertreatment.EthicsCommitteeandReferraltotheCourtsihen there is no clear adyancedirective and the family does not agreeon what the patientwanted for hin.rserfor herself,then the right answer is to refer to the etnrcscommrttee andfinally the courts.Hcre is a list of thc various kinds of consent,with the most desirablelisted first:. Direct patient rvishverbalizedby the patient. Forrnaladvancedircctivesuchasa proxy or a living will. Oral advancedirective. United group of fimily and friends. Croup of family membersdisagreeingon what thc patient would havewantedIn caseswhere there is no living will or proxy and the family members are not in agreement,:h. :*:.:,:pis to"encourageconsensus,",,requestdiscussion,,,or..talkwith the partiesiltvolved" Ifconsensus is not possible,you should refer the caseto the hospital ethicscom_mittee. The last step to pursue in the absenceof a clear consensusis relerral to the courtsor"seekjudicial intervention.,,For example,the Terry Schiavocaseended up in the courts becauseher husband and sev_eral of her friends said the patient told them that shc ncver wantecrto be maintained in apersrstentvegetativestate.The patientt parents stated that she never saiclthat. The ethics::-.TiU::does not have direct legalpower and their decisions are not alwaFsuniversallybinding Ifthe ethicscommittee is unabrcto bucr consensus,or the involved parties ignorethe ethics committee, thcn judicial intervention i, n.."rrn.y.ratrldliI(APLAN MEDICAL
    • End-of-LifetssuesIocrat ifr muchhe toldysis,oratienteand"00NoTRESUSCTTATE-(DNR)ORDERSA"DoNot Resuscitate,,(DNR) or<;::t*:,f*.:f..H.il?#J+,:i;:*,,jffii,H;[i.*::i::::*::J:;thepatienrttr il;;;;;r/LxrnrcmedicationsThat is all nothingmore.Deathofbreath.ruddenlossof pulse,bloodpressure,and the ability toForex&mple,a 42_year_oldHlV_positivernan is admittedfor hematuriathat isffii:i"ilfiT:11]:tJ;;iHeisDNRu"r"gvi..""*r,edandthevthinknotwanttodoeith".on.b..or:^"11"1:-1ry"lllt-TfhtectomvhoweverthevdowhatshouJdyou tell them?sethe"patientisDNR ad thereforepreterminal."Forexample,a 42_year_oldman with AII)S is bcingtakento the operatingroomj:1:::lfl*.-, r]resurgicarresidenrshrussh;,";;i;;;;.,ays,.oh wel,:i:::::ff::iffifttli l*l)- tls itcr"oantreavmitie.irth.s,,.g.,vi,of a relicfl"Whatshouldyou tell hrm?DNRdoesnot mean patientssh(resuscitation.DNRt,.;;;";;;;;#,;,,.._";::fruli?fJ:J::illJ#:$T:ffiIdorngor servesasan excusefor making" _irtut". oNnlo;;;;.", it is okayjust toletthepatientdie,or thar thc doctor doesnot have,. b. ;;;;;;i,^ patienrcanstilt betiesrm-lrtsThemostcommonmisunderstandingabout DNR ordersis that beingDNR must meanjT.ffH"t$lfr",tiJ,:,;:i*",, l",ti..A"rh.;.;;;;;Jisuncrerstandinsisthatbropsies,or dialysis.o*o * ,r, "..9i1other aspectsof routine good caresuch"r r;;;:nomaandneedsab,.0,,"J;;;il:IiJ:;"Tl]:lh,TiillT,il:[]::::i::fl.;$:lJ:;l;::lT*ffffi:i::::*o;-p,t.;;,;;d;,ilo**o**;u.,-.u.,,whenapatientdiestt ".. i, o,uaa].ilp"1l^Tj:.1?,iT:t": thnd-pointoftherapv.usuallyingintravenous;.;t;;;;;r,;;tnraptoupgradein theamountof thetnpv,,u.h u, giu-maystiluncrergo,",r;,;;;;;"::;1,;r,T:.,":il.1L..:i"j:T:fi:1,Ti,i:n.Apatinttrhenpatientshavecardiopuln.ronaryarrest,thereis presumedconnaresuscitationunlessthe patient specificalryand expressivety;::i.J,X.*:tJi:;1 alcsIlvIE
    • I intubated and maintained on a ventilator if sheis DNR. This is a confusing point becauseendotrachealintubation is often a part of the normal resuscitativeprocess.If the pl rientirDNR and he loseshis pulse then the doctor would not intubate becausethe intubation herewould be consicleredpart of theCode or resuscitative/CPRrlanagement. Honever,ifthepatient remains alive and has advancing lung disease,the patient can still be intubated ln. this case,the doctor rvould only defer CPR if the patient were DNR. Doctors Jo not haveto rernovethe endotrachealtube of all patients who chooseto be DNR. Many patients willnot allow themselvesto be made DNR becausethey believethe medical staff will not beasaggressivein their other treatments.For example,a 68 year-oldman with basalcellcanceris aclmittedfor evaluationandtreatmentof a fever.He hasbecnDNR for thelastsixmonths.After the chestX ray,urinal)sis,andblood culturearedonehestill hasafeverof unknownetiology.When you askthe residentwhy he hasntdone more tests,the responseis,"Well,wervill getto it, but thereisntmuchof arush,alierall,thcpatientisDNR."What do you tell hin.r?DNR doesnot meanarrythingmorethan deferringCPR,suchaschestconpressionsandelectricalcardioversion.In thiscase,it wouldalsoeliminateendotrachealintubationif thistreatmentwerepart of the resuscitativceffort.That is all.Thedoctoris expectedto man-agepain andthe diaplnosisof othermedicalproblemsjust asaggressivelyasshewouldina non-DNR patientunlessthepatienthasspecificallychosento deferthoseotherformsoftherapy.Doctorsdo not automaticallyhaveto havethc DNR orderrcversedjust to beinthe intensivecareunit or to goto surgery.AT]tho1rtginhI ( A ? L A N M E D I C A L
    • -End-of-LiferssuesIieise€neltsFTUIDSANDNUTRITIONISSUESAdultswiththeCapacitytoUnderstandTheartificial administration of fluids a<1nutrition is a medical procedure and treatmentthatcan be acccpted or refused tothertreatn.rent.,Artificialodr,ir"n competent adult in exactrythe same manner as anyrhaneatins..Artinciar,,,o;;*,:::l::r.ffii:xffi:;T,f,::.Tiil :i::il:l:Sastricor jejunostomy turre pracement. Artificialnutrition" would also refer to intrave-]onslyadministered nutrition such astotar parentcrar nutrition (TpN), also referred to ashyperalin.rentation.For exqmple, a 47-year_oldtheoretical physicistwith amyotrophic lateral sclerosisnasDecomcprogressivelynore clisabledto thc point of beinj virtually immobiiein a rvhcelchairHe is unablcgastricreeding,ut.u,,a,.ru,.o,lo:illT::,:,:?tijJil,,";#;":JJ:l;:j,*:nurse,isinsistingthat you reinsertit. What shouldyou tell her?Forcibleinscrtionby anyoneof an artificial feedingdeviceinto an adurtpatientwith thecapacityto understandthe meaningof its rcmovalis not allowed.If the patient,swishesareclearlyexprcsscd,thisisthesamcasrefusingaventilator,bloodtesting,or dialysis.Thisrefusalis subjectto the samecriteriaasthe refusaiof oth", tl.,.rupiar.you must be surethereisnta severedepressi.nunderryingtherefur", "ra ,n"t,i. riiuent undcrstandsthathema,vdie without the tube.If thereis no depression,tn"n tn. fnt,.r.,t hasthc right torefttseatherapyeen ifhe will diewithout it. putting thc tubetru.t in,o apersonwhohasrcfusedit isconsideredthesan.reasassaultandbattery,.AdultsWhoHaveLosttheCapacityto UnderstandDecidingwhat to do aboutartificialnutrition vherthe pati.rt cannotspeakfor herserfisamuchhardercircurnstance.Nutrition is the singlemostdifficult issuern termsof witb_holdingandwithdrawingtreatment.We canneverwithhold ordinarynutrition like foodtoeatandwaterto drink. The stanclardof certaintyregardinga patientt wishesin termsof.artificialnutrition is much higherthan wirh other ,i.ropri."- il"rnort havevery clearefidenceof whatthepatient,swisheswerein regardto artificialnutrition.II(APAN-M E D I C A L
    • If there is a health-care proxy, and thc healthcare agent says,"Thepatient clearly told methat they didnt want tube feeds,"you nay withhold the therapy. If there is a living willrvhere the patient themselveswrote,"Ido not tvish to have a nasogastric tube or otherforms of artificial nutrition," you may withhold the therapy.lf there is no advancedirective,but the family is in uniforrn agreement that the patient had expressedthe wish never tohave tube fecds,you may withhold the therapy.If clear wishesregarding fluids and nutri-tion were ncver clearly expressed,thcn there is inplied consent for the feeding basedonthe presumption that it would be the patients wish to be fed and on the f-actthat feedingand hydration are in thc patients best interest.Emotionally, the standard is different from the standard used to dcternrine whether or notordinary testing such as blood tests or CT scansshould be donc. The proxy and fanilycan say,"Thepatient never specifically told rne that he would not want a liver biopsy orMRI of the brain, but mv understanding of his wishcs in generalis that he doesnt want toundergo theseprocedurcs."This would not be the same for nutrition. Decisions on with-holding and withdrawing of artificial fluids and nutrition should bc treated the samewayasany other medical treatnent. There is a higher standard of evidencefor decision makingin some states.That is why this issueis so complex. Fcw people have left a specific,writtendocument concerningtheir desirefor tube feecling.The evidence has to be clear that a paticnt does not want artificial nutritjon. Thc routineassumption is that rnost people wish to be fed asa part of ordinary care.If the evidenceisnot clear,then a referral to an ethics comnittee, or possibly to the courts, is necessary.Thelevel of evidence regarding the patients wishes necessaryfor withholding and withdraw-ing artificial nutrition hasbeen treated by some courts asthe sameasthe level of evidencerequired in a criminal case.The system errs on the sidc of caution-perhaps letting a fewguilty people go free rather than sending a single innocent person to jail or execution. Ifyou lost consciousnesssuddenly and left no specific instructions, wouldnt you want thereto be a need fbr colrvincing evidence that you didnt want to be fed before your relativesrvere able to withhold nutrition and possibly let you die? Ethical consensusholds thatdecisiolrs to provide or forgo artificial nutrition and hydration (ANH) for patients wholack capacity should be made according to thc same standardsasthose uscd for any othermedical treatment. Despite this consensus,ccrtain statesimpose more stringent standardsfor withholding or withdrawal of ANH compared to other medical trearmenrs.PInhirlif,clrTTncEA SacnithetPasethprtoasmmthAIl s$ lBITTI(1:.^9 MEDTcAL
    • End-of-LifelssuesImevillhcrive,to.ri-onrotilvO ItoLPHYSICIAN-ASSISTEDSUICIDEhrphysicianassistedsuicide, the physician provides the patient rvith the means of endinghisownlife.The doctor doesnot actuallyaclministerthe substancethat endsthe patientslife.Although there is national controversy on the issue,the answer on the USMLE is ver1.clear;physician assistedsuicide is alwaysconsidered incorrect and ethically unacceptablc.Thisis true even if there is a local state law permitting the procedure. W1rat is legal doesn0tautomaticallyequal rvhat is ethical. Generally,physician assistedsuicide is requestedbypatientswho havea terminal diseaseand a limited life expectancyanyway.Neverthelcss,theseverityof the diseaseand eventhe discomfortand sufferingof the patient do not changetheansu,er.Physician assistedsuicide is alwaysconsideredto bc wrong on the USMLE. Theprimaryissueis one of intent. Physician assistedsuicide is inimical, or absolutelycontrary,to the role of the physician to savelife. This is true even if thc patient is requesting theassistance.A physician cannot ethically honor a patients wishcs to bc provided with themeansto end his life.EUTHANASIAfith euthanasiathe physician goesevenL.rrtherin ending a patientslife than in physician-assistcdsuicide. Euthanasia actually means that the health-care worker is prescribing andadministeringthe method of death. Thele is no place in the United Stateswhere eutha-nasiais legal.A physician cannot legally administer a lethal injection or any other form oftherapythat will help end life. This is true even if the patient is preterminal. Fluthanasiaiscthicallyunacceptable.TERMINATSEDATIONOFTHE"tAWOFDOUBTEEFFECT"Thereis an enormous difference between administering a lethal injection and givir.rgpainmedicationsthat might inadvertentlyshortena patientslife. The issueis one of intent. Iftheintent is to end life, it is wrong. If thc intent is to relievesuffering and accidentally-asanunintended effect-the patients life is shortened,then the treatment is acceptable.Thisis comparable to the differencc bctwcen a charitable donation and being robbed. If I giveS1,000to charityto help othersit is avirtue. IfI stealevenonedollar from you,it is a crime.Both eventsresult in thc transfer of monev. however.the ethical distinction is erormous.For example, a 67 year old man is admitted with metastaticprostate cancerto thebones.He is in cxcruciating pain despiteyour present treatment. He has a historyay..n1eisteleIfe]SltoIs!!!!p iiaeorcer
    • I chapterFivet!l!!p rueorcar-of COPDandthehousestaffareconccrnedthatincreasinghisparnmedicationswill decreasehis rcspiratorydrive.What shoulcll.ou do?Aslongasyou arenot purposelygivinghigh_doseopiatesin orderto endthepatient,slife.it is acceptabieto givethepain medicatior.rsevenif it might decreasehis rcspiratorvdrive.Theprimary ethicalduty is to rclievesuffering.you cannot.iustleavetl.repatientto suffer.Givethepatienttheamountof ntedicationtheyneedto rclievetheparncvenif, uninten_tionally,thereisan adversecffecton the respiratorydrive.FUTITECAREThephysicianis not urder an obrigationto givetreatmentor perform teststhat wi rotbenefitthepatient.Thisistrueevenif thepatientor the familyisdemandingit..I.hemajorproblemin withholdingor withdrawingtherapyon thebasisof it beingfutileisbeingsurethat therewill beno bencfit.It is hardalwaystr becertainif the treatrent rvill not herp.Ifit isclearthattherewill beno benefitthcnyoushoLrldnot qiveit.For example,a 57 year-oldwoman with cryptogeniccirrhosisis uncleryourcare.Sheis septicandhassevcrevaricealbleedingaswellasencephalopathvnotrespondingto lactulose.Sheis hypotensiveand on pressorsaslvell asintubatedfrom respiratoryfailure and you expecther to die from her liver diseasein thenext few days.ShedevelopsHepatorenalsyndromeand hasdevelopeduremia.The family is requestingplacementof a fistulafor rlialysis.What shouldyou tcllthem?In this case,thereisa clearurderlying preterminarcondition.you shouldnot startdiarvsisor placethe fistula.Dialysisin this casewi| not changethe outcome.DirJysisin this cascwould not prolong meaningfullife. Becausein this casetlialysisrvouldonly prolong thedyingprocess,withholdingit is ethical,evenif thefamily is requestingn.DETERMINATIONOFDEATHANDBRAINDEATHlhctrvo nethods of def ing death arc ternination of heartbeat and brain death. rf theheart is still beating,but thc paticnt is brain dead,thcn thc person is clead.Brain_deathcriteria have enormous significance for the abilitv to harvest organs for donation as wellasin criminal cases.BrBranbrBrYcofstbrofBrofp.u!tn
    • End-of-LifetssuesIi9t sLife,drive.suffer.intenll notmalorgsureelp.IfFor example, a man is arrested fcrr arrned robbery in which hc assaultsanothcrman. The victim has sustained cerebral hcrniation and has lost all spontaneousrespirations,cognitive function, and brainstem reflexes.you are calledasan expertwitnessto advisethe court. The allegedassailant,sclefenselawyer tellsthe.judgethatthechargeonhisclientshouldor.ybcassaultandbattery,notmurcler,becausethepatientsheart is still beating. The defcnselawyer contends that the victim can bcalivefor many ycars ir.rthis condition.l,hcma,rimum penaltv in some statesformurdcr is life imprisonment or cxecution.The penaltyfor assaultmay be onlv l0to 20 yearsin prison. What shoulcl vou tell the juclge?Braindeath is the legal definition of death. An assaultleading to brain death is a murder.Braindeathis irreversibleand permanent.A bcatingheart that maintainsbrood pressureandpulse does not equal being alivc. When wc, as physicians, determine the criteria forbraindeath are present,this is the legally acceptedstandard of death.Braindeathis a lossof brainstemreflexessuchas:I,tcL.IPupilary light reflexCornealreflexesOculocephalic(dolls cyes)reflexesCalotic responsesto icedrvaterstintulation of the tynrpanic membranefhe.rb:en(cof .furrt.rneorrsrespir.rtionsvsiscasegthef theteathwellbu candeternine lossof respirations by rentoving the ventilator and observing for signsof respiration.lf the criteria for brain death are rnet, theD an EEG or ccrebral blood-flowstud)arenot necessary.In other words, the clinical criteria of the absenceof breathins andbrainstcmreflexesaremore important than an EEG.This is becauseEECactivitywou]d beof limited mcaning if a patier.rtmects tl.reclinical brain-death crjteria.Braindcath should only be determined to be present if you have excluded other causesof markedly decreasedbrainstem and rcspiratory function. you must be certain that thepatientis not suffering fron an overdoseof barbiturates,hypothermia, hypotension, or theuseof neuromuscularblockingagentssuclraspancuroniumrvecurontum,or succinvlcholine.Thesecanall simulatebrain death.For example, a 35-year-old yroman is admitted aftcr having a serzurear a parr)i.HerheadCT scanshowsan intracranialbleed.Sheis intubatedbecauseof the lossof spoDtaneousrespiration.Therearc no pupilary,corneal,oculocephalic,or coldcaloric reflexeselicited. Which of the follorving shoultl you clonext?I ( A P L A NHMEDICAL
    • r |$rapterrivea,b.c.d.e.EEGEKGUrine toxicologyscreenPsychiatriccvaluationEthicscommitteeevaluationThis patient hasmet most of the criteria for brain death.An EKG jnosedeathat anypoint. Auscultationof the heartis all ,h", i, ..;"irt":",:t::::t#tlf:stoppingof the hcartyou shouldexcrucreintoxicationwith cNs depressantdrugsandhypothermiaprior to determiningthatthe patientis brain dead.Brain deathdoesnot specificallyrequiredeterminationby a neurologistif the physicianmanagingthe patientis comfortablewith the criteriadescribedanclhow to verify them.Thisis similarto not needingapsychiatristin orderto determinccapacity.If thepatientisclearlynot braindeadbecausetheirpupilsarcreactiveor theyhavespontaneousbreathing,a neurologistis unnecessary.If thepatientisbrain dead,thentheyaredead.Thephysiciandoesnor needa court orderor a relativespern.rissionto removelife support.Thedoctordoesnot needto askanyone,spermissionto stop the ventilatoror.other treatment,althoughUSMLEwill alwayswantyou to answer"discusswith thefamily,,,,explainyour finding.s,,,or ..buildconsensus,,firstratherthanjust turning offthe ventirator.Thismaysee- .nritrudi.tory.voushouldalwaysexplainwhat brain deathmeansto the patient,sfanily. you needto answer.,explainthemeaningof brain deathto the family,,asthe first choiceif it appears.on the otherhandthe farnilyi permissionor conscntis not requiredfor terminatinglifesupport,becausea personwhois brain cleadis considereddead.Insurancecompanreswillnot pay for the hospitalizationor managcmentof thosepatientswl.roaredead.you canharvestorgansfor transplantationfrom abrain-deadpersonif thefamilyconsents.you donot haveto waitfor theperson,sheartto stop.Actually,it ispreferableto removetheorganswhiletheheart isstill beatingbecausetheviabilityof th" t."nrplur.,t.aorganstronglycor_relatesto how longit wasunperfusedafterremovalfrom the donor,sbodv-Atec(slteatPiP(AIn(T]thatInoffe!(AplAN ) MFDtcAl
    • l + rChapter6: ReproductivelssuesABORTIONAr adultwoman hasan unrestricted acccssto abortion through the end ofthe first trimes-terFirst-trimesterabortions are clearly unrestricted. Women do not need the approval orconsentofanyone elseto obtain a first-trimester abortion. In the secondtrimester the deci_sionisstill betweena woman and her physician, but the easeof accessto a second trimes_terabortionis lessclear 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 clearryrestricted.consent by the father foranabortionis not required; the fetus is consideredasa part of the woman,sbody antl doesnothavethe individual rights of,personhood until after birth.Thereis no compulsion on the part of the physician to perform an abortron if performingthisprocedureis ethically unacceptableto the physician. The patient hasa right to have anabortion,but they dont have a right to force you to do it, if it is objectionable to you.Inaddition,it is considered unethical for a patient to seekan abortion for the purposesotgendcrselection.It is considered ethically unacceptableto creterminethe gender of thefetusandthen abort the fetus if the sexin unacceptableto the patient.Forexample,a 23-year-old woman contesto your office seekingan abortion. youperformgynecologicproceduresand you havebeen trained to d-oabortions in thepast.However,you no longer find it morally acceptableto perform the procedurealthoughyou know how. The paticnt is insisting on having the abortion and isangrywith you for"abandoningyour parjcnr...,!hatshouldyou tell her?
    • 42|chaptersixO:I q:"*t rule,if therc is a procedurethat the patientwantsbut that you do not feelethicallycomfortableperfornir.rg,you shouldrcferthe patientto onoth.. physician.youcannotbecompelredto accepta paticntyou d., not wantor to do aprocedurewith rvhich),oudo not agrce.Jhephysicianmustvoluntarilyagreeto the relationship.CONTRACEPTIONThcre is no limitation on the accessto contraception for either a lran or a wontan. lt iscntirelyat the discretion of the patient. This is equally t..r. fo, ,rri,.,o.r. Contraception isone of the issuesfor which a n.rin,is not necessaryto ot,anir,.onrro.lJ,lsconsidered partially emancipated Parental consentSTERII.IZATIONBoth women and men have free accessto sterilization. Consent is or. y necessaryfrom thepatient. Spousalconsentis not Iinslaborti,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.MINORSl"j:11^.:.1:, l,not necessaryfor cithercontraceptionor prenatatcare.ln casesinvolr-lng reproductiveissuesfor minor-s,the ansrverrvi te eitherto just treatthc minor or to-encouragediscussion,with theusMrF;r,tr;;;;r";;:;::".*:1,:il1"J*l:..."x,:;ff:T::i[?:::,.,,J;issuesinvolving minors. The rules on parental consent in the caseof abortion are lessclear.Some statesrequire parental consent for abortions and others do not. BecauseUSMLE isa national exanrination and the rules on parental _r*n, fJ"rion vary frorn state tostate,there cannot be a singleanswerthat cither says,,noparental consent,,or,,Ies,parentalconsent is necessary.,,Therefore, the ansrverwill be,.eniourage the patient to discusstherssuelvith parents.,DTIrT]d(I ( A P L A N MEDICAL
    • ReproductivetssuesIDONATIONOFSPERMANDEGGS#::il,::,:T:1."1i,:l"i:"j::::::"J^:::10l,r:donatespernandunfertirizedeggsIn addition, paymeut nlay be recei, , ---.---"t slcrrD ano untertrfized eggs.rvords,there is nn l.-.r/eo ror spcrm ilncl unti:rtilizecl cgg donations. In ot_h"errvords,thereis no legalor ethicalc,- Lcggoonattons.lnlherr.ic h^-,-.,-_onrrnndr.rtion t,r sellingsperntand unfertilizeddonated,but not sold.Thercis, however,a prohibition .. Jlrurr. sPcror ano un.loner.rr.,,+_^. - rrLgainstselling tertilizecleggs.Fertiljzcd eggsmayy b elo rot feellclan.youith rvhichnan.It iseptionisconsentromtheincludr of thcnvolr-r o r t oessarl)uctiveclear.ILEisatetorental;stheqj:19 MTDICAL
    • Chapter7. OrganandTissueDonationl 4 sAUTONOMYOFTHEDONOROrganand tissuedonation 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 fullyHLA rnatched and a highly compatible donor. There are no other donors at thistime and the patient will likely not survive long enough to find another donor. Youarescreeningthe brother for the donation, but hc is not willing to undergo thesurgeryfor the partial donation.What shouldyou do?Thereis nothing you or anyone-including a court of law can do to compel a person todonatean organ or tissueif he clearly choosesnot to do so.The needof the recipient hasnoimpacton mandatin€la donor to donate.This is true evenif the donation is uncomplicatedforthe donor and the recipient will die without it.ORGANDONORNETWORKASKSFORCONSENTFORDONATIONFor example, a 30-year-old woman is your patient in the intensive care unit forrespiratory failure. The patient hashad a motor vehicle accident and hassustaineda massiveintracranial hemorrhage. The patient is brain dead and will be removedfrom the ventilator. You know that there are numerous patients in your hospitalwaiting for organs. The family of the patient is with you. You have an excellentrelationship with the family and they trust you. What should you do about thedonation?I(APLAI MFDICAL
    • 46I chaptersevenOnly 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 askfor the donation. Even if your relationship witr.r the familv is excelent, the organ donornetwork hasan enormouslygreatersuccessrate in obtaining consent.physiciansthat askfor consent for organ donatiolr are far rnore likely to be refused.Becausea greater number.f refusalswould leadto a lossof potentiarorgansfor donation when the shortagestatuteof availableorgansis critical,it is againstthe raw f.r doctors to obtain this consent.Bylegalstatute,only thosespecificallytrained to obtain consentfor orqan donation shouldapproachthe family for this consent.In addition, thereis thc perceptionof an enormous conflict of intereston the part of thefamily nhen a caregiverattempts to obtain consent.{4ren a caregivcr asksfor consent,itleadssome familiesto believethat the health-careteam is not doing everythingpossibleto preservethe lifc of the paticnt. This makes it scer that the priority of the health-careteam is to obtain organs. It is essentiarfor the hcarth-care teanl to preserve its rerationship rvith thc family asthe advocatesfor prcserving the rife of the patient. In addition, theorgandonation networkhasa much greaterchanccof obtainingcolscnt, soif the primarvhealth careteamtries to obtain consent,it cor.rldlcad to a lossof neededorsans.PAYMENTFORDONATIONSWith the exception of renewatrletissuessuch as spermr unfertilizcd eggs,and blood, pay_n.rcntfor organs is consideredethicarly unacceptable.peoplc must not bc in the busincssofsellingorgans.The economicaspectsof organ clonationmust be ninimizecl so that pcoplebelievethat the patients who need organs the most w I get them, not that the rvealthvwillget preferential treatment. It is,howeveq acceptableto cover the costto the donor of dona-tior.r.lhere is a differencebetwecn reimbursing the donor for the cost of donation andcreatinga finalcial incentivcfor pcopleto,,sell,organs.ORGANDONORCARDSAlthough an organ donor card givesan indication of a patientswishcs for donation, family consent is still necessaryfor donation. Family objection can overrule the organ donorcard.PIIoSrlr(PialcaSCirPtlrlPPlctlTrtrfcalbi!t,qptl N) N4r orc.Ar
    • 47n conot askdonorLataskrnbcr;latutcnt. Byhouldof theent,ttrssibler-carettion-n,theLlTlAIVpay-:ssofeopleywillona-L a n dPhysiciansand laboratoriesaremandatedto report a nunber of medicaiillnesses.Themaipurposein reportinginncssesisbothepicremiologicaswenasto rnterruptthespreadofcertaincommunicablediseases.The illnessesthat arealrval.sreportableincludeAIDS,qphilis,tuberculosis,gonorrhea,andallofthe childhooddiseasessuchasmeaslcs,mumos.rubellaandpertussis.Thc list of other reportablediscasesis extensiye.Thesediseasesarereportableby sonrebody,not necessarilythephysician.Phvsiciansarealwayslegallyprotectedfor participatingin partnernotification.In gcneral,thehealthdepartmentperformsthe majority of contact_tracingeventsaswellasnotilyingthosethathavebeenilr closecontactof thepossibity of infection.fhenameof theso,.rrcepatientisalwaysprotected.Partnernotificationexistsfor diseasessuchasHIV/AIDS,syphilis,gonorrhea,andtuberculosis.In addition,thehealthdepartmentcanincarceratepatientswith tuberculosisto prer,entthespreadof diseasc.If a patientwon,ttell his or herpartner,thenyou must ansu/erthatyou must follow your duty to report.If the sourcepatiert still won,ttell his or herpartner,youarewithin your legarright to tell theinnocentthird party.partnernotificationandreportableillnessesarcanexampleof oncof thefewtimesthatthc patrentsautonomycanbesupersededbecauseofthe necessityofprotectingothcrs.My rightto autonomyendsrvhereyour safetybegins.I havean absoluteright to privacy,exceptwhen my restaurantseresfoodinfectedwithsarmonera,andthenthepatientsrightstoautonomybecomeressimportantthanprotectingothersfron harm.Tuberculosishasspecialreportingand public healthissues.In additronto doing contacttracingofthe contactsin orderto do ppD testing,thereisthespeciarrssueof incarcerationfortuberculosis.Patientswith tubercurosisshouldbeisolatedfor abouttwo weeks,whichisapproximatelytheamountof time thatistakesfor sputumto becomenegativefor acid-fastbacillilf a patientrefusesto takeantituberculosistherapy,physicianshavethe option ofChapterB: Reportablelllnesses[amlnorMTDICAL
    • | .ruo,"rrirr,lrcarceratingthepatientto preventthemfrom spreadingthedisease.Thisis onlyfor thosewho stiJlhavepositivestainsof their sputumfor acid_faitbacilli.Incarcerationfor tuberculosisis not thesamething asbeingarrested.It hasnothingtod0with the criminal-justicesystem.The incarcerationo..ur,-in a hosprtalnot in a prisonor jail. Youcannotforce-feedtuberculosismedications,but you canpreventpeoplefromwalkingat their leisurein the community to spreaddisease.Incarcerattonis a lastresortandis.onlyusedafteraother optionshavebeenexhaustedin termsot havingdiscussionswith thepatientandofferingdirectlyobservecltherapyat home.coA s phvity rtherhenwhaddaut(testPrePOSAltlnanrighHIll{!!P urorcer-
    • l r sl d oisonromSOItionsChapter9: HIV-RelatedlssuesCONFIDENTIATITYAswith all medical information there is a presumption of confidentiality on the part ofthephvsician.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 facilitythereis general consent given that allows the routine testing of blood for chernistry andhematologyand so on. There is an additional HIV-related consent required to testfor HIV.hen a patient signs a releaseto distribute or transmit medical information there is anadditionalconsent required for HIV or AIDS-related information. You cannot mandateautomaticHIV testing of patients without their specificinformed consent that you will betestingfor HIVFor example, a woman com€s at 10 weeksof pregnancy for prenatal care.Shehasa historv of sexually transmitted diseasessuch asgonorrhea. You offer HIV test-ing,which the patient refuses,asa routine part of prenatal care.Shereturns at 14and l8 weeksof pregnancy but is still refusing becauseof anxiety that shemay bepositive.You inform the patient that there are medications that can reduce trans-mission from mother to child to lessthan 2 percent. She persistsin her refusal.4rat should you do now?Althoughthere are medications to prevent transmission of HIV to the fetus during preg-nancl,you cannot compel mandatory testing of pregnant women. The woman has theright to refuse testing as well as to refuse antiretrovirals. Therefore, you should offerHIV testing universally to all pregnant women-but there is no mandatory testing of thepregnantwoman without her expressconsent to do so.If the woman is found to be HIV-positiveyou cannot mandate the use of antiretrovirals even though they are safe andI ( A P L A N MEDICAL
    • T]til50|chapterNine!l!!!p rureorcar-effective in preventing transmission of the virus from mother to ch d. Althoueh fromtime to time, there is aberrancyin the Jegalsysten.rthat tries to prosecutea drug_u.ingoralcohol-using pregnant woman, the autonomy of the mother lcgalry outweighs thc safetyof the fetus.For example, an HlV-positive tvoman comes to labor and clelitery at 40 weeksof pregnancy.Shehas a very low CD4 coult (lessthan 50) and a high viral load(more than 500,000).You offer her a Caesariansection and intravenous zidovu_dine, which can cut the transmission rate in half even on the day of delivery. Thewoman is anxious, but clearly has the capacity to understand the implications ofthis decisionon both her healthand the healthofher child.Sheis stirrrefusinstheC sectionand medications.What should you do next?Fortunately this circumstanceis rare and the HIV perinatar transmission rate in the unitedStatesis well undcr 5 percent.However,a rvomansright to chooseher own forms ofhealthcareare consideredsuperior to virtually all other treatment concerns.The wrong answerina question like this would be to give the medications an1.way,to gct a court order to compelthe patient to take the zidovudine, to askthe father for consentfor either the zidovudine orthe C section, or to sedatethe patient and pcrforn the C sectior.r.The autonomy of the mother is regarlvsuperior to beneficencefor the fetus. Althoush a40- lveekfetus is a viable child, the fetus is still inside the womans body and doesnt becomea person until it is delivered.A noman has the right to refuse HIV testing in pregnancl,to refuseantiretroviral medicati.ns in pregnancy,ancito refuse a c-section even if it willmarkedly benefit the child.PARTNERNOTIFICATIONThc highlevelof confidentialityconcerningHIV canonlybebreachedunderveryspecificcucumstancessuchaswhenthe healthof a third party is at risk.A crrcumstancesuchasthiswouldbervhenanHIV-positivepersonhasasexualor needle-sharingpartnerthatisatrisk.Themethodof notificationfollowsthestepsof first counseringapatientto notiryhispartnersvoluntarilyThis wourdbeidealandfollowsthegeneralthemeof uSMLE,rvhichis to first answer"encouragediscussions,,when listedasoneof the choices.If the patientis eitheremotionallyunableor unwilling to notj$ their partnersthenext stepis to notirythe Departmentof Healthto startthe processof contacttracing.Thehealthdepartmentinterviewsthepatientand attemptsto constructa list of partnersin orderto notify them.PiolTttrft(Py(ylsts(ttvst
    • ntV-RelatedrssuesIh fromsingorr satctyksrdl -letfThisisa voruntaryprocessand thercis neithera penaltynor criminal threatof prosecu-tlonif thepatientchoosesnot to corply. fheh*ih d"p".t;;r,t.,.n ,.rr.t, noticeto thepartnerthatthereis a bealth_relatrortheirpotentiar"*.*;; il:iiil.:.jlHffj,I#Hii:,i:jift:;*:.T;[:ffi[i[::]ff;l;;.:*errevearedtothepartnerandtheconndentiaritvorlf thepatiertisstilJunwilling to disclosethenamesofhis contactsyou cannotcompelhimtodoso.Thereis no incarcerationpaticntrvillnot notiff his partncrsrrmtnalpenaltyfor not disclosingthesenames.If arouhaveresarr--,,i,,,.,.,,.f;::X.r.T.,*.::,"j#j#5ffi:ii::,T..HJj*youdonotifythe partner,but it is r**{:t_#;1tiliilLt;:#J:::i"i"ffi#;:,TJff:iffi:i,::Forexample,you havea patientin your cJinicwho is accompanedby her boyui"il tn: is ciearlyhavingunpru-recredsexbecause,t " l, pi.grru.rt.Whenyouaskif her boyfriendknowsher HIV staru..,,Jr" ,"ys, _;;:.;;not_he mightleavemeif I told him.,you hayea protracteddiscussionaboutthecriticalinrportanceof notputtingherpartneratrisk.youstronglyenco"r"r"i., a ,.,, nr_ n*HIV status.On asubscquentvisit,whenyuu urkh"".ifrh" t or"noiln.a1", po.,n.,shesays,"Notyet.,,youkrow the boyfriendb.."",. h. ;..;;;ai., he, to th.officevisits.4ratshoulclyou do?--- -!!vir(I"^:..Ll.0",n," duty to the patient in rermsof her healthcarean<ther confidentiality.,toneyer,),oualsohaveaduty to protectthepartncr.you f,"". f.g"f i_.r",ty ifyou notii/thepartnly.At thispoint citheryou canasktheheaitha.pur,rn..* a ,ro,ifythepartneror::: lr:i Ir Iyo^urself.If thepartner wereto seroconvertfor HIV and you did not makesurehelvasnotified you rvouldbe legallyliablebecauseyou aJ ,.rJ,tolto* your duty toivarn.Thisis similar to havinga psychiatricpatientwho told rou rr"lvu, gorngto harmill.ili:-1tjn:rlnyouhaveadutytomaintaintheconfia"",.ii,i"i ,n"p"tient,youalso]laea duty to iDfofln the person at rrsk.nitcdealtherinnpelleor)mercy,willficasatis:hItirtt.(lPt,!p rarorcar-
    • 52I cnapterltineHIV-POSITIVEHEATTH-CAREWORKERSThere is no duty on the part of an Hlv-positive health careworker to inforn.r his patientlof his HIV status.Universalprecautionsaresupposedto be maintained.Theseshouldpro-tect the patients.An HIV-positive physician who practiceshigh-risk surgical and obstetricprocedures is expectedto maintain precautions to protccl tlre patients fiom transnission,REFUSAI-TOTREATHIV-POSITIVEPATIENTSIt is ethically unacceptableto refuse to treat Hlv or take care of HlV,positive patientssimply becausethey are HIV-positive. lf you have a physician to whom you refer patientsfor various treatments, it would not be ethical for that person to discriminate only on thebasisof the patient being HIV-positive. On the other hand, you cannot con.rpela physicianto take over the management of any patient if the physician doesn,t u.ant to do so.If yourquestion brings up the subject of rcfusal,the best answcr is to refcr the paticnt to someoneelsewho will perfnrm the care.T}antoHCrbtIrdct1tltltlAIthhI(API.AN M E D I C A L
    • ] s rntsro-r1c)n,rtshe1nurneChapter1O:SexuallyTransmittedDiseases(STDs)Theethicalissuessurrounding STDs havc to do lith partner notification, contact tracing,andreporting requirements. Although reporting requirernents vary somewhat fron-tstatet0state,certain diseasesare reportable nationally such as syphilis, gonorrhea, and AIDS.Herpessimplex is generally not reportable and there is no contact tracing for herpes.Contacttracing is predominantly used to intcrrupt a cyclc of transmission. Herpes cannotbeeradicatedfrom the body; hence there is no utility in treating the partner. Gonorrheaands,vphilis,however,can be asymptomatically carried try the contacts of our patients andtheycanbe transmittedto additionalpartnersevenif the sourcepatient is asymptomatic.Inaddition,syphilisand gonorrheacanbe eradicated(cured)with treatment.For exomple,tsob is a 32-year-old man in your clinic being treated for primarysyphilis.He is very embarrassedabout his diagnosis and he asksyou if his condi-tion rvill be kept confidential. Wliat should you tell him?Justbecause,voumust contact and treat partners of patients rsith STDs such as syphilisdoesnot mean you will breach his confidentiality and identit| him as the source to lriscontacts.l hereis a clearorder oftracing and treatinghis sexuaLcontacts.Ifthere is a choicethatsays"encouragehim to notif. his partners" or"askif he hasalready told his contacts"thatshouldbe the first thing 1oclo.If that is not a choice,then you should ofler to informthecontactsfor the patient if he doesDot want to do it. At all points you should be clearthat,vouwiJl not contact his partners and say,"llobgaveyou a disease."Forexample,Bobtellsyou that he is rot confortable informing his partnershim-selfand he doesnot want you to cloit either.What shouldyou tell him?!l!!!p nreorcer-
    • I ( A P L A NChapterTenThe Department of Health car.rcompile a list of contacts of patients with STDs and notifithe contacts that they are at risk. The Department of Health does not dir.r"rlgeBobs nameto the contact. The Department of Health contactsthe partners and saysthere is an impor-tant health issue concerning them that has come to the departments attention and thenasksthem to come to the hcalth departrnent. 4ren they arrive, the partners are told forwhich diseasethey are at risk, but they arer.rottold the identity ofthe source.The1.n1.1h.nencouraged to seektesting and treatment. The najority of patierts r^/ishto 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 Healththe names of his partners. He sayshe is mor.rogamousnow and, in fact, he isaccon.rpaniedby his pregnant wife. He hasnot told his wife ofhis condition. Whatshould vou do now?As always,you shouldanswer"encouragchim to disclose,""offercounselingfor partnernotification,"or somestatementthat is gentlein termsof respectingthe patientsautono-my.If thesearenot in the choicesor the patientrefusesthenyou nust directlynotif. hispregnantwife immediately.Her testingandtreatmentis essentialto protectboth her ownhealthaswell asto preventperinataltransmission.Congenitalsyphilisis a seriousanddangerousdiseasebut is entirelypreventable.For example,you politely inform Bob that you havea duty to protectboth hisrvifeaswell ashis child andyou areforcedto noti$. her or havethe l)epartmentof Healthnoti$. her of her risk of syphilisif hewill not do it. Ilob becomesfuri-ous and threatensto sueyou if you violatehis confidentiality.What shouldyoutell him?Youarelegallyprotectedif you inform a personat risk of harm. ln addition,thereis aduty to warn peopleat risk of harnr.Bob cangetasupsetashewants.Youarenot legall,vat risk.DEMa1Maldar<thinPatreletiveoccansuil nUIdrMEDTCAL
    • s sotifyLamePOI-thenl f o rhenChapter11: Malpractice!!l!!P ueorc,rLtertorisvnrdDEFINITIONNlaipracticeis a preventable errrMarpracticeisur-a"p",,a.nioi::?.:n:jJT,i:Hl"T:]:i:;:,LT;:*:f""Hl:dirrdof carein alocalcommLrnity.In otherwords,if theplysicianalAor did not do some-thingthatwasdiff-erentfrom whatislocallyaccep,"ap.u.,i." *u, .esultedin harm to thcpatientthenmalpracticeoccurrecr.Theintentor ievcrofgoodwl ofthe practitionerisr.1..,trelevantifharm occurred.Ifa vertir.efaiiureinsteadorr,,.,"-,o"liXi,,""Jln,Jr...l"J,""l:lfll:,.|lJ,l#:?rf"occurredif thepatientsconditionworsenedandhewasharmed.If thebestsurgeonin thewofldamputatesthewrongfoot,thennaipracticchasoc.o.rJ. Uo* ni." ,oneoneishasanenormouscorrelationwith hosuit,but it doesntestablishliablif,igry Pattetsmay beand how likely theyareto fi]eFor exampre,a surgeonis consultedto placea centrarline. Hc rsveryrude andarrogantand speaksharshlyto the patient.Thepatientsignsconser.rtalterbeinginformedof theconplicationsandalternativesin manng.i.n,. o pn"uroorl.,oru"occursandthcpaticntisinfuriatedthatthis,,high_hand"edbastard,,hurthirn.Hefilessuitagainstthesurgeonfor malpractice.Wl;1 will bethemostlikelyoutcomeofthc suit?In the same_way that being pleasantdoesnot absolveyou of liability,beingharshandunpleasantdo not equalrnalpracticc.A pneumothoraxil;nn n..^innut complicationofcentralline placement.Thepatientwasfully informedof thisandstill agreedto theproce-durc.Therehasnot automaticaliybecnwrongdolDgin thiscase.I
    • |.huo,u,a"u"nEvidenceof harm is an important part of establishingmarpractice. lhere must be both anerror ln the care,aswell asevidencethat there has been an adyerseeffect on the patient.For example, a patient with diabeteshasosteomyelitison an X ray ofhis foot. Thephysician does not perform a bone biopsy and givcs the patient oral cefadro:i:7lfor six weeks.After therapy is over, the osteomyelitis has completely resolved.The patient secssome literature on the Internet several months later conclu_sivelyshowing that a bone biopsy is an indispensablepart of osteonyelitis care todetermine an organism and its sensitivities.In addition, he seesthat intravenoustherapy is the standard of care.He files suit againstthe physician. What will be themost likely outcome?The patient is right that the physician deviated from the standard of care on these twopoints. However, his diseasewas effectively treatecl and thcre was no harm clone to thepatient, and in fact there was benefit. Therefore, malpractice has not occurred.DEVIATIONSFROMI.OCALSTANDARDSOFCAREPhysiciansmust practiceaccordingto acceptedtherapybasedon demonstratedefficacy.Becausethereis a certainamount of subjectivityin care,it is incumbentupon the physicranto determinewhatthelocallyacceptedstandardof careis.In addition,you mustfullyinform the patientof all optionsin carein orderto makea truly iformed choice.For example,a surgeonhas_just moved into private practicein BeverlyHills,California,aflerhisresearchfellowship.His patientwith lymphomasrgnsconsentfor anexploratorylaparotomyto stagelymphoma.He doesnot inform thepatientthat CT scanningisavalidoption.Thesurgeontellsher,,,Idon,ttrustthosescans.Wealwaysdid laparotomiesin my fellowship.,,Thepatientdevelopsanabdominalwoundinfectionleavingherwith a scarthat endsh...n..., o, a swimsuitmodel.In the suit that followsthe surgeonstates,,,ldid the mostaccurateprocedureformy patrentto excludecancerin the abdomen.That is what all my protessorsdidin their studies."Wlat will mostlikelybetheoutcome?Thesurgeonerredin twoways.First,hedid not explainto thepatientthat aCT scanof theabdomenis avalidoption to excludestageIII ly_pho_u. Becausehedid not fully informher,he will probablylosethe case.Second,the localstandardof careoutsideof certain!(AP!AN ) MEDTCAL
    • MalpraaiceI,othantient.herylrd.u-toISleresearchprotocols is to do only the scans.Becausethe patient developed a complicationhoman avoidable procedure and there has been harm, the physician is at fault and willprobablylose the case.The same reasoning would be true for a surgeon insisting on anarillarylymph node dissection for evcry patient with breast cancer instead of a sentinellymphnode dissection. If the patient develops edema and cellulitis from an unnecessaryprocedure,then there hasbeen harm. The sentinel node dissection is most often the localstandardof care.In addition, if the patient was not informed of the option of an axillarydissection,then there has not been full informed consent. The patient cannot choose aprocedureif shehas never hcard of it.INFORMEDCONSENTPROTECTIONAGAINSTLIABILITYErrorsandcomplicationsdo not autornaticallyimply malpractice.In termsof errors,partoftheliabilitydependson whetheror not the error resultedin harm to tne parlent.For example,a patientadmitsto the hospitalfor a kneereplacement.The staffforgetsto startthe patient on deepvenousthrombosis(DVT) prophylaxis.Thepatientdoesnot developa DVT, On transferringcareseveralmonths later thepatientobtainsa copyof the chartandseestheomission.He filessuitfor a devia-tion of care.What is the mostlikelyoutcome?Althoughit is a clearerror to omit DVT prophylaxisin this case,no harmhasoccurredtothepatientandit would bedifficult to obtainmonetaryreimbursementfor damagesif thepatientisunharmed.Complicationsof therapydo not imply malpractice.The main issuein determiningmal-practiceis whetherthepatientwasfully informedthat the Itarmcouldoccurandwhetherornot hewasinformedof othervalid optionsin therapy.If hewasfully informedandhesignedconsentan).way,thenmalpracticehasnot necessarilyoccurred.For exemplq anactressdevelopsstageIV non-Hodgkinslymphoma.you informher that neither surgerynor local radiation will be appropriate.Sheagreestoundergocombinationchemotherapyand hasbeeninformed of all the potentialadverseeffectsincludinghair loss,sterility,and peripheralneuropathy.Ihe usualandcustomarydoseofthe chemotherapyisgivenandthepatientlosesherhairanddevelopsneuropathyfrom the vincristine.Sheis not ableto work becauseof herappearance.Shefilessuitbecauseof this.What will bethentostlikelyoutcome?e trvoo thethermlin!!l!!p urorcar
    • I ( A P I A NAlthoughin this caseharm hasoccurredto the patient,the physicianis not herdliabreformalpractice.He hasfully informcd the patientthat her besioption for survivalwasche,nrotherapyand thathair lossandeuropathy couldoccur.Althoughit is unfortunatethatthishasoccurred,that doesnot makeit malpractice.INFORMEDREFUSATISASIMPORTANTASINFORMEDCONSENTlf a paticnt refusestherapy it is not sufficient to saythat the patient was a competent adultwho had the ability to refuse therapy. The patient must be fully informed of the effectsand possible outcomes of refusing therapy incruding all the harm that courd occur rf thepatient still refusesthen there hasbeenno malpractice. It is alsonot acceptabreto saythat apaticnt wasdifficult, abusivc,or unable to understand English.The physician hasan obliga_tron to provide information to adult patients with decision-rnakig capacity in a languagethat they can understand.For example, a 60-year-old rlan conles to the emergetcy department with onehour of chestpain and an ST seglnentelev.rtionmyocardial infarction. The patientis a recent immigrant who speaks French and untlerstands little English. youinform the patient that the besttherapy is angioplasty and possibly thrombolytics.You explain that they can develop intracranial bleeding from the thrombolyticsancl a hematoma at the site of the catheter placement from the angioplasty.Thepatient, anxio,s to avoid thcse complications, refuses both. you do not doublecheck the refusal with a translator. The patient dies and his family suesyou formalpractice. In your defense you point out the clear fact that you offered thepatier.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 atsoinfbrmthem of the complications of not receiving the therapy.ln addition, if there is the questionof a languageproblem,you must obtain a translatorto double checkyour patient understandsthe impact of withholding the treatment.In this caseit was not docunrentecrthatyou told the patient that he could die without the treatment. He was not fully informed.Youwould losethe lawsuit.PoLrPimy(Pp(RR[(illoI1irnIrltnMEDICAL
    • ableforas che-rte thatPATIENTSMUSTFUttYINFORMTHEPHYSICIANOFTHEIRMEDICATPROBTEMSFor example, a man is admitted for a possible DVT. He denies any past medicalhistory. He does not infornt you of his recent diagnosis of a gastric ulcer afterencloscopyfor severeuppcr gastrointestinal bleeding. There is no previous recordat this hospital. You give him heparin anrl he hemorrhagesrnassively.Hc suesyoufor harn.ringhim. His lanlrcr knorvs1ougaveheparin to a patient rvith a history ofbleedingtl.ratharmed the patient.What rvill be the most likely outconc?Inaddition to a patients rigl.rt to be fully infonned of the risks and benefits of therapr,,thepatientalsohasa responsibilityto inforn you of their entirc medicalhistory.Thereis nomalpracticeif the patient has a complication from a previoLrsillnessthat he did not tell)rcuabout and you haclno way of knorvir.rgol If the patient has a history of an allergy topenicillinand he doesnot tell you when you ask,you arenot held liatrleif ,votLadministerpenicillinnnd he developsan allcrgicreaction.RISKMANAGEMENTRiskmanagement is thc term applied to the administrative portion of the hospital devotedto assessingliability issuesin terms of care.Risk managententassessesdeviationsin carcandanalyzescasesin which rvrongdoing might haveoccurred in order to mininrize the riskof litigationfor the hospital.MEDICATERRORSThc pl.rvsicianhas a duty to inform patients of crrors in care if those errors will have animpacton the paticr.rtscare.The patient has a right to hnolwhat is happeningin hismanagement.This includes all errors that ntay affect the outcorrc of the patients care.lnforn.ringthe patient is not limited just to telling him about the errors that you krow helill find out about or to infbrm hin.rjust about thc ones that may rcsult in litigation ar.rdmalpractice.If I bring my carto you for repairand,vourassistantbreaksthe lvindshieldbyrnistake,I l.ravea right to be informed. The car is my propertv and I havc a right to knorvr.vhatis happeninglrrithit.tvtalpracticeIssNTt adulteffectsIf thcthatabliga-guageetI!j!!p rrarorcnr
    • 50IChapteretevenMEDICALOn the other hand there is no mandate to inform a paticltt about minor errors that willhave no impact on her care or treatment. If thc blood tests wcre delayedor a single testforgotten the patient does not have to be informed of this as rong as the informatioisobtained in a timely fashion and aslong asit will not impact her care.The main dcterni,nant of the rced to inform the patientis not the rnagnitudeof the n.ristake,but rathertheimpact on her life and healthcarc.BTCIPitcn ln (T]tl1suacaarotITImseI(A PIANI- r
    • l s tat willJetestion isermi-T theChapter12: Doctor/patientRefationshipBEGINNINGANDENDINGTHEREI.ATIONSHIPTherelationshipbetrveena doclenteredfrcetyon both sides.t.,:: :ti.:],.-^i.."."-tltis a voluntarvrclationshipthat is to beparticurarcroctorash..ph^i;;il1il:ff1"il,.IlHl$;::ff.1ffH::.lfi::l]:;toaccepta paticnt without his agreentent.A doctor must agr." to u.c.pt o patrent.There isnoobligation on the part of thc physician ,o ,...p, u pu,iJn,.-r.i,l ,, ,.u" ,.,u,.,,atterwhatneedthc patient hasand whatever expertisethe docto, n.,oypnrr"rr.For example, a patient with diabeteslives in a small town with onJyone endocri-nologist.The cndocrinologist hasa fulJ practice ancfis,.ro, o...prurg n._ puai.n,..The patient hasvery bad diabctesand has^a..,erycornplcx ,"gin-r.r, tlrot lr., fn-itypractitionerinsistsis beyond.thcscopeof his ,nde.rt"ndiri. .l.hcpatient showsup in the office and insiststo the office managcr that sheb. a.l.pt.a. Wfrut st nutabcdone?Thephysicianis under no legalobligationto acceptthe patient.Thereis considerablcmis-understandingof this issue.The physician, by training and,".iir",ar, ,, ,*.ed to aiclthcsuffering However there is stilr no mandate for rhe piysi.io.r ,o u...p, ,r.,.patient nor canapatient force a physician to take care of her. Even .ood Sumorita., laws,which protectscaregivers_fromliability if they aid a sick person in ,fr" *r.",, ao norinrce the cloctor to aidaninjured person. you may feel a m.ral obtigation,. h"ip ;;;;;;., but there is no tegalobligationto enter into a doctor/paticnt rclationship.ffri, i, i;f..",,t from a hospital!mandateto provide emergencytreatment to an).onewho comesto the encrgency depart_mcnt.Hospitals cannot turn anyoneaw:ryat the door of their._.rg"r,.y roo,, ifthey comeseckingcare.This doesnot mean they must provide continuous careafter discharge,but it!(A PtAN ) MEDICAL
    • iIchaptertwelveMEDICALcloesmean there is a national legalmandate for all hospitals to provide energency management and tleatment of all patientsOnce a patient anclphysician have enteredinto a carerelationship there is far greatercom-plexity in ending that relationship A physician camot suddenl,vend the relationship Hemust maintain the care of the patient until thc Patient can find an aPplopliate altefnatesource of care and he must piive"reasonablenotice"GIFTSFROMPATIENTSSrnallgifts trom Patlentsot nominal or modestvalueareacceptableon the part of th€phyri.i t-t.This is providedthat thcre is no expcctationof a differentform of therapyoro tligh., 1.u"1of carebasedor.rthe gift YoucanaccePta cakeat Christmasa balloononyour L,irthclay,or othertokensof esteem,trutnot if thepatientexpectsanextraor difterentprescriptionfor something,in exchangefor the giftThe ruleson giftsfron patientsarefar lessrigorouspreciseor ctearthanthe rulesongiftsfron.rthe-pharnaceuticalindustryThereisalraut()maticpresunlPtionthatgiftsfromi-ndustryahvayscarryan ir.rfluencetolvarda productserviceor prescribingpracticeGiftsfrom industryarevierveddifferentlybecauscthcrecanbc no otherintentionbehindthemexceptto buy influenceandalterbehaviorTbercisno suchautomaticpresumPtiononthepart of giftsreceivedftom PatientsDOCTOR/PATIENTSEXUATCONTACTSexual contacl between a physicitrn and a patient is alwaysinappropriate lt is unclear ifthere can ever be a completely acceptatrle,ethical rvay to alter the Physician/Patient relationship so that sexualcontactis acceptabteAt the vcry leastthe fhy"iciin alld patientmust mutually agreeto enclthe fornal prof-essionalrelationship of a doctor ancla patientIt is not clear horv much time mlrst elapsebetween the ending of the professional doctor/patient rclationshipar.rdthe beginning of a personalrelationshipfhc recotlmendrtionfor psychiatrists is somervhat unique The American Psychiatric Associatiotr guidelinesspecificallystatethat there can never be a sexualor personally intimate private relationshipbetween doctor and Patient even after the professional relationship has cnded ln otherwords, a psychiatrist should not havesexualcontact evenwith former Palient:These guidclines apPly no matter who initiates the relationship In other words it is notmore alceptable tbr a doctor and patient to have sexlralrelations if thc patient initiates thesexualder otbetwef o r a lI(APLAN
    • Doctor/PatientRelationshipiage-lmtatethe o ro l lenton)m.ftstn)hcsexualrelationship rather than the physician. Theseguiclelinesalsotake no account ofgen_deror sexualorientation It is arwaysethicalry unai-ceptabreto have a sexuarrelationshipbetweena psychiatrist and cither a current or a formcr patient. It is ethicay unacccptableforaphysicianof any kind to have a sexualrelationshipwith a current patient.i fa-ntlt.r/I ntsplr
    • l 6 sCHITDABUSEj}t:::_":Ti::":"ryreporters,ofchild abuse.This ncans rhat thc physicianhasadutyto report child abuseevenif they fcel uncomfortatrl",t;i;g .; .fhereis no discre_tiononrvhetheror not to report abuse.r" "aaiairt, ""." ,*0".1* .nuo abuscmust beteported.The reporting to child protectiveservicesshouldn"Oi"" ,_,.Orrely so thattherecanbeanurgentinterventionto preventfurther abuse_Forexample,a 20-yearold womanbringsher seven_year_oldsontnto the erter-genrydepartmentfor a brokenarrn.Thechildhasf,".n ,o ,t.,..-"rgency depart-menrtwicebeforefor variousin.juries.Thc mother ,,"", *r,i il, boyfriendwhoisnot thechildi fathcr you have_nodirectproof that at,rr. nn, o..rrr".f u,rAtl.mothersimplystatesthat thc chT:,l"r.:,ioi:".;; ; ;;"li;ij.lli.iilli::y,I"","#;;.|.;]H:::ouslydeniesit. What shouldyou do?Keportsuspectedchild abusecasesl::1,:,::0.,1".:,,.,1,"fo,;,;.,i;."n:,THr:ffiT,:::i":nlH1ili:*?T:;$ noabuseiound, the suspectedabuserhasno standingto nf" rui, "g"inr, you aslong aslixilT:::.i.::Ji;:.:Tii1,:rTthcrwordsasro"s",f""",.,**,,ancrhonestrvreporters,anyonewhor.,,,"*ooa,lltJo:iJ:il::L#:r:Jjl:lJT:ll"";;1,i111il:.::j:l:criteriaareoperatins.you rnusthave" ..",;;;;,;;;" the abuseand rheremustbeno elementof trying to harm or cmbarrassthe familvChapter13:DoctorandSocietyII(A PL.AN--MEDICAL
    • MSAththIfP(thP.tl(olIi:IIcirapterrhirteenM EDICALEI-DERABUSEThe samecritcria describedfor chilcl abusegenerally apply to elder abuse.Instead of childprotective services,thcre are adult protective scrvices.Reports made igood faitl.rcan beclone rvithout liability to the rcporter. The circurnstanceswith erclerabuse are resscrearthan with child abuse,becausethe elderlypersonis often a still_cornpetentadult who marobjcct to the report of the abuseon thc basisthat they are afraid of repcrcu.sion. in thehome or the lossof the home. Nevertheles.,ynu -or, report elder abuse,and partiallvbreaching the confidentiality of the patient antr fanr y is permissible in the interest ofprotectinga vulnerableperson.The other reasonthat elder abusereporting is lessclear is that there is no uniform nationalstandard fbr it in all 50 states.l.hevastnajority ofstates, however,lravea reportrng slstemsimilar to that for reporting child abuse.rhebottoline for USMLE is that you shouldanswerto"reportthe abuseto adult protective services,if the casers Drese.ted.IMPAIREDDRIVERSThe ruleson reporting impaired driversvary enormouslynationally.Thereis no otheraspectof medicalethicsandheaitrr-careregaritythat hassuchstate-to-statevariabity asthem.rnagementof the in.rpaireddrivcr,All statesrequirethepatientto reportsetzurec.lisorders;howcvertheperiodof tilrrethat thecrrivermuststayoff the .oaclvarlesvastryfromonestateto anotherandthereforecannotbetestedon the USMLE.Physicianscannot suspenddriving privileges.Or.rlythe statesponsoredDepartmentofMotorVehicles(DMV) cansuspendor revokedrivingprivileges.Arhenarlriverisimpairedln anyway,thc first stepis to encouragethe driverto reportthe impatrnent, to the DMVIn additio, the physicianshouldencourageall impaireddriversto rimit or curtairtheirdriving. There is no uniform agrecmentof what, besideseizuredisordersand visualimpairmentshouldbereporteclin all states.Only a few stateshavespecificlawsrequiringreporting of sycopal episodes.Not ail statesoffer immunity to physicians,suchastheprotectionsofferedfor reportingchildabuse,for reportingan impaireddriver.For example,yo:uaretheattendingphysicianon apatientadmittedto thehospitalwith a first-timeseizure.TheheadCT andEEGarenormal.you will not bestart_ingantiseizuremedications.Thepatientdrivesto work regularly.Whatshouldyoudo concerningthe patient,sabilityto drive?Intotrlthhid(mlirI(APIAN
    • DoctorandSocietyI67i:1aytheilyofIalrmtdrildbeeaftrlsnftMandatoryself-reportingof seizuresis requiredin all 50states.If thereis an answerthatsays"encouragerefrainingfrom driving"or"counselon alternateformsof transportation,"thatisthebestthing to do first.If that is not oneof the answersthenchoose"recommendftepatientinform the DMV" is thebestchoice.Forexample,you areevaluatingan 87,year-oldman in your officefor markedlyrvorseningcognitivedysfi-rnction,Heison anumberofcardiacmedicationsaswellthatlear.rhim sornewhatdizzy.Thereis evidenceof psychonrotorretardationanddelayedreactiontime on your examination.You areconcernedthat the patientregularlydrives.What shouldyou do abouthis driving?Ifthepatientdoesnot havea specificdiseasesuchasa seizuredisorderthat makeshimpotentiallvunsafe,then it is much lessclearwhat your responsibilitiesaretowardboththepatientaswellasto society.In caseslike thisthe bestansweris to recommendthat thepatientwith cognitiveproblemscurlail his driving or find alternateforms of transporta-tion.Giventhatthe reportingrequirementsaresovariableon a state-to-statebasisthis isoftenthebestanswerthat rvouldbeuniformlv true in all states.Forextmple,yo:uhavea65-year-oldmanwith progressiveglaucomain youro1fice.Hisvisionis severelyimpairedand gettingworse.Youstronglydoubt that hecanreadtrafficsignson the highway.Youhaverepeatedlyencouragedhim to curtailhisdrivingbut hehasnot.What isyour responsibilitytowardthispatient?lnthosecaseswherethe patientsvisualacuityis soseverelyimpairedthat you suspecthe1sadangerto himselfandto otherswhendriving,you muststronglyencouragethepatienttostopdriving.Youcanintervenedirectlyin the statesthat requireintactvisionfor recertificationof thedriverslicenseby refusingto providerecertification.In thosecaseswherethisisnot possibleyou must inform the patientthat it isyour duty to notify the DMV ofhisinpairment.Youdo not havethe right to removeor suspenddrivir.rgprivileges.youdo,however,haveaduty to reportavisuallyinpaired driverto the DMV sothatthe DMVmaymakeits orvndeterminationof whetherthe patientslicenseshouldbe removedorlimited.!<apll x) tleorcel
    • 58 ChapterThirteenPHYSICIANPARTICIPATIONINEXECUTIONSA physiciancan not ethicallyparticipatein executionsin prisons.This is true eventhoughthe execution is legal in that state.Participating as a physician in any ay in an executiondirectly opposesthe ejthical imperativeto preservelife. The physiciansethical duty torelievesufferingand to protectlife supersedesany ability to participatein the execution.For example, you are a psician ir a state prison.fhewarcien has asked yourassistancein checkingthe apparatusthat cleliversa lethalinjection schecluleclforusein an executiontonrorrow. He is not askingynu to aclnlinisterthe injection.You havenevermet the patient beforeand you haveno prior doctor/patientrclationship with the condemnedprisoner.{}rat should you tell the warden?A physiciancannot participatein any way in an executiolrasa physician.Participatinginan executionirnpairs your physician/patientrelationshipsrvith the other prisonerswhoarc ,vourpaticnts. It is ethically inpcrmissible to participate even at the level of a technicalcor.rsultant-cven if you have no doctor/paticnt relationship with the prisoner. You ma1not give the injeclion, start the IV lir.re,mix thc medications for injcction, or dcsign theformulation for the lethal injection. It is not even permissible for you to ccrtift that dcathhasoccurredunlessanothcrparty hasdctcnnined it first.TORTUREPhysicianscannot partjcipate in torture at any level.lheknowJedgeof torture mustbe reporteclancl opposedas you ivould report and oppose elder abuse,child abuse,oran impaired driver.You may treat those injureclby torture once the victins have beenremovedfrom an environment$heretofiure may occur;you cannottreatinjuriesto allorvpaticntsto bccomewell enoughto withstandnlore torture.I -
    • Doctorand Society]59rougl.r:ution.ltv toron.rrl .SPOUSATABUSEThecthicsar.rcrlegalitiessurrotindingspousarabuse.rcsomcwhatdifreret from thoseforchildabuseand etderab,se.tn the caseof spousal"b;;;, .;;;;;. dealingwith a. adultpatientthat.isgenerilllvcompetentconsequentl).1.oudo not havethesamcauthoritytoreporttheabuseagainstthe wishes.f thclvictimas,., .";i;i;; " ;;; ilffi;*Nlanyvictimsexpcricncingspousarabuseberievethci ";" Il;;;r; positionto beabretoleavethe relationshipor to report the abuscfor fearof worseoli.rre.Co,,r"q.r.lrtly ynucal]n-otreportthe abuseto thepoliceor to alyone .lr. rithout the ."pressconsentof thevlctim.For example, a 45_vear_oldrvringhacrhernoseb-o*n,nJ,T,",,lilli*, ::il:"":iilf i:i:ij[T:ijl]"past.rhcn1.oLrtell her,vourvill report the injury to th. poli." ,lr. beconresvcryanxiousandinsistsyou tcll no onebecausehcrhusbarair, ffi* officer.{,hatshouldyoudo?Wher.th_epatientr.villnot givccosentto havctheinjury reportccl,yousould answerthatvouw,ill"encourilgcthevictim to rcport,,or ,,offer.ou,.r.ling.,,,GUNSHOTWOUNDSRcportingofgrLnshot rvounds is mandatorybut from a clifferentperspectivethan the othertonruofreportinpl.The mandatory reportrngof gunshot wounds iscriminatinvcstigationofrhepersondoingtheshootig.o.o"* " ,.;:T:l;:.i#:H:,?theictinrobjects.Thesocietalneedfu,,"f.,y,.,p..r.a.,iiri"orrr"".,,r rn.patientin thecaseof gunshots.GIFTSANDINDUSTRYFUNDINGciftsfrom industry arc to be limitetr in both type and by numericaimoneraryvalue.Thcpresumptionis that all gifts fronr industry are an indirect attempt to obtain influence fromphyriciansin tcrrnsof thcrrprcscribingpatteflrs.Modest gif*;;r, than $100in valueareacccptableonly if they are netlical or educational in *,ur". fn oaf,., words, you canreceive$100.i.vorthof books or medicalequipment nr, ,., ."r."i ;"st get a $100checkl".l::1-1:1OUt::,the industry.mal.slonsor educatior.ralprcsentatronsaslong astheyconot lnterlere witll the content. Physiciansnray accclrt mea.sthat are in associationwitheducationalexperiencessuchaslecturesor contcrenccs.Phvsiciansare prohibited from accepting gifts from the industry that are purely gearedtoenhancethe inconteof the physicianor D.terelvfor entcrtairrrr,"r,t.Fn. ""0-ple, the physi-clancannotaccepttickctsto baskctballgantcsor otlter sportitrge€r]ts,tlteatertickets,skitrtps,or gift certificatesto cleparfpsll 51e1g5.-18ll-ru4ronicalma)r theeathrust, o rcenlowIIIi-!l!!p r,arorcer
    • Chaptert4: Doctor/DoctorRelationshipl z tREPORTINGIMPAIREDPHYSICIANSPhvsicianshave as much of a duchirdabuse.Arthough*",;;,ji,:":?:::il]ffT.i.r,1tl:T,::",,|jl1lff::;avoidingreportingan impairedphysicianwhenthe impairmentis clear.If you know trratanotherphysicianis not functioningnornaily and may be a dangerto pahents,the privacyof the physicianis lessimportant thanthe safetyof hispatients..I.hisis truewhethertheimpairmentis from substanceabuse,a psychiatricdisorder,Alzheimcr,sdisease,or anemotionaldisturbance.Youshouldreportphysiciansandstudents_in_trainingto theirlocalsupervisortirst;reportaresidentto hisprogramdircctoror dcpartmentchair;andreporta meclicalstudentto hisdeanor coursedirector.you shorrldreportattendingphysiciurxto th. a.pnrtmentchairordivisionhead.If the attendingphysicianis a self_employedphysicianrn privatepractice,thelrthereis no departmentchairor dir.isiont "ua to r,vti.t, you canrnakea report.youshouldreportphysiciansin thecommunityin privatepracticeto thestateboardof medicalconductor the statehealthor educationdepartment.The keyis to go to *ho.rr.. .ighthaveauthorityoverthatphysician.Thelinesofsupervisionar.m.ch cl.ar., i thehospitalorin medicalschool,wherether. a." .1"a,,.r;re.uirors.For example,Dr. Smith is an attenclingin endocrinologythat is doing a monthas the attendingon the generalmedical scrviceat Ki"ng,sCounty Hospital inBrooklyn.Unfortunately,his housestafffinds him gettiu; loston the wayto thebathroomin the hospital.In addition,he hasno t-no*t."ag"of generalmedicalpracticeand he cant rcnember thc casesafter the residen-tspresentthem. Theseniorresidenton servicementionsthisto you anclasksyou. ndui.. "oout *not todo giventhatAlzheimer,smight bedeveioping.Whatshouldyou tell hin?I ( A P L A N MTOICAL
    • J ChapterrourteenM E D I C A LThe residenthasa dr.rtyto report the potentiallyimpairedphysrcianto the department chairThiswr alrowfor aprivate,confidentiarinterventio,,.ith tn" utt.ndingphysicia.Itcanallowfor anevaluationtlsibrethataimpai,"o;;,;.* .fifi:;::::jll:fiiHffiJ..;ltilT*::*:**cometo light without this report.ln addition,the ratesof substanceabusefor physiciansarethe sameasthe ratesofimpairedphysicia.,-ayb"thffiTi;i,r:::,i::,j;ffil:il:,*:,::L.i"i:ffi:"lTabuse.Catchingsubstanceabusebeforepatientharn o..r., Or"u"rrr,malpractice.Thephysiciancanbesuccessfullyrehabilitatejand r""r".i ,. f".,U... Youonly havea duty to reportbehaviorthat affectspatientcare.If a physiciangoesout towild partiesbut thereisno detectablei_pni."nt of pnti"n, .o;., ,n,, ,. nu, ,omethingto:."r,Tj;::_:ffiijlll:.::,",:i,,oos,usebadransuage,andricreinamotorcycresinsbehaviorsrou.,a.uruu.o,,ua-1,!:::1il:i:il:,L.JJdutvroreportisba,"de.ru.l,.er"yoiThebottornlineisthatit isyour.mandatoryduty to reportanimpairedphysicianwhomay:#:ili:;,:T-;::JrH*Youhavetheameirotectionsroryou.,"rron."pn.-ti,,!asrongastherepo.,,,-"0",,,tijl}ffiXil:f}"#thereportisfoundtobeuntruiPHYSICIANDISAGREEMENTSIf an,attendingphysiciandisagreeswith a residentsimpropermanagement,thereis rittreprob,lembecausethe attendingphysicianh". ,h. "u;;.i;;;o ou.rrur. the resident.It ismuchnore problematicif the residentdisagrecswith the attendingphysician.li,i::::*l finds what may be an error in managementwith the attendingphysician,the USMLEfirst wantsyou to aevidence-basedmedicine.,,,r;lJ;il:,::::i;,.J:fJ*;:H.,T:l;:il;T:.,:itto whatever is the version of a ..,rocary.,,-Donotg,.."*;,;;;J.r,Hil:lilii:::ill.*fiffi:il:;**: ;:iwithout first trying to havca discussiorvith trredivisionheador clcpartmentchair.Inaddition,do not answer,.Informthe patient.,,what if theresidentiswrong?Disagreementsbetweenphysiciansarehandredin muchthcsamewayasthe reportinganimpairedphysiciani, t.,ur.,atea,.*."pt thatyou shouldalwavsfirchchhaI(API"AN-
    • tment:ian.Itspos-ifwtseiciansg thetance, Theut torg tolangI o nlillli-r1""Ofu.l*t:n withthepersonwith whomyouaredisagreeing.youcannotmakechangestn a patientt care withoutchangarhe",,",di.,;h;i:;;;i"::,ffn:,11,:i:l:;:1ilffi-;$:i::,.":l:jl;hasanabsoluteright to direct the careof the patient, ur.,dkrrnlv , ,hut ,s gorng on.Doctor/DoctorRelationshipinayruellets-tllllP ueotcnr
    • l r sRESEARCHANDEXPERIMENTATION-PARTICIPATIONCONSENTIn most w?ys,the consent issuesfor participation in expcrimentation and researcharenotverydifferent from those surrounding any other mcdical treatntent or procedure. Thcresearchsubject must be fully informed of the potential risks of the intervention as wellasthepossiblebenefits.The sub.iector participant must bc entering the trial voluntarily-ilithout cocrcion. If the subject is not an adult or lacks the capacitv to unclerstandthe riskofthetrial,then a valid surrogatesuchasa parentor guardianmust giveconsent.Thediffcrencebetween participating in experincntation and receiving a treatment is thatthestudymedication 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.rcethc accumulatjonof scientificdata. The bottom line on experimentation is that participation must be vol-unfary.PRISONERPARTICIPATIONThesamerulesapplyto theparticipationofprisonersin researchasapplyto nonprisoners.Prisonershavethe sameright of refusalandinformedconsent.Thereis to beno removalorabridgementof rightssimplybecausethcpatientisa prisoner.TNSTITUTTONATREVTEWBOARD(tRB)An Institutional Review Board (IllB) is an independent reviei.vingbody that evaluatesinvestigationalprotocols prior to their implenrentation to ensuretheir validity and ethicalChapter15: Experimentatiot!!!!p rrarorc,rr
    • r(Apt_ANChapterFifteenintegrity.Thc IRB is comprisedof representartivesofdifferent areasofthe hospitalor medi-cal schoolthat includc clinicians,educators,ethicists,clergl and scientists.The idea is to l.ravca broad basedgroup that can evaluatenot only the scientific pararnetersof a protocol,but alsoensurethat the processof intbrmed consentis accurateand that thetreatmentsand proccdurcsbcing studicddo lot presentan undue risk to the patientsbeingenrollcd. The IRB also ensuresperiodic revievvof the data so that a trial can be stoppedearly on occasion.A study cannot con.rmencervithin an irstitLrtion without IRB approval.For example, a group of invcstigators stud]-jng the eff-ectsof artiretroviral medications on paticnts with HIV/AIDS submits their study to the IRB for revierv andapproval prior to implementation. The pianned protocol is to study rvhether givirg antiretroviral medicatiols to patients rvith AII)S makes a difference in theiroutcome rvher.rconpared to starting the rredications after clischarge.Half the patientswill rcceivea placeboand the other half rvill receivethe antiretroviralnedications. The study r.villrandonize patients adnitted to the hospital for acute opportunistic infectior.rs.Thc IRB rejects the study on the basisthat it would not be ethical torvithhold potentially lifesaving therap,vfrom a group of patients in rvhich the efficacyl.rasalready been proven. ln addition, the llll3 rejectsthe study becausethe consent fonr wasnot translated into Spanish.The IRBspurposeis alsoto makesurethat a studyseeksto ansrvervalid questions.It isnotvalid to l.ithl.rold proven cffcctivetherapy to gather data on how some patients are harmedjust to produce a publication.There is no randomized,placebo-controlledtrial provingthat antibiotics arc better than placeboin patients with severepneumonia. This is becausethe conceptof the randomizedtrial hasonly beenin existencesincethe secondhalf of thc20th centuqr RecausePenicillin was already the stanclarclof carefor pneumonia, it rvouldhave been unethical to perforrn a study in which antibiotics rverewithhcld from patientswith pneruronia and to watch thesepatieDtsdie. It would alsobe unethicalto do a studyof steroidsin minimal changenephroticsyndromewhen the efficacyis clear.lhe I RU is a responseto the Nuremberg War Crimes Tiibunal, tlurir.rgwhich thc rvorldconsensusthat experimertation rvithout consentis unethical and not allowablcbccameclear. Nazi experimentation during Vorld War II lvas coerccd, without corsent of theparticipants,and collecteclclatathat involveclthe unnecessaryand willful harm of humansubjccts.The moclern IRB is tl.remethod of ensuring safcty,cthical integrity, and freedomfrom coercior.rin clinicalinvestieatron.FfirrehrillIirTPllI]c7nl lirdMEDICAL
    • ItxpeamentatronIdr- FINANCIAI.DISCTOSUREhcn inestigators publish or present researchdata, clisclosurcof all relcvant sourcesofiinancinplfor the rvork is required. If r am p.brishing a study conparing two crifrcrentanti,retroviralmedications,it is important to cliscloseto thc audienccin a Grand Roundsthat Ihar.erecciyedfr.rndinglfrom antirctroviral rnanufacturcts. If I am putrlishing a stuclyon aninplantabledefibrillator,it is mandatory that I revealthat I ou,part of thc companythatnanufacturesthe cquipr.nent.Financialclisclosurcis essentialto help ensurean obJectiyejnte4)retationof researchclata.Thereasonfor doble-blind placebo cor.rtro ccrtriars is rrr.t we know that the cresireof thepeoplerunning the studyar.rdcollcctingthe datacaninfluencetlte stlrdyresults.Disclosureof financig helps undcrstancra possiblebias ir.ra study.The m.st importantmoderncxampleis an articlein thc journal ThcLo.tlcetoi the danplersofthc measlesvac_cruation ln addition to nrany othcr flaws in the studl, the author failed to crisclose.andTheLaucetfarledto inyestigate,the financiar arrangenent of the autrror with a rival vaccinenanufacturer.The studywasinvalid,althoughpublished,becausethe author wasattempt_iugto invalidatea current measlesvaccinein hopesof acquiringapprovalfor the nrarkct_ingand rcimbursenent of his own vaccine.This is an cxcellcntexampleof lvhy financialdisclosurecan help preservescientific intcgrity.ers:hen g,ecial.-altr-toasasot:d)gS Ct edtstydnnIII ( A P ! A N MEDICAL
    • l r gBRAINDEATHl, An 80 ,vear-old man is adn.itted to the hospital with a massiveintracranial bleed.He has been placed on a ventilator becauseof tbe respiratory failure associatedwitlrintracranial herniation, When you try to remove the ventilato5 there are no respira-tions. The patient makes no purposeful moventents. There is no pupilary reactionwhen you shine a light in his eyes.There is no nystagmus on cold caloric questiontesting. Oculocephalic and corneal reflexesare absent.Hc left no specific wishesforhis care.Which of the following is the most appropriate action regarding this patent?Remove the ventilator.Make the patient DNR.Placea nasogastrictube to prevent aspiration.Get a court order authorizing you to remove the ventilator.Do an EEG (electroencephalogram) three times separated by slr hours eachtrme.a,b.c.d.PracticeQuestionstl!!P r,rrorcar
    • !trIeracticeQuestionsCHITDABUSE2. Youarearesidentin theemergencydepartment.An irateParentcomesto youfuriousbecausethesocialrvorkerhasbeenaskinghim aboutstrikinghischild.Thechildisr.5-year-oldboy who hasbeenin the emergencydepartnent four timcsthisyearwitlseveralepisodesof trauma that did not seemrelated.Today,the child is broughtinwith a child complaintof"slippinginto a hot bathtub"with a burn wound onhitlegs.Theparentthreatensto sueyou andsays"How tlareyou think that aboutm€?Ilovemy son!"What shouldyou do?a. Givereassuranceto the Parentsandtrcatthe patientsiniury approPriately,b. Ask risk managementto evaluatethe case.c. Admit the childto removehim from thepossiblydalgerousenvironment.d. Callthe police.e. Askthe fatheryourselfif therehasbeenanyabuse.f. Speakto the wifeprivatelyaboutpossibleepisodesof abuse.g. Explainto theparentsthat the nexltime this happensyou will haveto callchiidprolectrveserYlces.h. Reportthe familyto child protectiveservices.i. Givethe parentsa referralto a family theraPistthey can seewith the childthefollowingweek.clt!l!!P mrorc*
    • cusi s airhtnhis: ? ICONFIDENTIATITY3. Youareworking at the deskin your hospitalwhenanotheremployeeof the hospitalasksfor information abouta paticntwho wasadmittedlastnight with a pulmonaryernbolussecondaryto cancer.you know the detailsof the .ua.. Th. personrecuest_ingtheinformation statesthat heis a closefriend andco_workerof your patie;r. Heshowsyou properidentificationprovinghereallyis a co_workerof your patientwhoa].o$.rk in rhehospit.rl.hich of thc followingisthe mostappropnateresponseto this requestiGivehin the information on the patient.Givehim the information only if heis a relativeof thepatient.Inform him that you are not at liberty to give detailsregardingthe patientwithout the patientspermission.Havehim signa releaseor consentform beforerevealingtheinformation.4 You are seeingpatients in clinic when two men in dark suits and dark glassescome inand show you badgesmarking them asmembers ofa federallaw enforcement agency.The identification is legitimate. These,.men in black,,inform Fou that they are mak_ing a"minorinvestigation" of one of your patients. They ask to look at the patient,schart for a few minutes, saying,"youwouidr.rtwant to interfere with a federal inves_trgation, would you?"{hat should you do?a. Give them the chart.f.Givethem the chartbut watchwhat theydo with it.Askthem to signa releasefor the chartsoyou areabsolvedof responsibility.Tellthem you cannotshowthem the chartunlessthereis a signedreleasefromthepatient.Tellthem that you cangivecopiesbut not theoriginalrecord.Dont givethem the chartbut readthe relevantinformationto the[r.d.a.b.c.b.c.d.!!!!!!) raeotcnr
    • ]eracticeQuestions5. Youareapsychiatristin sessionrvithapatientwhotellsyouhethinkshisbossatworliis persecutinghim. The patienthashad mild schizophrenia.The patientasksyouifyou cankccp a secretand then tellsyou that he is planningto kill his boss"whenthe time is right."Yousay,"Ofcourse,everythingvou tell me during the sessionwtllalrvaysbc confidential."What shouldyou do?a. Keepthe patientssessionconfidentialbut make attemptsto discouragethepatientfrom hisplan.b. lnform your medicaldirectorandlet him handleit.Inform law enforcernent agenciesof the threat to the patients boss.Inform the patients bossthat he is in danger.Inform both the patients bossaswell as law enforcement of the threat.6. Youarediscussingthecareof anelderlywomanwith herfamily.Althoughsheisawakeandalert,thepatientisveryill andphysicallyfragile.Youareawaitingthe resultsofabiopsyfor what will likelybe cancer,which hasalreadymetastasizedthroughoutthebody.Thefamilyasksthatyouinform themtirst abouttheresultsof thebiopsy.Theyareveryloving and caringand areconstantlysurroundingthe Patient.Theydo notwant to depressthe patientfurther,andbecausetherewill beno hopefor a curethelseeno reasonto ruin herrcmaininglife with this inforrnation.What shouldyou tell them?a. Youwill honor their wishes.b. Youagreewith their rsishesandyou askthem to giveyou the neccssarywrittenrequest.Youaskthem to involvetheethicscommitleefor thehospital.Youtell themthat you areobligatedto inform thepaticntof all the findings.Explainto themthat that decisioncanonlytremadeby thehealth-careproxy.c.d.c,d.f A PLAIt) MEDIcAL
    • PradiceQuestionsI85workou ifvhenrvillfJ Yourpaticnt has just recently bcen cliagnosedwith familial adenomatous polyposis(IAP). This disorder is chronic, progressive,and fatal. There is a genetic test that cantellrvhetherchildren of parents r.viththe diseasewill develop it. The test is very accu-rate.The patient has becone divorced and refusesto give you his consent to infornlhisex-wife who nor,vhas custody of their three children. He threatens to sue you ifyourevealelementsof his medical care to his ex-wife.Vhatshould you do?Respectthe patients right to confidentiality.Transferthe patients care to another physician aslong asthe patient agrecs.Ask the health departnent to inform the patients ex-wife about the diseaserisk.Seeka court order to inform the patients ex-wife.Inform the patients ex-rvife of thc risk to the children.Inform the ex-wifes doctor.(} Youareseeinga patientin clinic who hasdevelopedtuberculosis.He is an undocu-mented(illegal)immigrant.His familywill needto bescreenedfor tuberculosiswithPPDskin testing.He is frightcnedof beingdeportedif the Departmentof Healthlearnshisin.rmigrationstatus.rhatshouldyoutellhim?c.d."Dont rvorry, the Depafimcnt of Health does not ask or report immigrationstatus.""Onlypeople who are noncompliant with medications are repofted to thegovernment.""Dontr/orry, I will fully treat you before we deport you.""lam sorry br.rtthereis nothing I cando about it; thereis nandatory reportingto the govcrnment,a,b,c.d.f.keI aryf,t:yb.
    • a4]PradiceQuestionsM F D I C A LDONATIONOFORGANS9. A couplc comesto seeyou after having tried in-vitro fcrtilization and artificialinsemination.Theyareveryhappybecausetheyhaverecentlybeensuccessfulin giv-ing birth to a child.Theyhavea significantan-lountof leftovcrsperm,eggs,anclsomefertilizedgametes/embryosandtheyarethinking aboutsellingthem.What shouldyou tell thcm?a. It is legalto sellonly thc eggs.b. It islegalto sellonly the sperm.c. lt islegalto sellboththespern.randeggsbut not theembryos.d. It is illegalto sellanyof thenr.e. It is legalto sellallof them.10. You are a fburth-year medical student with a patient who hasbcen in a severcmotorvehicle accident.The patient hasa subdural hematoma that led to cerebralherniationbefore it could be drained. C)verthe last ferv days,the patient has lost all brainstemreflexesand is now brain dcad. You have the closestrelationship with the family ofanyone 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 tamilyb. The rcsidentbecauseyou areonly a studentc. Attending of recordd. Hospitaladministratione. Organ donor networkIt lI(A PLAN
    • PracticeeuestionsIIl. A 50 year-old malc gambler owesmoney to everyoneantl is seekrnga rapid sourceofcash.He answersan aclyertisementin a foreign newspaperoff..lng S:O,OOOfo. oo" ofhiskidneys. He comes to seeyou for medi.ui "*f""iir" prio, to th" upprurrnlto b" odonor.Whatshouldyou tell hin?It is never acceptabieto receiveany money for solid organs or bone rnarrow.It is acceptableaslong asthe recipienttruly needthe organ.It is okay as long asthe donors ren.rainingkidney is healthy.It is acccptableifthe surgery for both the donation aswell at the impiantation inthc recipient is occLrrringin a forergn country.I{eimbursement for cost of traycl and lodging for the donation is acceptable,butprofiting frorn the donation is unacccptable.12. A man.arrives at the emergcncy department on a ventilator after an accident, I{e isbrain deaclby all criteria. He has an organ-donor card in his wallet indicating hisdesireto donate.Thc organ_donor team contactsthe fanily. The fan.rilyrcfusesto signconsentfor the donation.Vhatshould be donc?a.b.c.o.a. Removethe organs an.v.{ay.b. rait for the patient,sheart to stop and then removeStop the ventilator and remove the organs.Seeka court order to overrule the famil,v,Honor the wishesof the family; r.rodonation.the organs.c.d.MTICAL
    • IeracticeQuestions14.DNRORDERS13. You havea patient with severemultiple sclerosisthat is advancedand progressivewhonow developsrenal failure secondaryto diabetes.The patient is alert and haselectedto put the DNR order in place at her own d.iscretion.The patients potassium levelisnow markedly elevatedat 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 dialysisif the DNR is reversedfor the procedure.c. Go aheadwith the dialysis;ignore the DNR order.d. Give kayexalatcuntil the DNR statusis discr.rssedwith the family.A patientfrom a skilled-nursingfacilityis admittedto the hosPitalfor severeuppetgastrointestinalblceding.The patient hasa l)NR order in place.The blcedinghasnot stoppeddespitemultiple transfusions,octreotide,Proton Pump inhibitors,andendoscopy.He needsmonitoring andevaluationin an intensivecareunit.trat shouldyou do?a. ReversetheDNR orderandtransferto theICU asnecdcd.b. ou cannotbeDNR andbein the ICU.c. Transferto the ICU asneeded;okayto beDNR in the lCU.d. He cangoto the ICU with the DNR but cannot8oto surgery.e. He cangoto the ICU with the DNR but cannotbeintubated.15. A man is admittedfor acuteappendicitis.He is elderlyand hashad a home DNRorder in placesincehe had a previousadmissionfor anotherreasonlast year.Heneedsurgentsurgeryfor theappendicitis.He still uishesto be DNR.What shouldyou do aboutthe surgery?a. No surgerycanbedonewith a patientwho isDNR.b. RevcrsetheDNR orderfor the surgery.c. DNR is acceptableonly ifthe surgerydoesnot requireintubation.d. Surgeryis acceptablewhile DNR if an additionalconsentis signed.e. DNR doesnot precludesurgery;proceedrvith thc appendectomy.!!l!!P meorcar-i
    • PracticeeuestionsI az;sivewho.selectcdn levelisupperrg hass,andNRHeEI,DERABUSE16.An84-year-oldwomanis seenbyyou in clinic for routinemanagementof hermulti_plemedicalproblems.Shecomesaloneanclyounoticethatshehls beenlosingweightandhasseveralcontusions.Sheis a widow andliveswith hergranddaughterandhergranddaughtershusbandwho recentlylosthisjob. On questilning shetellsyou thathergranddaughtershusbanddoesoccasionallystrikeherwhenhersdrunk.hat shouldyou do?a. Reportthe abuseonly at hcr specificreqLrest.b. Arrangefor a meetingwith your patientandthegrandson_in_law.c. Removethe patientfrom the homeandplaceherin an adulthomc.d. Hayea homchealthaidplacedto keepaneyeon the patient.e, Arrangefor an orderof protectionfrom the policc.f. Reportthegrandsoninlauts abuscto adultprotectiveserviceg. Speakdirectlyto thc grandsonin law abouttheproblem.EXECUTIONS17. Youare the staff physician in a statepenitentiary in a statewhere capital punishmcntis legal.An execution is in processand thc warden calls you becausetl.retechnicianis unableto start the intravenousline that is necessaryfor the lethal injection.Thewarden wants you to start thc line and supcrvisethe pharmacist.rlrat should you tell him?a."Noproblem, I will start the line right away.,,b."Icanstart the line, but I cannotpush the medications.,,c."Ican start the line, but I cantror prepare or tnlect the medicatrons.,,d. "Iam sorry; I cannot participate in thc execution at all asa physician.,,e."Ican take careof all of it.,,I ( A P I A N MEDIAL
    • ]PracticeQuestionsEXPERIMENTATIONlg. Youarepreparingaclinicaltrial of differentdosesof acertainmedication.Thismedi-cationhasalreadybeenprovento beclinicallyeffectiveandisnlreadyapprovedbytheFoodandDrugAdministration(FDA).Youareonly studyingto seewhetherahigherdoseof the medicationwill leadto enhancedbenefit.Which of the followingistrue concerningyour study?a. Institntionalreviewboard(IRB) approvalis not necessary.b. lnformed consentis requiredto participate.c. Informedconsentisnot requiredbecausethemedicationhasalreadybcenFDA-approved.d, Informedconsentisnot requiredbecauseyou aretrying to demonstratebenefit,not harm.1g. which of the following most accurately describesthe ParticiPation of prisoners inclinical trials and research?a. There is no need for informed consent.b. No monelarycomPerlqaliontnayoccur.c. Prisoners are not Permitted to participate asresearchsubjectsd. Their rights are identical to a nonprisonere. Researchon prisoners is alwaysconsideredunethical.f. Participation in researchis an accePtedmeans of winning early releasefromPrlson.I(APLAN MEDICAL
    • PracticeQuestions20. Youarc in the processof finalizing the results of your rcsearchfor publication. youarethe principal investigator of a clinical trial studying the effects of HMG-CoAreductaseinhibitors on cardiac mortality. A prominent manufacturer of one of thesemedicationsprovided major funding for thc study.hich of the following is the most accuratein an ethical prcparation for authorshipof the publication?a. Accepting money from a company prohibits you from being listed asan author.b. Fundingsourcehasno impact on publication rcquiremcnts.c. You can bc listed as the author after the institutional review board checks thepaper for evidenceof bias.d. There are no restrictions on your authorship aslong asyou disclosethe financialaffiliation.e. There are no requirements aslong asthe data are accurate.f. You do not have to do anything aslong asthe checkswere written to the institution and not to you.Vhich ofthe following most accuratelydescribesthe primary role ofan institutionalreviewboard (IRB)?a. Protect the institution from liabilityb. Protect the physician from liabilityc. Ensure the ethical and hunanc treatment of human subjects in experimenta_tiond. Ensure the studv is scientifically accuratee. Ensure that the study is financially feasiblefor the institutionnedi-rytheigherDALefit,s l n21,It(Ap!A,N MEDICAL
    • 90 PracticeQuestionsM E D I C A LGENEIICIESIING22. A 35-year-old female patient comes to your oftr-cewith a large form to be filled outcertifiing that her health is within normal limits. This is asa part of pre-employmentevaluation and is required in order for the patient to get the job. The form also askfor the resultsof the patientsAPC (adenomatouspol)?osis coli) gene.This is ir.rorderfor the company to determine which of its long-term employeeswill need expensivecarc.What should be 1.ourresponse?a. Perform the test.b. Perform the test,but do not sharethe results with the employer.c. Do not perform the test.d. Ask the patient if shewants thc test performed and the results reported.e, Perform the colonoscopy; the employer is entitled to know about currert healthproblemsbut not future ones.f. lnclude the test only if the patient hasfamily members with colon cancer.23. You have a patient with a strong family history of breast cancer.As a matter of thepatients request,you perforn.ra BRCA genetic test to seeif there is an increasedriskfor breast cancer.The patients employer is requesting a copy of any genetic testingthat may havebeen done.What should you do?a, Give the cmplover the information.b. Refer the employer te the hospital lawTer.c. Bring the requestto the ethics committee.d. Refuseto provide the information to the employer.e. Civelhe inlormationif it i. poitire on d rcpeateam.Glf24.25I ( A P L A N
    • PracticeQuestions 9lOIFIS24.Youarea resident invited to a dinncr given by a pharmaceutical compar.ry.tn additionto the dinner there is a lecrure plivenon a mcdical subject as rvell asa $500 giftcertificateto a departmentstorefor attendingthe presentation.fhich of the following is thc most appropriate action in this case.aa. lt is entirely r.rnethicalto acceptany of it; refirseeverytbing.b. It is only ethicalto attendthc lecture.c, t)o not acceptthc noney, but the tlinncr ald thc iectureare ethici,rllyaccept-aDle.d, Yournayacceptlll threecornponenrs.Cashpaynents from industry are acceptablcaslong asthey arc not tied to pre_scribingspccific medications.Youcan acceptbecausc1,ouare a residentand not an attending.25. Youhavc been asked to give Grand Rounds at a hospital. A manulacturer of a llewmedicaldeviceis sponsoringyou. ln cxchange,you arebeing offerecla $1,000teeforyour talk.rhatshouldyou do?Younust refusethemoney.Yourna).acceptotrlyaslong asyou donateit to charity,Younlal acceptaslongasvoudon,trcvealthehonorariumto theaudience.It is permissibleto takethe moneyaslong asyou rliscloseanyotherfinancialorbusinessconnectionwith this or auyothcr company.Youmayacceptthe moneyaslong asyou subnlit the contentof your talh to anindependentpanelfor reviewto ensureobjectivity.a.b.c.d.[r,lpLnN) meorcnr
    • r{APtA}lJPracticeQuestions26. Youhavebeentakingcareofa patientadmittedrvithpalpitationslrom a panicattackHe is somewhathyponranicwith prcssuredspecch,:Lnxiety,ar.rdflight of icleas.Aftuseveraldaysheisfcelingn.ruchbctterandheisextrcmelygratefulfor your help.Heisrluitc wcaltl.ryandheoffersto borrowfivemillion dollars-fronthe bank,,tohchryourvith your rcsearch."Wrat shoulclyoutcllhiu?a. "laccept!"b. "Tlrankyou veryn.ruch,but I cannotaccept.,,c. "Iaccept,but only for a studyofbipolar disorder.,,d. "Iwould bchappvto takcyourrnoncy,but I musthaveyou evaluatedby psl,chia_try first."27. You ltave a patieltt in your clinicproblcns. Her familv is extrenrelythey cookedat home, a cake,and ahat should yoLrdo?a. Acccpt the gift but report rt.b. Accepr thc gift.c. Offer payment for the food.d. Refr-rsethe gift.e. Tt is erhicalto Jcccptthc $ilistaff.f. Accept the food but not thc scarl28. You havebeen invited to participatein a.,Medical jcopardy,,gamesponsoredby apharmaceutrcaimanufacturer The rvinners arc to receive$1b0 gilt certificatesto themedical schools bookstore- All of the participants arc to recervea stethoscope.Theaudience 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 anclstethoscopc,but rot the gift certificate.e. None ofthc gifts areacceptable.H29yrhois an elderlywornanrvith multrle medicalgratefulfor your careand theybring you a nealscart.if vou sharethc food r.itl.rthc restof the house3(MFDICAL
    • PracticeQuestionstack.fterie isyoul|lv/ArDs-sPEcrFrctssuEs29. A 32-,vear-oldpregnantwoman comesto vour prenatalclinic. Shehasa history ofsyphilisandgonorrheain thepastbut herVDRL/RPI{isncgativenow.An HIV testisofferedasaroutinepart of herprenatalevaluationaswellasbecauseofthe historyofpreviousSTDs.Youexplainto hertheimportanceof thetestfor herbabysrvellbeing.Sherefusesthc testwhenoffcrcd.trat shouldvou do?No test;shehas the right to refusc.PCR RNA viral load testing asan alternative.Consentfor HIV testingis r.rotneededin pregnancybecauseit is to protecttltehealth of the baby.Add the test to the other routine teststltat are to be drawn.Administer enpiric antiretroviral therapy to prc€l.lt perinatal transnrission.HIV testir.rgis nolv part of routine prenatal care and no specificconsentisneeded.30. You havea patient who is an HIV positive physician. He has reccntly found out thathe is HlV-positive.He is very concernedabout confidentialityand you are the onlvone who knows he is HlV-positive. He asks you who you are legally obligatecl toinform.What sl.rouldyou tell him?His insurancecompanyState€lovernmentHis patientsHis patients,only if he performs a procedure such assurgerywherc transnlrssjoncan occLlrNo onc without his direct written consentHis employerThe hospitalhuman resourcesdepartntentaa.b.c.f.D.c,d.f.I ( A P L A NrM E D I C A L
    • j PracticeQuestions3I. You have an HIV positive patient in need of drainage of a dental abscess.Thereisadentist in vour nultispecialty group practicc. He knows you are an infectious dls.eases/HlV specialist.Your office manager tells you the dentist and his staff are,,scaredof your HIV-positive paticlrts" and tltey dont want to seethem.What is your response?a. This is illegal;the dcntistis liableand can be sued.b. You request the medical director and have hin.r instruct the dentist to sccthepa etrt.c. Youprescribethe useof oral antibioticsaloneinstead.d. Referyour patient to anotherdentistoutsideofvour group practice.You arc evaluating a new patient tltat hascome to your clinic for nranagementofhisHIV infection.He hashigh CD4 ccllsand a lorvviral load and doesnor requireLrerlment. He is marrieci and doesnot practice safesexwith l.riswifc. His wife is unatvareor ner nusDaltds HIV stittus-What is your duty?a. Encourage discr.rssionbetr,reenthe husband ancl rvife and strongly suggesthedisclosehis HIV statusto his .wife.b, You urust keep his HIV statusentirely confidential at all timesc. Have the city Department of Health inforn.r the rvifc.d. Sendthe Iife a letter to con.reto your office becauseof an"urgenthealth issue,.rndthcrrirrformh(r )our5eli.e. There is no need for partncr notification aslong asthey are practicing satesex,You have ar.rHlV-positive paticnt in the office. you ask her if she has infbrrl.redherpartncr that sheis HIV-positive. Shehasrcpeatedlvresistedyour attempts to haycherinforn the partner.Shcis pregnantnjth his child.The partrcr is in the waiting roonr.rrrdyou h,rvemct him nrlrrl timr..What sl.rouldvou do?a. Infbrm thc partner no/.b. Respecther confidentiality.c. Referyour 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 HIVsrarusllt3132.33.MEDICAL
    • as-:dIMPAIREDDRIVERS34, An {i7-year-oldman contesto seeyou for foJlow-up to a minor concussion sustainecla fervweeksago.He was in a minor motor vehicle accident in whrch his head hit thedashhorrdbut hedid not losec,cussis.Herenewedhi,d.i"".,,r;::::J;T:i*:;::j:"_*i]j,,11.iili;lllll"jlithathemustwearglasses.you arcuncertainwhetherthc patientshuld bedrivi.s.hat shouldyou do?PracticeQuestions|95b.c.d.f.iseInform the patients family ancl explain to them that they should not allow thcpatient to continue driving becauseit is dangerousfor hitnN{RI of the brainNeurology evaluationStart aricept to improve his memc,ryDiscussthe issuewith the patient and encouragehim to fincl alternate methodsof transportationRemovehis licensefrom himMandatory reporting to the police!l!!p u:orcar
    • IPracticeQuestionsTNFORMEDCONSENT/DECISION-MAKINGCAPACITY35. A 37 year-oldman comesto your officetbr his regularvisit.He hasseemeddepressedfor sometimebut refusesto discusseitherhisfeelingsor treatmentopti37. LHnprlt39of any kind. He does not want to use antidepressantmedications. His only medicttions are vitamins. Your relationship with him is excellentbut he iust wont conftonthis feelingsof depressionalthough he firmly deniessuicidal ideation. You prescriberserotonin reuptake inhibitor for him and tell hin that it is a vitamin. Over thenenseveralmonthshis mood markedlyinprovesandhefeelsmuchbetter.Which of the following nost appropriatelycharacterizesyour action towardthtpatient?a. Youractionis appropriatebecauseit benefitedthePatient.b. Youractionis appropriatebecausethereuereno sideeffects.c, Youractionisnot appropriatetrecauseyou arenot a psychiatrist.d. Your action is not appropriate becauseyou treated the patient without his coll-sent.f.Your action is appropriate becauseyou are sincerelytrying to help the patient. iYour action is acceptableaslong asyou inforlll the patient now that he is feehrgibetter.36. A 67-year-oldwornanis diagnosedwith breastcancer.Sheis fully alertandveryspe-cificallyboth verballyarcl in writing tellsyou that shedoesnot want to havesurgetyon herbreastto removethetumor,Shefully understandsherconditionandtreatmentoptions.This is a decisionher husbandand sonboth disagreewith. Overthe nextseveralweeksthc patientbecomesconfusedandlosesthe capacityto understandthedetailsof hermedicalcarc.The hrrsbandand sonnow approachyou to performthesurgery.{hich of the followingis mostapproPriate?a. Refuseto do surgeryandfollow the originaladvanccdirective.b. Performthe surgeryonly if the requcstis in writing.c. Honor the familysrequestandperformthe surgery.d. Consulttheethicscommittee.e. Askthe familyto seeka court order.f. Performthesurgeryonlyif you reallybelieYethatit will benefitthepatientin thelongterm,I ( A P L A N MEDICAL
    • 37. A 52-year-oldman with cerebralpalsyis beingevaluatedfor screenrngcolonoscopy.Hehasa mentalageof 8 anda second_gradereadinglevelin termsot comprehension.Helivesaloneandsurviveson a combinationofpublic assistanceandalow_payingpart-timejob sweepingfloors.you havethoroughlyexplainedthe procedureto himin termsof risksand benefits.He repeatedlyrelises the procedureentirelyon thebasisof "I just dont want it.,Whatshouldyou do?a. Performtheprocedure.b, Seekconsentfrom the family.c. Honor his decisionanddo not do thecolonoscopy.d. Seeka court ordermandatingtheprocedure.Mr. M. consentsto a procedureon his left ear.After the patientis anesthetizedDr.W.discoversthat the right earis in greaterneedof surgery.What shouldthesurgeondo?a, Performthe procedureon the right earif it is clearthat it is morenecessary.b. Wakethe patientup andseekconsentfor a differentprocedure.c, Seeka secondopinion from anothersurgeonandproceedwith themore neces-saryprocedure.d. Performtheprocedureon both ears.The risks of the treatment were not explained.The explanation was not in a languageFou were sure shecould understand.Sheexperiencedharm from the study medication.Someone who didnt understand the study obtained the consent.All of the above.PracticeQuestions]9zseverelyoptionsmedica:onfront:scribea:he nextard the38.ls con-y speurgerytment3 nextrd them ther thc39 A 52-yearold spanish-speakingwomanhasarrivedfor the first dayof a clinicaltrialof chemotherapyfor breastcancer.you suddenlyrememberthe needfor signingaconsentform.Youaska nredicalstudentto,,getthe consent.,,Hewalksup to thepatientand saysin English,,,Signthis,,andshesigns.Shecompletesthe trial but herhairfallsout andshefilessuit againstyoufor an improperinformedconsent.Why will this lawsuitbesuccessful?a.b.c.d.(l!!P rrtorcnr
    • IPracticeQuestionsL(Aar-AN) MaDtCAL40. An unconscious man is brought to the emergency department for a motor vehicleaccitlent hemorrhaging profusely,hypotensiveand stuporous. you havenevermet thepatient before and no one at your institution knows hin.r.He is rvearinga T-shirt thatsays,"Kissme, Im il JehovahsWitness."Mrat should you do about the blood transfusion?a. Givethe blood.b. Wait for him to awakenenough to sign conscnt.c. Wait for the family.d. Seeka court order.e. Giyeintravenousfluidsalone,41. A 34 year-old man is brought to the emergencydepartment with f-ever,headache,anda changein mental statusleading to significant disorientation. His head CT js normaland he is ir.rneed of an urgent lumbar puncture and intravenous antibiotics. He isagitated and is laving off anyone who tries to get near him. Co rvorhersaccompanvhim. The resident informs you that the patient is pushing awaythe Iumbar punctureneedle.rtrat should you do?a. Sedalethe patientwith Jorazcpamand perform the lumbar punctureb. Wait for the family to obtain consentc, Ue bloo.lculturesa:.rn lltenutired. MRI of the braine. Ask the co workers to sign conselt
    • A 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 hasclearlytold both you and the brother this inthe past.The patientsbrother believesthat the proscription againsttransfusionsis"barbaricand stupid."hat should the patients brother do?a. Arrangea JehovahsWitnessmeetingto discussthe situation.b. Ask their parentsto make the decision.c. Ask the doctor to make the decrsron.d. He should not giyeconsentfor the transfusion.e. He should give consent for transfusion.Mr. Sakierviecis a 32-year-old man with severemental 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 andonlya small chanceof prolonging his survival.Vhatshouldbe done in terms of his medicaltreatment?a. Proceedwith the chemotherapyb. Confer an"expcrtpanel" to deterrnine therapyc. Bonemarrow transplantationd, Ask the guardian what is in the best interestsof tire patientPracticeQuestions 99I(A PA N ) MCDICAL
    • I(A PLANIPracticeQuestions44. A 27-year-old pregnant woman presentsin her lasttrinlester ofpregnancy with severecephalopelvic disproportion. Her physicians have recommcnded a caesariansectior,Shedoes not want to undergo the surgery.Shetirlly understands the procedurc anrlsheis unwilling to suffer the discornfort of surgery.she hasbeen informed that rvith-out the C-scctionher fetusmay not survivechildbirth.What should you do?a. Honor her wishesand do not perform the C sectionb. Psychiatryevaluationc. Sedateher and perform the surgeryd. Obtain a court order to perform the surgerye. Explainthe situationto the babysfatherand askhim for consentA 5z-year-old man seesyou in follow-up after a radical prostatectomy. He had beenfully ir.rforrnedabout the risk of the procedure such asincontinence and impotence,Neither ofthese adverseeffectsoccurs.While searchingon the reb he finds that thererstreatment without surgery involving the implantation of radioactive seedsor pelletsin the prostate.He files suit againstyou becauseof an improper informed consent.What will be the rnost likely outcome of the suit?a. He will losebecar.rsethere were no adversceffects.b. He will losebecauseall the risks of thc surgery were explained to him before hesignedconseut.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.45.MEDICAL
    • PracticeeuestionsItolarithseverett) sectlon.edurc andthat withad been)otence.at there-pelletsrsent.ore ]re46. A 58-year-old man is out of town on business in New york. He has a myocardialinfarction and deteriorates cardisdisoriented""0"""J,:o,liJ;:l,.]lJHilii,ri,illil,l;Ji,::i:lij;ibypass.His wifeis thehealth_careproxybut sheisin anothercity.you wouldlikc herconsentin order to performthe surgerybecaus.rheisth. a.rignutedsurrogate.rhichof thefollorvingis true in this case?a. Shemustcometo thehospitalto signconscntin pcrson.b. ThewifemLrstdcsignatea localpluardianuntil her arrival.c. Younust repeatthe angioplastyinstead.d. lblephoneconser.rtis only validfor ninor procedures.e Takeconsentfor thcbypassoverthephoneancrhaveasecondpersonwitnessthetelephoneconsent.47. trlr.Doroneis a 22_year_oldman who sustaincda subduralhcmatomaanda brainc(rttusronrn a motor vehicleaccident.He needsbloodin orderto havethenecessarylifesaving.surgerydone.His parentsrefuseto allorvthe transfusionbasedon theirreligiousbeiiefs.Whatshouldbedone?a. Honortheparentswishesanddonot givethcblood.b. Givetheblood.c. Waitfor a formal hearingwith ajudgeanda court.:erna- 48. A 27-year-oldJehovah,sWitnrrcf,sesa,transfusi.;;; $i ",;"i,THfi1.*#:,lliJi,.|;jli"i1l3.Ji#lrstandsshemay die without the blood.Whe.nshetur., .onr.i-orrn.rs her husbandnhoisnot a lehovahtWitnesssaysto plivethe bloodand hcwill srgnconsent.What shouldyou tell him?a. Yourvill honor his wishif heis the proxy.b. Youwill honor hiswish andgivetheblood.c. Youwill givethe bloodonly if thepatientis unconscious.d. Youcannotgivethe blood.!tl Pt-l tt) l,,tcorCer
    • IiIlO2JPracticeeuestions$j!!p r.,lrorcarMAI-PRACTICE49. A medicalresidcntadmits a patient overnightwith uncontrolledblood prcssure.Hemeans to write an order for the angiotensin rcceptor blocker I)iov.rn at l0 mg olce aday.Becauseof his sloppy handwriting the nurses and pharnracy administer digoxinat 10 mg a day.This is a drug that is rarely used at a dose .b.vc 0.5 mg a dav.Threedayslater,the patient developsa hemodynamically unstable rl.rl.thrndisorder that theresident very sincerelytries to decipher but is unable to until thc patrent transfers10the intcnsive careunit. At this point they discoverthe overdoscofdigoxin. ,lhepatientand the family never discover the overdose.Which of the following most accuratelydescribesthis situation?a. Therc is no riabirityfor the residentbecausethe oyerdosewasunintentionar.b. There is no liability for the rcsident becauscthc pharmacy should havedetectedthe crror.No liability existsbecausethe error is unknown to thc patient.No liability existsbecauseit was an accident.The resident and hospital are both liable for harm to the patient.No liability existsbecausetherewasno per.manentharm to the patient.a.ITIof the follorving most closeiy representsthe role of risk managernent in thenosprtalaa. To ensureproper ethical management ofpatientsb. To ensureproper clinical careofpatientsc. To act asa patient advocated. To clari$. communications from the medical staff to the patiente. To minimize the legal risk to the hospital from litigation7rIItrEIIIIi lI!iic.d.e.f.It /
    • PracticeQuestions51, You explained the risks and bcnefits of bone marrow transplantation versuschen.ro-therapy to a woman with leukemia. This was part of an IRB-approved trial. you toldher that the transplant hasthe highest chanceof cure of the diseasebut also the high-estrisk of immediate dcath. Sheunderstood what you said and signeclthe consentfortransplantation,Shedicsasa resultof the bone marrow transplantand her husbandsuesyou for wrongful death.Mrat will be the most likelv outconc?He losesthe lawsuit becauseBMT is the standard ofcare for this patientsageanddisease.He wins becausehe was not informed,He wins becausechernotherapyhaslessrisk of death.He losesit becausethe patient was fully infbn.ned about the risks and benefits ofboth alternatives.He loscsbecausethc trial was IRB-approvcd.52. A 57-year old corporate executivc comes to the energency department with an STsegmentelcvation myocardial infarction. He rcceivesthrombol)rtics but haspersistentchestpain, rvorseninglcft 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 adverseeffcct of the angioplasty balloon. you tellhim that the benefit will be that it stops the chest pain. He opts for further medicalmanagement without angioplasty bccauseof fear of adverseeffects.He dies and hisestatesuesyou.ltrat rvill be the most likely outcome?a. You win becauseyou fully informed him of the adyerseeffects of the proce_dure.You win trecausehe refusedthe treatment offered.You losebecausepaticnts cannot refuselifesaving therapy.Youlosebecauseyou should havedone the angioplastybeforethe thrombolyt-ics.You losebecauseyou did r.rotinform the patient of the seriousconsequencesofforgoing angioplastl.b.c.d.b.d.
    • lo4|eracticeQuestions!tlpLlt.t) v r orcaL53, A 72-year-oldwoman is admittedto the hospitalwith gastroenteritisand dehydra-tion. Thereareno indicationsin the chartof her havingdizziness.Shealsodoesnotdirectlyinform the nursesof her dizziness.Sheasksto bebroughtto the bathroorn,Sheislefl aloneon the toiletwhenshebecomeslightheaded,faints,andhits herheadagainstawallsustainingalaceration.Thepatientandherfamilysubsequentlyfilesuitagainstthe hospitalfor negligence.{rtratwill bethe mostlikelyoutcome?Shewins secondaryto thenegligenceof thenurses.Shewins secondaryto the negligenceof the physicians.Shewins if shehassustainedsignificantbrain damage.Shelosesbecausetherewasno significantinjury.Shelosesbecauseshedid not inform the nursesshervasdizzyor lightheaded.MEDICATERRORS54. A 70-year-oldman is admittedto the hospitalwith endocarditis.At sevendaysoftherapythe antibioticorderexpiresandyou forgetto reorderthemedicationfor twodaysin themiddleof afour-weekcourseof intravenousantibiotics.Thereisno clini-caldeteriorationandtheantibioticsarerestarted.What shouldyou tell thepatient?a. Tellthepatientit wasa clericalerror.b. Becauseit wasnot clinicallysignificantyou do not haveto sayanlthing to thepatient.c. Apologizeandtell the patientthatyou forgotto reorderthe antibiotics,but thathewill beall right.d. Inform your chiefresidentbut not thepatient.e. Askthe nurseto tell the patientaboutthe error.55.a.b.c.d.e.N5t
    • eracticeQuestionsj tosrydra-snotoom.heade surt55. Youare a resident managing a private patient with cellulitis. The patient has a history of congestiveheart failure and a normal EKG. The patient is on digoxin, an ACEinhibitor and a diuretic, but not a beta-blocker.You cannot find a contraindicationto the useof beta blockers either in the chart or in discussion with the patient. youaskthe private attending why there is no beta-blocker and he looks at you as if youhadanoxic encephalopathy.He sa).s,"Ihave been in practice for 40 years.Don,t youthink I know what I am doing? Ileta-blockers are dangerous in congestivefailure.,Thepatient looks proudly at the attending and says,"Ihavethe smartestdoctor in thervorld."rhatshould you do about this disagreenent?Wait for the attending to leaveand give the patient a prescription for carvedilol.Suggestto the patient that he should find another doctor.Report the physician to the statelicensing board.Do nothing; he is thc attending of record.Bring the disagreementto the chief of service.Help the patient find a good lawyer and volunteer to testii/.MEDICATRECORDS56. A patient of yours hasgone to the hospital to obtain a copy of her ntedical record forher own review. The hospital refusesto releasethem to her on the grounds that shemust provide an adequatereasonfor wishing to seethe records.Shehascome to seeyouto askif this is true and how can sheget her records.What should vou tell her?You,asthe physician,cangetthe recordsfor yourselfto view,but shecannot.Thehospitalwill giveher the recordsaslong asyou ask.Shehasthe right to haveher own recordsaslong asshehasalegitimatereason.Shehasthe right to her own recordsevenwithout givinga reason.Only anotherphysician,hospital,or insurancecompanycanhavefreeaccesstoherrecords.Shecanhavethe recordsaslong asshehasfully paid herhospitalbills.s oftwoLini-a,b.c,d.f.a.b.c,d.IIIit(Apt-Arl M E D I C A L
    • PracticeQuestions58.57. Which of the following most accuratel).describesthe ownershipof the n-redicalrecord?a. The recordis entirelythe 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 physicaLpaper or electronic record is thc property of the patient.A man comesto the emergencydepartment after a stabwound. Your notes documenta 500-ml lossof blood. Later that night the patient developsasystoleand dies.YouUnd the lossof blood was originally really 3,000 rrl, which rvasnot recorded by 1-ou.What shouJdyou do to correct the documentation?a. Usecorrectionfluid to eliminatethe 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 sametime asthe original note.e. Write a new note with the current date and time.MINORS59. The neighborof a l4-year-oldboy bringshin to the energencydepartmentaftersus-tair.rir.rga laceration to the scalp fron.rhead traurna. You evaluatehim and detcrminethat suturing of the scalpwill 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 leastone parent.d. Wait for the consent ofboth parcnts.e. Seeha court-appointcdlegalguardian.f, Conscntis not necessaryin this case.M T D I C A L
    • medicalPracticeeuestionsI to7or clec-physicalrumer-ttes.You,I )ou.60.A 1s-yearoldgirl comesto theclinicfor dyspareuniaanda r.aginalclischargc.Onspeculumexaminationyoufind,t. r,or..rui.ii;r. ii;;;;;;.; "" " negative.Tircinfectionis modcst and thereis no cmergency.{rhichof the follol,ing is the mosr appropriateaction to takc?a. Ceftria,rone/azithromycinnow in a singJedose.b. Make at leasta.good tirith,,effortto notifr her parentsand treathcr.c. Wait to inforn at leastone parenr.d. Treat only if the patient agreesto infbrm her parents.e. Trcat her nol,and infornt the par_entslater.6l A 12 ycar ord boy ad his tlther are involvcd in a motor vehicle accident that resultsin a severehemorrhage requirilg an LrrgentHuna o"nri.,rion. Both of therl areclearll.alert ancl undcrstancIehovahswitnesse,""a "r.,1^1-lllrvithouttl.rebloodtheymaydie Theyarebothelu.irrghlrrodlr.lt[ui{,r)on rcligiousgroundr.{hat should you do?a. Honor their nishes;no transfusionsfor eitheroneb. Obtain a court order to transflsc tlre chilclc. Giveblood to the child bur not to the fatherd. Psychiatricevaluatione, Useintravenousiron in both ofthcn asa trloodsultstitutcI Explain the situation to the child and ask l.rim for consent for the transfusiolrtti:i;[i:,?:*T:*iffi::"crinicarterrissingapcriod.Herprcsnancvtestisthepregnancyco,fio.,-;"i;;;;,1;:.;1t :i::-tt^ roushcisadamantthatvoukcepWhatshouldyoutcllhcr?a. "lu,ill give you the careFou need anclkeep it confitlential.,,b, "lwiil not mention it to ),ourparerts unlcsstbey ask.I can,tlic.,,c. "Iam sorry, but I mLrsttell tl.rem.,,d...Irril]ntlttell,vottrparents,butInrrtstl.nfornrthefathcrofthebaby.,,sus-ninet<lptlru) l,lro rcnr
    • IPracticeQuestionsM E D I C A L63. A l2-year-oldgirl presentswith severeright lower-quadrantabdominalpain anrlnarked tenderncssand is found to haveacuteappendicitis.The child is at a sleep-awaycamp.Youarenot ableto locateherparents.Theyarenot at homeandvoucan-not reachthem on the cellphone.Thecampcounselorandthc clirectorof thecampbring in thechild.Whatshoulclyoudo?Do not do the surgery tvithout parental consent.Ask the camp counselor or director for consent.Ask the patient for consent.Perfbrm the appendectomy.Give intravenous antibiotics alone.64. A 16-yearold femalecomesin for treatmentof severecysticacnewith Accutane(isotretinoin).Shelivesaloneandis self-supportingwith ajob asa waitress.Shehasbeenout of herparentshousefor ayearandpaysall herown bills.you havejustfin_isheclinformig her of the potentiallysevcreteratogenicitvof isotretinoin.Her acneis severeandshewould still likethe isotrctinoin.What shouldyou tell her?a. "Thismedicationcant.totbetakenby worlen of reproductiveage."b."Usebenzol4peroxidctopicallyinstead.,c. "lwill giveyou the isotretir.roinif your parentsaccompanyyou.,,d. "Iwill giveyou the isotretinoinasrequested.,e."Iwill treatyou with isotretinoinifyou havea consentsignedby yourparents.,,a.b.c.d.e.
    • PracticeeuestionsJand:an-mPPIIYSICIAN.ASSISTEDSUICIDEANDEUTHANASIA65, A 65-yearold man comesto se,.i1::,11.j:,",,i"ffi;;"..:"r[il::nHT[[li:ffTHi;:ffi:,ilHJ:iff Jil,"*,::T-*lJ*r,..,"""r;.:;..;iig.oro.,o,.opyundmood.Heisaskingru oo..r..r,l-,Tldeniesdepressionandseemsto havea normaitoencihis,tft. ;;"r;;, ;: ;turPnonor combinationof medicationsthathecantake5*J*fftTJ#";:::;ilr;,*il:"*x:Tjfi,il:ii.":1,:,*,_jrWhrchof thefollowingis mostapprop atein thiscase?Providethepain meclicationsasIProvidethepatien,,n;;.;;;r,toropriatebut not themeansto endhislifel"l" I"0*ru,r.i."r,;:::*il;::,oendhisriieReferhim to a specialistin this arcaIn-patient psychiatric evaluatjon fstart antl.depressanr,ot tuicidal ideationa.b.c,d.f.{{l!!p rurorcar
    • ]eracticeQuestions66.fulll competer.rtand hasbeensufleringfrom progressivelyworseningamyotroplirlatcralsclerosisfor severalyears.He is not imr.necliatclypreterminal.Despitethh,htfindshisclualityof life to treunacceptable.More inportant, hecorrectlypredictsthlhis lcvcl of function will deteriorateoverthe next sevcralmonthsand thathemavbccorncventilatordependent.He is requestingthat ).ouadministera lethalinjectionin hishonc. IIc isnot depressed.Hisfamilyisarvareof hisdesircandthcyarewilLingto honor thepaticr.rtswishes.Youhavediscussedappropriatepalliativcclrc issues.rhat should you tell him?a. You tell him that you will horror his l,ish bccausc he is competent andnotdepressed.b. You tell him that you will honor his ivish becausehis condition will rvorsenorutl1l1e.You agreeto his wish becausehe has a rigl.rt to a better quality of life.You tell hinr that you cannot help hinr becausethete is no statelaw authorizingrt.You tell hin.rthat under no circumstancescan )ou participate in euthanasia.bu sa,vthat it is okay aslong asit happensin Orcgon.d.f.PHYSICIANIMPAIRMENT67. You are a fourth-year meciical stuclent on a subintcrnship in obstetrics. You troticetlrat the resident hascome in rvith alcohol on his brcath antl some abnormal behavior.(, rn( cxC(Pl()uiccrn lo nr)lica.l.rat should ,vouclo?a. Nothing;,vou are subordinate to the resiclent.Talkto the residentdirectlyaloncbut dont mention it to the program ctrectorTcll thc dcan of students.Report hin.r to the statelicerlsing boar-d.Reporthim to the chairpcrsonor program directorof his department.In.rn.rediatelyinform his patients whorr you feel are at risk.A 79 ycar old man comes to seeyou for assistanccin ending his life. The patienlD.d.f.M E D I C A L6l
    • eracticeQuestions]tttnt tsphics,hcthatmaytlonling3S.68. Youare an attending physician at a university hospital. One of the attendings fromanother division seemsto be having memory difficulty. You havc found hinr twice inthe hallway having forgottcn where he was going. The residentstell you on the sidethat they dont rely on him at all because"heforgets everl.thing we sayan1.way."Thcchicf of serviceknows but doesnt have enough attendings to fiIl the yearly schedulesohe renrains in placesupervising troth rcsident perforrnancc aslvell aspatient cirre.What shoulcl vou do?Nothing; the chief of servicealready knows.Talk to him directly.Tell your division head.Report him to the statelicensing board.69. Youareanattendingatalargeprograr.nin NewYork.Youareout atabaron Saturdaynightwhcnyou noticeoneofyour residentsin thesamebar.Sheisclearlydrunk.Theresidentis sittingbehind1ou,too intoxicatedto noticeyour presence.Sheis kissingamanrvhoyou know is not her husband.Youleavebe{oreshenoticesyou.Tl.refoJ-lowingdayyouseeheratthehospitalmanagingpatientsanclsupervisinginterns.Herbehaviorandmedicalmanagementseemconpletelynormal.Whatshouldvou do?Speakto her dircctlyaboutherbehavior.I)iscussit withherprogramdircctoror departmentchair.Reporthel to the comn.ritteefor physicianimpairment,Do nothing.D.c.b.c.d.MTOICALI(APIAN
    • ll2IPracticeQuestionsd.e.b.c.d.PHYS|CTAN/PAT|ENTRETATTONSHtP70. A physicianin a busy inner-city environrnenthasdevelopedhis practiceoveryearsto thepoint whereheno longerneedsto solicilnewpatients.He doesnotto expandhishoursofwork sohedecidesto limit hispractice.He instructshisstaffto beginrefusingto acceptnewpatients.Which of the followingmostappropriatelydescribeshis action?a. It isboth legalandethical.b. It is ethicallyacceptable,but illegal.He iswithin hislegalrightsto refusepatients,bu1it isconsideredethicallyceptable.It is both illegalandunethicalto refuseto acceptnewpatients.It is ethicalaslong ashearrangestransferof careto anotherphysician.71. You have a patient who has recently been diagnosedwith myeloma and he ising treatment options with you. You are the full-time employee of anfacilit1.1g1 by a managed-careplan and you have recently receivedwritten itions not to bring up sub.jectssuch asbone marrow transplantation in myelomapatients. The reasoningwas that they are outrageously expensiveand do not curedisease,although it may extend survival. The data that they extend survival areentirely conclusive.ln addition, in a private meeting with the meclical director,louhavebeen told that the expendituresper prtient load of careof eachof thewould beexaminedyearlyto determinewhichphysicianwould bepromoted.What do you do?Fully inform tl.repatient about the risks and benefits ofbone marrow transplan.tation.Refer your patient to an oncologist to have this discussion.lransferthe patient to another primary-care provider.Advise the patient to file suit againstthe managed careplan.Give the patient treatment with melphalan or thalidomide which bothable therapy.f. Inform the patient about bone marrow transplantation if he asksyou aboutit.[APLAN) MTDTCAL
    • -teracticequestionsI ru I72. Youhavea patientwho is a 57-year-oldnan with a historyof HIV who hasrecentlybeenfound to haveseverecoronaryarterydisease.He hasthreevesselswith lessthan90percentocclusionand left ventriculardysfunction.He is referredfor blpasssur_gery.The cardiothoracicsurgeonat your hospitalrefusesto operateon your patientbecauseheis scaredof touchingHIV positivepatientsfor fearof seroconverslon.Heisalreadyon a beta-blocker,ACEinhibitor,andaspirin.Whatshouldyou do?a. Add calciumchannelblocker..b. Performangioplastyandstenting.c. Add clopidogrel.d. Havehischiefof servicecompelhim to do theprocedure.e. Referthepatientto anothercardiothoracicsurgeon.A 60-year-oldmalephysicianwho is aninternisthashada fernalepatientfor thelast20years.Both losttheir spousesseveralyearsago.Theystartspendingtime togetheroutsidethe office.The femalepatientwantsto begina sexual/romanticrelationshipwith the phvsician.rtratshouldhetell her?a."Icanneverdo thatwith you,ever."b. "Wecanbesocial,but not sexual."c. "Weneedthe ethicsboardsapprovalfirst.,d."Icannotdateyou and beyour doctor-maybe in the future we candate,afteryou getanotherdoctor."e. "Becausethis is your initiativewecanbegindating.,,lherntice73.S -rt:-hetu
    • l14|PracticeQuestionsi PUBTICHEATTHANDREPORTINGREQUIREMENTS74. Vhich of the following doesnot need to be reported to the health departnent?a. Salmonellab. Gonorrheac. Herpessimplexd. Tuberculosise. Measles75. A 38-year-old bus driver is seenin clinic for fever,cough, and sputum with anapicalinfiltrate as well as sputum positive for acid-fast bacilli. The patient is unwillingtotake tuberculosis (TB) medications consistently and his sputum remains positiveforTB. Direcdy observed therapy while in his home has failed. You continue to cajole,discuss,encourage,threaten,educate,advise,and beg hin.rto takethe medicationsbuthe refuses.What should you do?a. Nothing, he hasa right to autonomy.b. Arrest the patient and put him in prison.c. Remove the family from the house.d. Removethe patient from his job asa bus driver and incarceratehim in a hospitalto take medications.e. Physically restrain the patient and place a nasogastrictube to give the medications.I(A 9IA N M E D I C A LRE77,
    • IIIiPracticeQuestionsI5A 27 lrcarold man is seenby you afterthe diagnosisof syphilis.Asyou areadministeringhis treatmentyoufind heisquitepromiscuous.Youinform him thatyou nustnotiE,the Departmentof Healthand that his sexualcontactsneedto be treated.Heisextremelyembarrassedandaskshorvtheywill find out.Whatshouldvou tell hin?f.You will notift them yourselfbut you will not give his name.You wiil notill. them and must let them know he was the contact.You will tell the Department of Hcalth but he himself must tell the contacts.The Department of Health rvill send a letter or call the contacts and let themknow they have a serious health issue.They will test and treat the partners butwill not reveal his name.He doesnt have a choice; he has to give the names.Their individual doctors will inform the contacts.REPRODUCTIVERIGHTS77. You are the general internist in a large, multispecialty physician group. The office-based pregnancy test on your patient hasjust become positive and you estimate thegestationalageof the fetus at eight weeks.You are a very deeply religious person in aconservative,midwestern city and you are opposed to abortiolr becauseyou believelife begins at conception. After extensivediscussior.rabout the options, your patientasksto be referred fbr an abortion.Which of the following is the rnostappropriateaction?a. Inform the patient that you are morally opposed to abortion and you cannotmake the referral.b. Terminateyour relationshipwith the patientasher phvsician.c, Propose social work/psychological evaluation ofthe patient.d. Tell hcr you will makc the referral aftcr a 30 day consideration period in whichshemay changcher mind.e. Refer the patient fbr the abortion.v,b.c,d.alo)rlt!l!!!!/ u:otc,rl
    • IeraaiceeuestionsMEDICALc.d.a. b .. c .d.78, A 16-ycar-oldfemaleis in your officebecauseshehasjustfound out sheisShediscussesheroptionsandasksyou to referherfor anabortion.Shestatesthatparents do not know shc is prcgnant and shedoes not want thcnt to knolv.What shouldyou do?a. Refcrher for the abortionwithout parentalnotitication.b. Makea"reasonableeffort" to contacttheparents,but still referfor theabortionif you cannot contactthem.Do not refer for abortion without parcntal consent.Seeka court order declaring her emancipated.Strongly encourageher to discussthe issuewith her parents.79. A voung husband and rvife visit your office to discussrnethods of contraception,Thewife decidesthat shewants a tubal ligation for sterilization. Her husband is shockedand strongly objects stating that thcy haveno children. His wife is clcarthat shenantsthe sterilization and that shewishesto be referred for the procedurc.What should you do?Reterfor the tuballigationasrequestedby thewife.Referaftera psychologicalevaluation.Do not makethe referralbecausesheisyoutg.Do not makethe referralbecauseshcmaychangeher mind.Refcronlyrvith the husbandsconsent.
    • PracticeQuestions I l 7}nt.herior-rhelednts80. A 35-year old married woman with four children is in your office seekinga termina-tion of an unrvanted pregnancy in the first trimester. Later in the day after you givethe patient the refcrral, her husband calls and is very distressedbecausehe does notwant the abortion to occur. He very much wants to keep the baby and tells you thathe even has a namc picked out.What should you tell him?a. You rvill try to talk his wife out of the abortion.b. You will cancelthe procedure immediately.c. You sayyou cannot hold up the termination withoul a court order.d. You cannot prevent the abortion without paternity testing confirming that he isthe father.e. You savyou have an absolute duty to the nother to honor her wishes no matterwhat his personal feelingsare.81. A 3O-yearold woman presentsto the clinic during her third trimester.The estimatedgestationalagcof the fetus is 28 rceeksand sheis seekingan abortion. The patient isgenerallyhcalthy. An ultrasound of the fetus at 26 $/ecksand routine genetic testingshowed no abnormalities.What should you tell the patient?a. Its okay; you will go aheadwith the abortion.b. You will be happy to comply if shecan get a court order.c. No way,third trimester abortions are prohibited.d. Legally 1oucan only do it if hcr life is at risk.e. No, you cant do it becausethe fetus is norn.ral.L(APLAN ) MTDTCAL
    • l t 8 PracticeQuestionsM E D I C A LSPOUSATABUSE82. A 42 year old man comesto seeyou for routine managementwhcn you inquire aboutmultiple scratchesand contusions as well as a black eye.He sayshis wife routinelrabuseshim and is"beatingme up pretty regularly, doc." He dcnics hitting his wife,You seehim a few weekslater and he has a new version of thc same injurics. Youarevery concerned about his injuries and you tell him that you areplalning to rcport theinjuries. He very clearly statesthat he doesnot want theseinjuries rcported.What do you tell him?a, You have no choice but to report the injuries bccause you are a mandator,yrePorter.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 hereis no spou.alabu.ereporting.e. You will report it if you find evidencethat the r,rifewas really the attacker.SUICIDE83. A 68 year-oldmanattemptedsuicideby driving hiscarinto atelephonepolewith theinter.rtionalpurposeof endinghis life. He wastbund sevcrelyhemorrhagingandintheemergencydepartmentherefusesto givehisconsentfor surgerynecessaryto stopthe bleeding.He statesthat he wantsto die.He wasrecentlydiagnosedwith cancerandrefusedsurgeryto removeit. He statesthat his life hadbeencompleteandnolihewishesto endit.What shouldyou do aboutthe surgeryto stopthe bleedingnow?a. Followhisstatedwish andwithhold surgcry.b. Performthesurgery.c. Obtain a court orderto forcethe surgery.d. Askthe familymembersfor consent.TO84.85I(A PIAN
    • tbout.inelywife.!l arct thclory1elnp:rIORTURE84. youare a civilian physician and you have been askedto participate in the interrogation of a prisoner suspectedof carrying out a terrorist attack.Therc is very significanteyidenceto prove his participation in planning subsequent attacks.you have beenaskedto monitor the patients oxJ.genlevel during a simulated ,,hanging,,and,.stran_gulation" of the patient to determine if supplemental orJgen or intubation is necessary.hat should you do?a. lt isethicrlll pcrmis.ihlcto pdrticipdtc.b. Participation is permissible only if he hasbeen 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 groupof prisonersisbroughtto arnilitaryhospitalin whichyou work.Theyaretobescreenedprior to transfercitherto long-terminprisonmentsot rn somecases,tobereleased.Younoticethat severalofthe patientshaveburnsthat look rikecigaretteswereput out on them aswellasseveralbrokenbonesthat havestartedto heal.hat shouldyou do?a. Reportthe injuriesassignsof possibletorture.b. Reporttheinjuriesonlyon thepatientsto bereleasecl.c. If you area military physician,you sl.rouldreportthe injuries.d. If you area civilianphysician,you shouldreportthc injuries.e. Youronly duty is to treatthe injuries.t(A p tAlt ) M€DtCAl
    • IPracticeQuestionswtTHHOIDtNGnIflTHDRAWAIOFMEDtCAtTREATMENT86. An elderlypatientwith multiple medicalproblemshasbeenadmittedto yourcarein the intensive-careunit. Thepatientis in a persistentvegetativestatesecondarytoanoxicencephalopathyand hasnow developedsepsis,hypotension,gastrointestinalbleeding,and respiratoryfailure requiring intubation. There is no improvementexpectedin the underlyingseverebrain damage.Renalfailuredevelopsto thepointof needingdialysisbut you feelthedialysiswould becompletelyfutile.Which of the followingisthemostappropriatestepin management?a. Hemodialysisb, Peritonealdialysisc. Renaltransplantationd. Givealbumine. Recommendthat dialysisnot beperformedA 33-year-oldfemaleboxersustainsa cervicalspinefractureduring thewelterweightchampionshipmatchin LasVegas.ShehasafractureofCl andC2resultingin paraiy-sisfrom theneckdownandisventilatordependent.Sheisfully alertandunderstandshermedicalcondition.Therehasbeenno improvementfor thelastthreemonthsandthereis no hopeof recovery.Her manageris the health-carepror7.Sheis frustratedbut not depressedandis repeatedlyandclearlyrequestingremovalfrom theventila-tor.Sheunderstandsthat shewill not survivewithout theventilator.What shouldyou do?a. Removetheventilatorassherequests.b. Obtaina court orderto continuetheventilator.c. Seeklamilyconiensuson removingtheventilatord. Seekapprovalofthe healthcareproxy.e. Sedatethe patientandcontinuetheventilator.87.5Aa!AN ) MrDrcAL
    • Jrltt88. A 48-year-oldwoman hasdevelopedstageIII non-Hodgkinslymphomaand needscombinationchemotherapyfor treatment.Without therapyshehasno hopeof sur-vivalbeyonda fewweeksor months.With therapyshehasan 80percentchanceofcompleteremission.Sheunderstandsthisentirelybut insiststhatshesimplydoesnotwantthe therapy.Thereis no evidenceof depression.Whichof the followingis themostappropriateaction?a. Psychiatricevaluationb. A:,krhelarnilyforthciropinionc. Seeka court appointedguardiand, Honor the patientswishese. Offer radiotherapyinsteadf. Riskmanagementevaluatron89. An elderly patient with progressive Parkinson diseasecones to seeyou becauseoffever,cough, shortnessof breath, and sputum production consistent with pneumo-nia. The patients Parkinson diseasehas been worsening and he has become quitedepressed.He hasinsomnia, early morning rvaking,and weight lossaswell asanhedo-nia. He is refusing antibiotics and is asking for palliative care only to help him die.What shouldvou do?Psychiatric evaluationSedatethe patientComply with the patients wishesSeekthe opinion of the familyEthics committee referralComply with the patientt wishesaslong ashe is DNRa.lt.c.d.f.!ll!!!/ vrotc,lL
    • 122 PracticeQuestions 90. A 55-year-oldman hasbeenadnrittedto the hospitalfor worseningof his nentaistatus,poor nutrition anclinabilityto eatwhenfed.ThepatienthasCreutzfeld-Jakobdiseaseandu.illnot likelyimprove.Overthe lastseveralmonthsthepatienthastoLdyou repeatedlythat hedoesnot want to be"keptaliveasa vegetable"with artificialnutrition andhydrationbyanymethod.fhehealth-careproxyform specificallystatesthereisto be"no placementof a nasogastricor gastrictubefor enteralfeeding."Thehealth-careproxyagentisa nurse.Theproxyinsiststhatyou havea.lejunostorny(ltube)placecltellingyoutheprorytbrrnonlyexcluclestheNG andG-tubes.Whatshouldyoudo?a, PlacetheJ-tube.b. Telltheprory shcneedsto geta court orderfor the J tube.c. Tellthe proxl sheneedsanethicscomrnitteeevaluation.d. Do not placeanyforn oftube for artificialr.rutritionor hydration.e. Transferthepatientscareto anotl.rerphysicianwhofeelscomfortableplacir.rgtheJ tube.A 35-year-oldhomosexualman is a victirnof a motor vehicleaccidentin whichhe sustainsheadtrauma resultingin a largesr.rbduralhematoma.His breathingisbecomingworseand endotrachealintubation is being consideredfor mechanicalventilation.His familyincludinghismotheraswellashismaledonrestiepartnrrispresent.His motherinsistson theintubationbeingperformed.Thedomesticpartncris the health-careagent.The agentstatesunequivocallythat the patientstatedbothverballyanciin writing that hervisl.redneverto beplacedon a"breathir.rgmachineforanypurpose."4ratshouldyou do?a. Honortheproxyanddo not intubateb. Honor the nothers wishcsandintubirtethe patientc, Consulttheethicscommitteed. Neurologyevaluatione, Try intubationfor 24 48hoursto seeif herecoversf. Ask theopilfon of the restof the family92.9391.!!l!!p urorcer
    • Practicentalkob.oldcialltesfhe( l -:h1Salis3I.h)rhe92. A 75-.vear-oldman is admittedfor a myocardialinfarction and a strokethat leaveshim in a persistentvegetativestate.He is a rvidow,neverdesignateda hcalth careproxy,andleft no u.rittenevidenceof hisu,ishesfor himself.His nephewanddaugh-terwantto continrreall formsof therapyinclucringartificiarnutrition andhydration.Hisson and the patientsbrotherrvantto stopevcr).thing.Both partiesbelievetheyLnorvthcwihcsof thcpatienWhatshouldyoudo?a. Encouragecliscussionarnongstthc famil1..b. You,thephysician,rnakethedecisior.rin thebestinterestof thepatient.c. Stopall fonr.rsof therapy.d. Obtaina courtorderseekinga court appointedgr-rardian,93 An 84-year-old noman with severeArzhcirners diseascis admitted to your skilednursingfacility.Shehaslost the ability to conrmLrnicatc,is becl_bound,ar.rdunabletocat.she did not appoint a prorr and tbere is no rvritten or clearvcrbal advancedirective of ,vhatshc uanted for hersell Multiple family members routinely visit her and1ouare unable to achievea clear consensusamongst the famil). of what the patieDt,srvishesrvere.What should you do in terms of hcr care?a. Follow the wishesof the eldestchild.b. Follow what you think is best.Askanotherattendingphysiciansopinion.AsJ<thehospitaladministratorfor consenr.Pur.rrcanclhic:eornnrittec( Jludtiotr.)
    • ]PracticeQuestionsM F D I C A L94, A 72-ycar-old man cones to seeyou becauseof severepain from metastatic prostatecancer to the bones. His pain has become progressively more severeand has notresponded to localized racliation, flutanritic, or goscrilin. ln addition, numerous painmedications have failed to achicve an acceptablelevel of analgesia.He needs moreintense pain malta€iement with subcutaneous or intravenous opiates. He also hassevereCOPI) and there has been concern about the effect of the opiate medicationson the patients respiratory drive. In other words, the only way to achievea sufficientanrount of pain relief is to use medications that may shorten his life, inadvertentlribecauseof respiratory depressiolr.The patient is fully alert and has the capacitytounderstanclthe problem.Which of the follorving is the most cthical way to approach his pain managernert?a, It is all right aslong ashe is DNR.b. It is acceptableaslong asthe patient understands the risks.c. It is unacceptableto shorten life.with physician administered medications.d. Intubatc the paticntthen givethe pain medications.e. Leavehim in pain aslong asthe 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 dependenton endotracheal intubation and rechanical ventilation. There is no hope of rccovervand the patient is unable to comntunicate. Thcre is no health-care prory and thepatient lacks the capacity to understand her problems. Her husband produces a liv_ing will signed by the patient on whicl.ris written the statement,,,I do not rvish to Lremaintained on a ventilator if there is no hope of recovery."He does not recall evercliscussingthe subject with his wife.{hat shoulclyou do?a. Continue the ventilatorb. Risk management evaluationc. Rcmove the tube and the vcntilatord. Seeka court order to remove the ventilatore. Ask the rest of the family rvhat they thinkITAPIAN
    • atelotl l n,reLaSn sntrYlto96. An 84-yearold wonan is aclmittcdwith abdominalpain. On the secondhospitaldayshebecomcsfcbrile, severelyhypotensive,and tachycardicfrom an intestinal perforatioo. The patient is disoriented rvith no capacityto understand hcr medical problen.rs.There is no responseto antibiotics, fluids, and dopanine over the ncxt 4g hours andtherearc signsof significant anoxic cnccphalopathy.Altho.gh th"r. i. ,r.rohealth-careprorlz,the family is in uniform agreementon what the patient wourd havewanted forherselfhad shebeen able to speakfor hersclf.rhich of the follorving cannot be stopped at the direction of the tamiJy?VentilatorBloodtestsDopamincFluidandnutritionNothing97. A 73-year-old man has been brought to a chronic_care facility for long_tcrm ven_tilator nanagement. The patient has advancedCOpD and is unableto be weancdfrom the ventilator. A trachcostomy h-asbeen placed. A nasogastric tubc is in placeto.deliver tube feeding. The patient is fully alcrt, and undcrstaids the situation. He isasking to have the nasogastrictube renroved becauseof discorfort.4rat should you tell him?a."Iwill get that tube out right away,sir.,,b."l,etsseehow much you are atrleto eat first.,,c. "Iwill pull it out if you let me put in a gastrictube.,,d,"Letme talk to your family first.,,e."Doyou havc a health-care pror1,?,,f. "Noway dude, we make the clecisiorrsarouncl here, not you.,,g. "Onlyif you promisenot to sueme.,,h.Arcyou crazv?Do you think I am going to let My patient starve to death?,,a.b.c.d.
    • PracticeQuestionsM E D I C A L98. A 47 year old man r,vithcnd-stagerenal failure hasaskedyou to stop his dialysis.Thepatient fi-rllyunderstands that he will die if he stops dialysis for nore than a few da,vsor wecks.Hc is not depressctland not encephalopathic.What should you tell hin?a."Ineed a court order first."b."lam sorry; I dont feel comfortable doing that."c."Icantdo that.Psician assistedsuicideis not ethical."d."Irvill stopwhen yegetyou a kidneytransplant."e."Yourvill feelbetter if I sedateyou so that you stop disagreeingrvith me."f.AlthoughI disagrcewitl.ryour decision, I will stop the dialysis."g."Icannot do that. We alreadystarted dialysis.Now we have to continuc."h."Notuntil you pay your bill."A 92-year-old man with Alzheimers diseasehas been aclmitteclto the hospital withaspiration pneumonia. He is on a ventilator and has a nasogastrictube in place.Hedoes not have the capacity to understand his meclial condition. You find a living willjn an old chart that says"Noheroicmeasures,""lwant to be DNR," and"Iwish to bekept comfortable."Thereis no proxy and there is no farnilyavailablewith whom youcan cliscussthe natter. He has no pr ivate physician with lvhom you can discussthecase.What should you do regardingthe ventilatorand tube feeding?a. Continuc both for now.b. Removethe ventilatorand the tube feeding.c. I{emove the nasogastrictube but continue the ventilator.d. Seeka court appointcdguardran.e. Decide rvhat vor.rthink is bestfor the patient.99.
    • helys100.Which ofthc following best approximatcs the role ofthe health-careprox1,?a. To explain the physician,splan to the familyb. To conrey the wishcs of the family to the meclicaltcamc. To communicate and carry ou1thc wishesofthe patientd. To nake decisionsbasedon what he or shegenuinely belicvesrsthe bestinterestsof the patiente. To carryout the financialdccisionsofthe patientrvhenhe or shelosesthe capac_Ity to speak101A 34-year-old woman with three chilcrrenpresentspregnant at 20 weeksofgestationalagewith anemia and severegastrointestinal bleeding requiring transtusron to saveherlife. Sheis a JehovahsWitness and sheis refusing biooj tr"r.rr-f.rrion.Vhat should you do?a. Honor her wishes,no transfision.b. No transfusion now but the transfusion is mandatory after the secondtrinlesterwhen thc fetus is a potentially viable baby.c.liansfusethe patient.d. Seeka court order mandating the transfusion.e. Get consent of the father of the babvrhIei11)eLI3I(A PIA N) MEDICAL
    • JeracticeQuestionsMEDICALto2.-T_-f!iIIIMr. Barberisa58-year-oldmanwho hasa cardiacarrestaftersurgery.He suffe.sp., !manentbrain damagefrom anoxicencephalopathy.He is jn a permanentvegetative:stateandventilatordependent.His wifeandeightchildrenarepresentin thehospitat !andrequestin writing for theventilatorto bestopped.After its removalhecontinuesIto breath. They are asking for the intravenous lines to be rernoved and all blood test-ing to be stopped. They agreethat this was his wish for himself. He did not leaveawritten advancedirective such as a living will but he clearly told his family,,.l don,twant to be a vegetable."He never designateda 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 careof the patient to another physician.e. Remove the IV lines and stop blood draws asthey wish.f. You can withhold additional new treatments and tests,but you cannot stop thosealready started.i
    • I rzg.sper-ltative)spitaltrnuesI test-:ave adonthoseNoNeedforFurtherStudiesWhenBrainDeadAnswersandExplanationsl, (a) Remove the ventilator.The patient meets the criteria for brain cleath.Theseare: negativecorneal reflex, nonvstagmusrn responseto caloric stimulation of the tympanic membranes, negativepupilary and oculocephalic reflexes,and the absenceof ,ponon.o.,, respirationwhen the ventilator is held. Ifthere are no brainsten reflexesan.1the patient will notspontaneouslybreathe,then the patient is brain dead.There is no hope ol recoveryinthis circumstance.An EEG is noconsistentwithb,ai,,deuth.s.nitJffifll,l..;fiH*:::1:::il",:T:;1,*States.Although the heart hascontr.nuedto beat,it is the sameastaking the heart outof the chestand seeingit beat in a specimen pan simply becauseof the automaticityof the hearti intrinsic conduction path*oy. Wh.n n pntient is brain dead,you do notneedto seekcourtor cthicscorlapatientisbraindead,.",r"ilil; jt"t":il::il:HTiil:i:: :lifir#i:patient.Thebrain-deadpatientis dead.Thisrvool.tb. "s illogi."l asplacinga naso_gastricfeedingtubein a cadaveron the autopsytable.Remember,althoughyou havelegalright tnlurn off theventilatorimmediatelyon apersorwho isbrain dead,you sh9yl4talkto tl-re--familyfirst.Ifthere isananswerthatsays"discuss,""conference,,o, arriyiiiii *"iJi ird"ti"g ,n", y.u lv"", to alwaysachieveconsensusfirst,thenthatdiscussthema*er-,,r,,r.,.0,,,",iifii:;,:,ffi:::tJ:J,jr,1T:i:jj:i]if.."ltube. -Jt(A pt"AN1IMEDICAL
    • Answersand Explanationstl!!p urorcrlMandatoryReporting2. (h) Reportthe family to child protectiveservices.Although,in general,it is better to addressissuesdirectlywith patientsand theirfamilies,thisisnot thecasewhenyou stronglysuspectchildabuse.Reportingofchiidabuseis manclatoryevenbasedon suspicionalone.Although it is frighteningto beconfrontationalwith the family,the caregiveris legallyprotectedevenif thereturnsout to beno abuseaslongasthc reportwasmadehonestlyandwithout malice.Youdo not havethe authorityto removethe child from the custodyof the parents.Onlychild protectiveservicesor the courtscando that.The policewould be appropriatefor anassaulthappeningat that exactmoment,but the policearenot appropriatetoinvestigatechild abuse.When you havea suspicionof child abuse,it doesntmatterwhatthe parentssay.That iswhy talkingdirectlyto themotheror fatherisincorrect.Whenyou suspectabuse,evenif the familydeniesit, you must still report.PrivacyofHealth-CareInformationintheWorkplace. ,r, |3. (c) Inform him that you are not {MV rc give detailswithout the patientspermission..,{r irl-.,1,r,rggar<lingthe patientConfidentiality is a fundamental right of all patients. As part of maintaining thepatients autonomy in revealinginformation only to those they wish to be informedof their condition you must refuseto releaseany specificinformation ofthe patientsmedical history or current medical problems without direct pern.rissionfrom thepatient. Respectthis right even if the person asking is, indeed, a cq-wo1kg1-ey sysntheir superior. You have no idea if medical information may be used to discriminateagainst the patient. Scparatefrom this, third parties have no automatic right to apatients medical information unless they are directly involved in the care of thepatient. This would hold true even if the person seekinginformation is a health-careworker 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 releaseofinformation confirming that they are giving 1oupermission to releaseinformation.
    • AnswersandExplanationsI4. (d) Tellthemyou cannotshowthem thechart unlessthereis asignedreleasefromthe patient.t 5 llelrLildbernsbunlyatetoterct.:nntYou cannot releasea patients medical records unless thcre is a clear,signed releasefrom the patient or there is a court order. This is true no mattcr who rs asking. Ifthe federal agents have a court order for the records ,h;; ,;;;;"r. a right to theinformation. A court order, warritovjorateconndentiarityirir.;"ili,lii,llrj:]ilil:J;.":,*i[.JTil:"J;1"#medicalrecordasa physicalobjectis thep-p*ty "r trr"pifri.iu, o. r.,.nrth_.n..I;1:l,r.jr:^1"-tl t?.-ation isthe_propertyof thepatient.rn asense,theinformationisrrkca person5 house.No one hasthe right to enter your home without eitheryourpermission or a court order allowing the investigation. This is also true even il thepeople requesting it are law enforcement agcnts.We all have a constrtutional rightagainstillegal searchand seizureof our property.BreakingConfidentialitytopreventlnjurytoOthers5. (e) Inform both the patientsbossaswell aslaw enforcementof the threat.A patientt right to confidentiaiYourdutytoprote.,,n.t,* "rTlt^1111^Int-ttn::tntt otrsonsrighttosafetvbeginspatienttmedicarinrormation:::i::TiT;:i ;ff :::Ti:::il ;:i::.:iTill:dulywarned.If larvenforcementisinfo.-"d urdth. pot.rr,lnlli.,r_ ir r.,o,irrfur-.athenyou areheldliableif thereis injury to thevictimDutytoInformthepatientFirst;WithholdingInformationfromthePatient6. (d) Youtell them that you areobligatedto inform thepatient of all the findings.Yourfirst duty is to keepthe patient fully informed about her healthcare.Unlessthereis significantevidenceofabsorutedutytoth"r"*;*i::itf"T#fljl.j:iilffi :#*lljff;psychologicalharm to a patientwould bean activelysuiciauti..,on *fro wasgivensignificantbadnews.:drt-lll:!!p rureorcrr-
    • r32Innr*",, undExplanationsThe 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 requesttowithhold infornation is in rvriting or is from the hospital ethics committee. In thiscase,the ethics comn.ritteeis not necessarybecausethere is no substantive questionof the right action to inform the patient first. The health-carc proxTs opinion andparticipationareonly mandatedif the patient losesdecision-nakingcapacity.lf thepatient has decision-making capacity,the health-care proxys opinion is not clifferentfron anyone elses.BreakingConfidentialitytoInformOthersofGeneticDiseases7. (e) Inforrn the patientsex-wifeof the risk to the children,The patients right to confidentiality endswhere it comesinto conflict r,r,iththe safetyof other people.The right to confidentiality is extren.relystrong, but it is not universaland absolute.In this case,the children of the patient have a right to knorv whethertheir lives will be cut short by the di.seaseof familial adenomatous polyposis (FAp)and colon cancer The most important elemcnt is that sc,reelrjngfor polyps shouldbegir.rat th_e_agggfl2 with screeningsigmoidoscopy evcry year.Colectomy needstobe done if polyps are found. Hence, in FAP there is a very specific intervention thatcan prevent colon cancerand a very specificscreeningthat can be clone.ln addition,the nother hasa right to knorv whcther her children will become ill and how to planfor that. If a child falls and breakshis leg,ole parent cannot claim confidentiality asareasonto withhold this critical health information from the other parent. As a part ofdivorce, the stipulation that eachparcnt nust inform the other parent of health careissuesfor the children asthey arise is a standard part of the agreement.Although, inthis case,the health care issueinvolves the private health of one parent, the issueisstill pertinent to the other parent asthe caregiverof the children.The right to onepersonsto privacyis not asimportant asthe right ofanother personto safety.This is establishedstandard and doesnot require a court order.you rvill havemore liability from the mother of thc children if sheis NOT jnforned than fromviolating the confidentiality of the patient to inform. She can successfullvpursue alegal action stating you, the physician, did not infornr her that her children were atrisk of the"injury"of the genetic disease.I(APLAN MEDICAL
    • AnswersandexplanationsIThe health departmentdoesnot do notification for ger.reticdiscases.The healthdepartmentnotifiespartnersandthepopulationatriskof transnrissiblecliseasessuchastubercuiosis,HIV STDs,andfood-or water-bornediseascs.t f 5lmmigrationStatusConfidential(a) "Donitworry, the Department of Health does not ask or report irnmigrationstatus."As a physician or:r ethical duty is to provide medical careto patients. Neither physi_cians nor the Department of Health act as information servicesto rcport peoplesimmigration statusto thc government. Thcre is no mandatory reporting to the gov_ernmcnt either before, during, or after the treatment of tuberculosis. Incarcerationto 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 thegrantable reasonsfor asylunt. Mandatory reporting of immigration status would bea direct impairment of thc physician/patient relationship.Sperm/Egg/EmbryoDonation9. (c) It is legal to sell both the sperm and eggsbut not the embryos.The patient can sell and d!!3te unfertilized gametessuch as sperm and eggs.Bothspern and eggs are considered cqual. A fertilized gamete or embtyp can also be{g1gteJ.Howcvcr,it i (urrenllyill(g,rlro,rll embryo,.-I(API"AI{ ) MEDICAL
    • AnswersandExplanations!l!!!p urorcarWhoAsksforDonationConsent10. (e) Organ-donor networkThe rules concerning organ donation are quite specific that the medical team takingcare of the patient must not be the ones asking for the donation of organs.This is aconflict of interest.It pits the familys perception of the physician ascaregiveragainstthe impression that the medical staffjust wants the organs.There can alsobe signifi-cant amounts of irrational thinking associatedrvith grief such asthe family thinkingyou only want to turn off the ventilator so you can harvest the organs. The medical team n.ruststay clearly in the role of the people trying to preservethe life of thepatient. Thc other most practical reason for the organ-donor network to ask is thattheir chance of successfullyobtaining consent is far, far in excessof physicians whoask.The organ donor network doir.rgthe askingboth preservesthe ethical integrity ofthe medical team in the eyesof the family aswell asmarkedly increasing the supplyof viable orsans availablefor donation.PaymentforOrganDonationlsUnacceptable11. (e) Reimbursementfor costof travel and lodging for the donation is acceptable,but profiting from the donation is unacceptable.Thereisanenormousshortageof acceptableorgansfor donation.Assuch,cashpaymentwouldfavortheorgansgoingto thepersonwho wasthewealthiest,not thepersonwith thebestmatchor greatestneedfor theorgan.Theorgansmustbeuniformlyand fairly distributed.If sellingorgansis consideredunethicalin the United States,thenit isunethicalto participatein acash-for-organpracticeanywhere.Asphysicianswecannothaveseparatedomesticandinternationalethicalsystems.
    • AnswersandexplanationsI t35takingtisis againstignifi-nkingnedi-rf the; thatwho.tyofpPlyFamilyRefusalCanOverruletheOrgan-DonorCard12. (e) Honor the wishesof the family; no donation.Althoughtheorgan_donorcardindicatesthepatient,swishto donatehisorgans,it isstillunacceptableto harvestorgansagainstthedirectwishofthc fbmily.If weweretooverruJethefamily,thentherewould.beno point in askingth"rn ,o .or,r"nt. Wty urkconsentfor donation,if we would takethe organs""y_;; ifthey saidno?Theorgan-donorcardis an indicationof thepatient,swisi* i", ii^ not fully binding.DNRDoesNotLimitOtherFormsofTreatment13. (c) Goaheadwith the dialysis;ignore the DNR order.A "Do-Not-Resuscitate,(DNR) order is veryspecificallydefinedasrefrainingfromcardiopulmonaryresuscitativeefforts..suchas ch.r, ;;";;,;.rr, antiarrhythmicmedicationssuchasamiodaroneor lidocaine,and electricalcardioversionin theevent^of,thepatient,scardiopulmonaryarrest.A ONn ora., in, nothing to do withany of the other forms of carethat the patient i, *..iil"g. ; L)NR order hasnoimpacton the useof dialysis.you shouldpretendthat th. oNn orae.aoes,ot existwhenevaluatingfor dialysis.Hyperkal.-iu i. lif. ,frr*i"i"S. i " illogicalto useaninferior rherapysuchaskayexalatefor the long_term;;G";.", ot the hyperka_lemiaof renalfailureif dialysisis indicated.Thispatient;, ol_ut", nt.rt, and abletounderstandhis or her own medicalproblems.ffr. p"i*,1 i"_lfy rsnot relevantinl::T: :1-,T*.Uior-making pathwayif the patientt u, tt ..nfu.ity to understandnrsor her own medicalproblems.ble,ay-1lyES,nsr(APLAN M E D I C A L
    • 135Ionr*"r, andExplanationsDNRDoesNotPrecludeICUManagement14. (c) Transfer to the ICU asneeded; okav to be DNR in the ICU.A"DoNot Resuscitate"or DNR order means no cardiopulmonary resuscitativeefforts in the event that the patient dies.There is to no other automatic limitation intherapy besidesthis. DNR orders are often confusedwith generalizedwithholding ofcare such astransfusion or ICU management. DNR orders are not the sameasstop-ping the active management of the patient. DNR ordcrs do not automatically meanthat the patient is immediately terminal or that there is an automatic assumption ofpalliative care only.15. (e) DNR does not preclude surgery; proceed with the appendectomy.DNR is not meant to be a generalizedlimitation on all forms of therapy.You can stillintubate patients even if they are DNR. No additional forms of consent are requiredever.rif they are DNR. DNRjust meansyou are taking death asthe endpoint of givingtreatment. In the event of cardiopulmonary arrest do not give the additional therapyof cardiopulmonary resuscitation,defibrillation, and chestcompressions.DNR is nota gencral equivalent for withholding any other forms of therapy except these.llajjl9 MEDTcAL
    • Answersand ExplanationsG i !!l!!p vrorcnrt57ReportingofElderAbuseMandatory16. (f) Reportthe grandson-in-lawt abuseto protectiveseryice.Elderabuseiscommonandyou havetheright to reporttheabuseovertheobjectionsofthe patientin themajorityofstates.Thereportingrequirementsfor erderabusearelikechild abuseexceptthat theyarenot uniformly mandatoryin all states.Althoughthelegalrequirenentsarenot identicalin all states,theethicalrequirementof physi-ciansto reportabuseisclearanduncompromising.Thereportingofelderabusedoesnotdependon thewishesofthe patient.With theelderlyyou oftenhaveacompetentadultwho is simplyfrail or impairedin someotherway.Although the patientmayseethelossof the careof the familyasa worseproblcmthan theirinjuries,you musractto protectthepatientfrom anenvironmentthat might kill her.you cannotspeaktothegrandsonor notify thepolicewithout thepatient,sapproval.Honrehealthaidsarethercto clean,cook,dress,and otherwisemaintainthe patientsneeds,but theyarenot securityDersonnel.DirectPhysicianParticipationNotEthical17,.Jd)"I am sorry; I cannotparticipatein the executionat all asaphysician."Theethicalguidelineofthe AmericanMedicalAssociationandtheAmericancollegeof Physiciansareexpresslyclearthat a physiciancannotparticipatein.,any actionwhichwould directlycausethe deathof the condemnedor assistanotherindividualto directlycausethedcathof the condemned."Thisincludesstartingtheintravenousline,mixing the medications,formulatingthe n.redications,administeringthe medi_cation,andevengiving technicaladvice.In fact,it is unethicalevento beobservinganexecutionin your capacityasa physicianbecauseit givesthe suggestionof youracquiescenceto the procedure.It is not ethicallypermissibleto certifi the deathunlessit hasalreadybeendeterminedby anotherperson.The primary role of thephysicianin termsof beneficence(doing good to others)and nonmaleficence(notdoingharm) arecompletelyincompatiblewith participatingin executionl(!you arethephysicianin a prisonyour physician/patientrelationshipcannotsimultaneoq,slycontainboth the roleof the caregiverandthe executioner,sfacilitatoidependingonthedayof theweek)It isethicallyperrnissibleto giveanxiolyticmedicationsprior tothedayoIexecutionlo relierethesufferingof thepe.soncondemncd.-
    • IAnswersandExplanationsNecessityofInformedConsent18, (b) Informed consentis requiredto participate.All clinicaltrials requireinformed consent.Experimentalsubjectshavean absoluteright to know that theyareparticipatingin a trial. This is true evenif the medica_tron studiedhad only benefitand no adverseeffect.you woulclst l needinformedconsent.As a principleof autonomy,you do not havethe right to do somethineforsomeoneor to someonewithouther consent,evenif it helpsyou.ID thi, sense,Icouldnot giveyou moneyasa gift without your consent.Thedesignof the institu_tional reviewboard (IRII) is to assurethe ethicalintegrity of all clinicaltrialsat aninstitution or facility.An IRB is an independentboard of reviewerswho must nothaveanydirectgainor harm from theimplementationof thetrial in orderto assureobjectivity.All humanexperimentsrequirethe approvalof the IRB.Hence,if I designeda trial comparingwhetherme givingyou $50or $100asa ta-{,freegift madeyou happier,I rvouldstill needto getIRBap-prorrnlurrayou_ould haveto signaninformedconsent.PrisonerParticipationinExperimentation19. (d) Their rights areidenticalto anonprisoner.Prisonershavetheright to participatein clinicalresearchtrials..l.heyarealsoentitledto monetarycompensationfor their participation.participationcannotbeusedasacriterionfor shorteningtheirprisonsentence.Essentially,prisonershaveall thesamerightsin termsof their participationin clinical..rear.h u, nonprisoners.This alsoincludesthe right to refuseparticipation.It is not unethicalfor them to participate.The ethicaldifficultiesbeginwl.renthe porverof choiceand informed consentareremovedfrom theprisoner.Incarcerationdoesnot rcducetheprisonerto thesubhu-man,animallike statusof unfair treatmentor not havingtheright to refusepartici,pation.Clinicaltrialsthatoccurin aprisonmust undergothesamerevrewprocessbyaninstitutionalreviewboard(IRB)asthoseoccurnngoutsidctheprison.you cannotforcesomeoneinto researchjust becausehe is u priron"r. you cannotcoercethemrntoparticipatingby suggestingit will shortentheprisonsentence.!ll!!p urorcar_
    • lutelca-nedfore, ItuDisclosingFinancialAffiliationsattheTimeofpublication20. (d) Thereareno restrictionscial affiliation.i onyour authorshipasIongasyou disclosethefinan_Thereis no automaticethicaldifficulty with industry sponsorshipof clinicaltrialsandexperimentation.Financialsupportfrom ".o_pui do., not eliminateyou asanauthoraslong asyou discloseall of your financialaf&liationswith the company.Theabsoluterequirementto revealfinancialor businessaffiliationsat the time ofpublicationis necessaryfor all the authors.Thisis true evenif the dataareaccurateandunbiased.you must revealgrant supportfor your trial evenif the pagnentsaremadeto a third party suchasthehospitalor medicalschoor.you maystil havebeeninfluencedto altertheoutcomeevenifyou havenot personallfreccive<tthepaymentsdirectlyinto you own bankaccount.Thekeyissuein termsof researchandpublica_tionsisnot whetherIou or your tnstitutiontook moneyfrom companiesbut reveal_ingthefinancialconnectionsbetweentheauthorsand,ha.o_porry.AnswersandExplanationsitt9annotureaxlve; a|leSO:e.rety)tnRoleofthetRB21. (c) Ensurethe ethicalandhr manetreatmentof human subjectsin ex?erimenta_uonTheinstitutionalreviewboard(IRB)reviewsall experimentartrialsto makesurethatthetreatmentof thesubjectsisfair andhumane.partofthis responsibilityisto makesurethereis adequateinformed,consentandthat the askedquestronis a validques_tion.In otherwords,theIRBwill makesurethattheplaceboenJof thetrial doesnotwithholdclearlybeneficialtherapysimply to co ectdata.The IRB makessurethatallhunan subjectsunderstandp,reciselywhattheyareagreeingto pa.trclpatein. TheIRBmakessurethat thereis sufficientmonitoring of th! studi sothat if a treatmentisfound definitelyharmful or helpfulthentrial ,iop, ir.,ord., to switchthe subiectsinto themorebeneficialarm of it, oncethepoint LuaU".r, prou.n.!l!!p r*aeorcnr,
    • t40IAnswersandExplanationslRBs developedout of the experienceof the Nazi war crimes tribunal at Nuremburgin rvhich it becamc clear that experimentation was prcrftrrmeclon humans ^/tthor.ttthcir consent and without concern for safcty.The I RB ensuresthat tne paueDrneyelsufferspurposeful harm simply to answera scientific question. ln sltort, the functionof the IRB is to ensLrrethat thc careof thc subjectiu the trial is more rmportantthanthe collcction of data.You cannot usean unethical n.rcansto achicvean ethical end.EmployerWantsMandatoryGeneticTestingofWorkers22. (d) Ask the patient if shey/ants the test performed and the results reported.Employersdoot l.ravea right tr thc confidentialhealth-carcintbmation of patients.You may pcrforn and report certaiD tcsts to the enrployer at the request of thcpatient. ln adclition, genetic testir.rgis, asof yet, of unproven valuc. It is not yet clearwhat to do with the resLrltsof thesetestsin terms of their impact on the standarilmanagementof patients.A positivetestfor the ApC genedoesnot mean the patientwil) get cancerof the colon.A negativetcst clocsnot mean that the patietrtwill trotgct cancer.A negatiYetcst is insufficiently sensitiveto rule out cancer.The nesativepredictivevalue is insufficie.t to rule out c.ncer.lhe only thing that is clearabourthe ethics of the genetic testing for cancer is that we wish to prevent discriminationand therecan be no mandatoryreportirg of geneticinformation.CeneticInformationprivacy23. (d) Refuseto providethe information to the employer.The enploycr has no right to the geneticinformation of a patient. Canceris nottnnsmissiblc to fcllow cmployees.None of the geDetictests have an impact on jobperforn.ranceor job safety,which arc the only tbms of information that an emDloyerhasa claim to.I(APLAN MDICAL
    • s!trIIGiftsfromlndustrv24, (c) Do not accept the rnoney, but the dinner and the lecture are ethically accept-able.Drug companies constantly surround physiciansin an attempt to influence prcscril>ing patterns.It is ethically acceptableto participate in eclucationalactivitiessponsoredby the pharmaceutical industrl. Modest mealsare also ethically acceptable.Althoughthe speakermay accepta cashhonorarium for preparing and giving the lecture, it isnot ethically acccptablefor members of the audience to acceptdirect monetary pay-ment for participating. Hence, it is ethically acccptableto attend the lecture and themeal,but not to accepta checkfor cashfor the participants.HonorariafromIndustrv25. (d) It is permissibleto takethe money aslong asyou discloseany other financialor businessconnectionwith this or anyother company.Industry sponsorshipof the speakersin medical educatior is acceptableas long asthere is no expectationof the conpany controlling or influencing thc content ofthc presentation. ln other words, you are not allowed to simply be an advertisementfor the companl pretending to be giving an objective presentation of ncdical data.Speakershave a mandatory responsibility to discloseall financial participation withind ustrl. This allows the audienceto judge for itself whether there is undue influenccfrom industry altering the content of the talk in thvor of a particular product. Thereis r.rorcquirement to clonateall speakersfeesto charity, Ihere is no requirement forprior review of a presentation to an independcnt monitoring board for content.Answersand Explanations t 4 lInappropriateGiftsfromPatients26. (b) "Thankyou very much, but I cannot accept."You cannot acceptgifts from patients who are clearl).having cvidcnceof an acutepsy-chiatricdisturbance.Evenif thc patient is not ill enough to qualify asincompetent,gifts frorn patients must be truly objcctive ancl clean in a way that there can be noqLrestionof acuteemotionaldurcssleadingto the gifi.!!!!!, veotcer
    • Ionr*"r, andExplanations!l!!!p rurrorcrr-AcceotableGiftsfromPatients27. (b) Acceptthe gift.Smallgiftsfrom patientsof limited valueareethicallyacceptable.Food,plants,andsrnallarticlesof clothing suchasa scarfareall acceptable.Refusingsuchsignsofgratitudewouldbehurtful to thedoctor/patientrelationshipif theyarea signofthegoodrelationshipwith you.Giftscanneverbe tied to a specificexpectationof caresuchasa particularprescriptionor the successfulcompletionof paperworksuchasdisabilityforms.Thereis no reportingor disclosurerequirementfor smallgiftsofnominalvalue.AcceptableGiftsfromIndustry28. (a) All the gifts areacceptable,Acceptablegiftsfrom industryarenevertied to ParticularpracticePatterns,sPecificdrug prescribinghabits,or any expectationof practicebehaviorchanceparticularto a specificproduct.Industrymay sponsoreducationalexperiencesaslong astheyarenot restrictingthe contentin anyway.Besidesmodestmeals,the otherformsofacceptablegiftsarethosewith directeducationalor medicalvaluethat enhancethecareof patients.Directmonetarypaymentsfor simpleparticipationarenot accePt-able.In this case,the gift of a stethoscopewill only enhancepatient care.The giftcertificateis acceptablebecauseit is to a medicalschoolbookstore.A gift certificateto adepartmentstorewould not beacceptable.Thevalueof giftsshouldgenerallybesmall,whichisdefinedatpresentasbeinglessthan$100in value.Giftsshouldnotbegearedmerelyto entertainment.Ticketsto concertsor sportingeventsarenot accept-able.Pens,notepads,andsmallpiecesof rnedicalequipmentsuchasa stethoscoPeorreflexhammerareacceptable.
    • AnswersandExplanationsI![!!p r,aeorcer_t 4 5ts, andgns ofof therf carerch asifts of:cific:ularth.yrsofthegift:atebebePregnancy,RighttoRefuseTesting29. (a) No test;shehastheright to refuse.Patientscannotbetestedfor HIV againsttheir specificrefusal.This is true eveninthecaseof apregnantwomanwhenthebaby,sheaftf,t "t ,t"i.. In fhct,HIV tcstingrequiresanadditionallayerof consenteventhoughit is only a bloodtest.Werecog_nize,that.invasive,potentiallycomplicaa.ap.o..ai..r ruJ nl roineedadditionarc.nsentbecause",,rr"r,i riLr,r,jilffi ,fii"T:.::,1il:iitheseprocedures.In general,blood testingf", ;;;;";;;.matotogy doesnotneeda specific,additionalconsentbeyonJge,r..d h;iui-.;ent. .fhereis a lowthresholdfor acceptingthat thereis implied .orrrerrton trr.-il.* .r the patient,spresencein thehospitalor office.Thisisnot truein thec"r" "i if* ,ru ,"r,. Thcreisno suchthing asan,,implied,,consentfor HIV testing.Er""ii"rgl, the babyhasasmuchasa30percentrisk of gettingthevirus from ah;_;;.;;. -"rher cannotbetreatedagainsther will. Thereasoningis the same.ffr" *.-u"lr.;gnt to choosetheli,nisem,enrolh:r.own bodyoutweighsthe right of th" Ib;.;il undeliveredfetusrsnot endowedwith the powcrof an individj ia."ri f"r; ":i".ron,,in thelegalsense.Thisis thesamereasonincaesarian,.ctio,.,.u.nirtr,.i;i-.i:i?;::l:t-omanhavinstherighttoreruseaH|V-PositiveCaregivers.NoMandatetolnformpatients30. (e) No onewithout his directwritten consentPatienhwith HIV havearight to privacyaslongastheyarenot puttmgothersatrisk.Youhaveno mandatoryobligationto inform thestate,jrisinsurance,or hisemployer.Youandthepatientdo not hayea n.randatoryobligatlontu i,riurlll fri. patientsof hisHtV."l:* evenif he is a surgeon.This is becausle"" UIV_p"""r1y.physicianposesnosignifieantri.kof rrun,mis:iorrt,,r brr;ah,, ,.;^- -,t"to prevailin order to or".,."rrrtttottto a patient universalprecautionsaresupposedU1;ffiL]*il":J*::ilT:ffilT,il*,",::1Tl::;:;J"Til;;Pt-or
    • 144I AnswersandExplanationsThere is no implied consentin terms of HIV. It must be expressedin writing. Health-care workers are at risk of HIV from accidental transmission from HlV_positivepatients. Yet, there is no requirement that all patients be tested iorder to prel,enttransmission to the health-care worker. All patient blood and body fluids areto betreated asif they were HlV-positive. If the automatic right to know the HIV status0fthe patient does not exist, then the patient does not automatically have the righttoknow the HIV statusof the physician. It works both wavs.DentistRefusaltoTreatH|V-positivepatients3l . (d) Refer your patient to another dentist outside of your group practice.It is unethical for a physician or other health_careworker to decline seeinganypar_ticular group of patients basedonly on a specific diseaseunlessthey are being askedto 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 takeon a patient without his consent. The medical director cannot do that either.Thedoctor/patient relationship must be entercd in a voluntary way on both sides.youcannot force a doctor to seea patient anymore than a patient can bc forceclto seeaparticular physician. Oral antibiotics alone are insufficient for a patient who needsa surgical drainage. The boards often mix an ethical issue with a concrete medicalalternative to seeif you would pick an inadequate therapy rather than make a deci-sion in an ethical dilemma.L(APLAN) MEDtcAL
    • AnswersandExplanationsIt45:alth-sitiverventlo beus ofht toPar-;kedtakeTheYouPartnerNotificatione e a:edsical32. (a) Encouragediscussionbetweenthe husbandand wife and strongly suggesthedisclosehis HIV statusto his wife.Youhavea duty both to protectthe privacyof your patientaswell asto protectthehealthof innocentthird parties.Ifyour patientispracticingunprotectedsexwith hispartneror issharingneedles,heshouldbestronglyencouragedto noti$.thepartner.Ifthis doesnot happen,you arelegallyprotectedto revealtheHIV statusof apatientif you believethat personis endangeringthe life of anotherperson.When partnernotificationdoesoccur,it is usuallythe responsibilityof the Departmentof Health.It isthe healthdepartmentthat shouldsendtheletterto thepartnersnotilting themof the"urqenthealthissue."33. (a) Inform the partner now.Youhavefull legalprotectionif you inform the partner.The safetyof an innocentpersonisalwaysmoreimportant thatprivacy.you arenot legallymandatedto informthe partnerdirectlybut you areprotectedif you do.you haveno liability in break-ing confidentialityfor this purpose.you definitelyareliableif the patient,spartnerseroconvertsand,voudid not tell him hewasat risk eventhoughyou knew Thisis ayersionof the Tarasofcasein psychiatry(Tarasofv. Regentsof the Stateof California,l7 Cal3d424[1976]).If a mentallyill patientdisclosesto you in confidencethatheis planningto iniure someone,you havean absolutemandateto inform both larvenforcementaswellasthepersonat risk.Ifyou know thatharm mayoccur,but youdo notl.ring,then you areliabJe.If partnernotification is goingto occur,you mustinform thepatientthat you will inform herpartner.![!!p ueorcrr-
    • t46 Answersand ExplanationsMandatoryReportinglsNotNational34. (e) Discussthe issuewith the patient and encouragehim to find alternatemeth-odsof transportationThelawsconcerningthe impaireddriver arenot universalbetweenstatesexceptfordrunk driving.Thereis no nationallawguidingphysicianreportingof an impaireddriverfor reasonsof age,cognitiveimpaiment suchasAlzheimers,or neurologicaldiseasessuchasmultiple sclerosisor Parkinsondisease.A fewstatesrequiremanda-tory reportingto theDepartmentof MotorVehiclesin orderto restrictor removeadriverslicense.Most do not. Somestatesoffer protectionfor physiciansin casethereport is not honored.Most do not. Theratesof motor vehicleaccidentsremainedstablein older patientsuntil the ageof 70when thereis a slightrise.Howevetth€highestrateof motor vehicleaccidentsin all agegroupsis in thoseabove85.Thisgror.rpof the veryold exceedseventeenagersin termsof the rateof motor vehicleaccidents.Becausethestandardsfor reportingof theimpaireddrivervariesbasedonthestate,therecanbeno questionwhercthecorrectansweriseitherto reportor notto report becausethis is a nationalexamination.All that canbe universallyagreedupon is that you shouldencouragea potentiallyimpaireddriver at anyageto seekalternateformsof transportationor to havesomeoneelsedrive.MisuseofBeneficence35. (d) Your action is not appropriatebecauseyou treatedthe patient without hisconsent.A patientmustgiveconscntto anytestor treatmentperformedupon him aslongasthe patienthasthe capacityto dccide.Physiciansarenot actingethicallywhentheytreatapatientwithout hisconsentevenif it benefitsthepatient.lt isverydifficult forsomepeopleto acceptthat goodwilland sincerityarenot sufficientto overridetheabsolutenecessityfor informedconsent.Thisistrue evenifyou areright in thesensethat the treatmentwill help the patientand that only the patientwill benefitfromthe procedureor treatment,This is true evenif paymentis not received.Autonomyof the individual outweighsbeneficence,which is the desireto do good.This is thephysiciansdesireto treatthepatient.Anotherwayof sayingit is:I havearight to besickandmiserableif that is whatI want.I(A PI.AN M E D ! C A L
    • Answersand Explanations/DecisionsMadewhileCompetent,ValidwhenIncompetent35. (a) Refuseto do surgery and follow the original advancedirective,Thepatientin this questiongavea clearadvancedirectivewhile shestill had decision-makingcapacity.This must be follorved.This caseis especiallyclearbecauseitstatesthereisboth a clearverbalaswell aswritten advancedirective.Casesin whichthereisno clearadvancedirectivearemuchharder,It doesnot matterif the familysrequestis in writing. The casewould be consideredtoo straightfbrwardto warranttheinterventionof an ethicscommittee.Evenif the ethicscommitteefor somerea-sonrecommendedthe surgery,you would still haveto refusebecauseyour duty is tofollow the patientswishes,no one elses.You cannotrefusea decisionmadewhilecompetentsimplybecausethepatientlaterbecomesincompetent..[fthiswerenot so,thenall wills would beinvalid.A personswill is a form of advancedirectivefor theirpropertyaftertheybecomeunableto speakfor themselvesdirectly.LimitationonDeterminationofIncompetence37. (c) Honor his decision and do not do the colonoscopy,lust becausea patient may be incompetent in certain areasof his life does not meanthat he is not able to consent for medical procedures. The patient describeclhas asevereand perrnanent cognitive impairment; however, he is still able to refuse theprocedure. A patient can be considered incompetent for financial issues but stillhavethe ability to make medical decisions.It would not be advisableto recommendroutine medical procedures against the will of the patient. This would mean literallyforcing him into the endoscopy through restraints or sedation.Incompetence in oneareadoes not mean total incompetence. The court recognizesa much lower standardof cognitive ability to reliably consent or refuseprocedures conpared with financialdecisions.lt is easierto be declared inconpetent for financial decisionsthan it is formedicaldecisions.l!!l!!!2 urotcer
    • 1 4 8InnswersandExplanationsI{APLANConsentlsSpecifictoEachIndividualProcedure38. (b) Wakethe patient up andseekconsentfor a different procedure.Youmustobtaininformedconsentby specificprocedure.Consentfor anotherprocedure or clearmedicalnecessitycannotinfer consentfor anotherprocedure.Neitherthe medicalnecessityof the procedure,the seriousnessof the condition,nor theassumptionthat any reasonablepersonwould consentis sufficientto assumethatconsentis given.Thepatientis not awareof hissurroundingsandconditionbecauseof the sedation.You cannot havean"informedconsent"without waking up andinfbrming the patient.Anotherexamplewould bea bloodtransfusionin a JehovahsWitness.If, duringaprocedure,aclearbut unexpectednecessityfor bloodtransfusionarises,you mustwakethepatientup andaskaboutthepatientswishesto haveor nothaveblood.Theconsentor refusalmustbeinformed.Youcannotsaythat becauseofthe necessityor sedation,thatyou should.justgivetheblood.On the otherhand,justbecausea patientis a JehovahsWitness,you cannotassumethat he will refusetheblood.A refusalmustbeinformedaswell.Thepatientcould,afterall,bea JehovahsWitnesswho doesnot agreewith that religionsteachingon blood. Eachproceduremustundergoanindividualconsentprocess.InvalidConsentBecauseofLanguageandtheWrongPersonObtaininglt39. (e) All ofthe aboveFor consentto bevalid,the personwho thoroughlyunderstandstheproceduremustexplainthe risksof it in a languagethepatientunderstands.Thehospitalis requiredto providetranslatorsto acconplishthis end.M EDICAL
    • AnswersandexplanatlonsI t49)ce-herthehatConsentlslmpliedinEmergenciesI 40. (a) Give the blood.rn an emergency,unlesstheconsent to procedures.Th.rrels an extremely clear advancedirective, there is implie4be fully informed to makepatient is not conscious to make a decision. He cannotor limily available there ,achoice There is no advancedirective, proxy, living will,makeadecision,, ,n" o.r, ]-ll lnt"substitute"for hisjudgment.Hence,wemustdirective.youaon,o,dn.uo,rr".estsof thepatient.A shirtisnotasufficientadvancernthiscase,is death.Even,:r"llll:ln:Y.I,/s therisksof deferringtherapSwhich,wouldrefuse,n" o,oro."o.j-ll--1isa r:f:v.ihs witnessvoucannotbecertainheutonao *ooti t.,",il";Ii::i::::av"w-ellevervotherlehovahtwitnessrefusesspecincariysayhed;;J;;T;:lilH::i#ff::ft T.:i"aiuiaupnti",,t,*u,t:jjT:,il1J,lT::i:ffi"restauranrwhereaItheresidentsarwaysorderptzza.mll.m*?,yit::iiffi:;:i:ffi:i,Tii*;m**i;{l;fmuli::*:",.mi*,jiilii::::;T::ht:ff,1.:!andmaybehewill .r. o ,ntr::1::nsent.orrefusalmaybethepatientwill consent,transfusion.t rsnot sufficientevidenceofa chorceoffood or bloo<iuscndhsonrotofrsthel sre{{!!P neorcrr-
    • r50Innr*"r,undExplanationsMTDICALEmergencyProcedureinanAdultLackingCapacity4I . (a) Sedatethe patient with lorazepam and perform the lumbar punctureThe patient describedis not unable to give either an informed consent for the pro_cedure nor is he able to make an infornted refusal of the proce<Jureeither, He doesnot have the capacity to understand his medical condition and the consequencesofdeferring the lumbar puncture or the antibiotics. There is no prorlr or family memberavailableto 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 makedecjsions 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 managemeningitis adequately.You cannot wait for the family in a caselike this.If a patient hasan urgent, life-threatening, dangerous,or even severclypainful medi_cal condition, and the patient is not competent and hasno family or prory available,then the medical staffcan do what they feelis necessaryto protect the patient withouta specificsigned consent.You would be more at fault for withholding therapy in thispatient than you would to do the lumbar puncture. Acting in his best interestsou!weighs a formal consent that you cannot immediatelv obtain.r(Apr-AN
    • r Pro-: doescesotmberment.makecon-lnagenedi-lable,:houtr thisoutSubstitutedJudgmentWhentheproxyDisagreeswiththepatient42. (d) He shouldnot giveconsentfor the transfusion.Thepurposeof a health,careprolT is to cauy out the rvishesof the patientin thecventthat the patientbecomesunableto makedecisionsfor himsell Thekeyissuehereis "thewishesof the patient.,,Theprory is not a personwho isjust to givehisownopinion ofwhat he (theproxy)thinksisbestfor thepatient,if rhepatient,sclearwishesareknorvn.Thcprory or health_careproxy,,agent,;or,durablepowerofattorneyfor healthcare"islikea mailcarrier.Heisto carrf thepatient,smessageswhenthepatientcannotdeliverthem himsell your mail carrieris not supposedto bewritinglettersfor you.He isjust supposcdto transmityoursaccuratcly.._t.heonly differenccisthatif thepatientdid not put hiswishesin writing theprory isauthorizedto makcdecisionsbasedon what hewastold by thepatientor whennothingelseis availablcrvhatisin thebestinterestsof thepatient.In this case,the proxl is a brother who very stronglydisagreeswith the patient,swishesagainsttransfusion.Thepatientdoesnot wantbloo.l.TheprorT_ust not giveconsentfor the transfusionbecausethat is thewish of the patient.TheprorT is notthereto wait for a patientto losccapacityand then takeover It this werethe case,thenno lastwill andtestamentwould bevalid.Thelastwill andresramentconveysapersonswishesfor theirpropertyfor whentheyhavedied.Deathrstheultimateformof lossof decision-makingcapacity.The executorof the will is to obeythe will, notdecidewhathethinksshouldhavebeendone.Answersand Explanations t 5 lI(APtAN-MEDICAL
    • AnswersandExplanationsllg:39 MEDTcALNever-CompetentPerson,BestInterestsStandard43. (d) Askthe guardianwhat is in the bestinterestsof the patientThis patienthasneverbeencompetentso thereis no possibilityof trying to deter-nine what hehadwantedfor himself.Thereis no family to actin his bestinterests.Youcannotsubstitutejudgmentfor a personthat hasneverhadjudgment.Thiscaseinvolvesdecisionmaking on the leastaccurateof the decision-makingstandard,which is to determinewhat would be in the bestinterestsof the patient.The reasonthis isthe leastaccuratemethodof givingor withholdingconsentis that thereisnowayto besurewhatthe patientwould havewantedfor himself.With a bestinterestsstandardwe havethe difficult problemof determiningwhetherthe guardianisbasing their decisionon what the patientwould need,or the guardiansown subjectivestandardof whattheywould wantfor themselves.In thiscase,theburdenof therapyfor no chanceof cureisworsethanthe option of simplydeferringtherapy.If thereisa court-appointedguardian,thenthereisno point of an"expertpanel."Thequestionhereisnot oneof whatthebestmedicaltherapyis,but what isin thebestinterestsofa patienttoo mentallyimpairedto makehis own decisions.PregnantWomanRefusingC-section44. (a) Honor her wishesanddo not perform the C-sectionA competentadulthastheright to dowhatshewantswith herownbody.Thisistrueevenif the decisionseemsfoolishor unwise.This is alsotrue evenif the patientispregnantand the fetusis potentiallyviable.Until the babyis born, a fetusdoesnothavethe rightsof a"person."An undeliveredfetusis.judgedasapart of thewomansbody;henceshehasthe entireright to choosewhatwill goon. Psychiatryevaluationanda court orderareinappropriatebecausesheis fully competentasperthedescrip-tion in this case.Thefatherdoesnot havetherightto decidewhatto do anymorethanhehasaright toconsentto anappendectomyfor themother.Themothersright to refusea C-sectionisthe sameasa mothersright to chooseabortion.Thefatherhasno say.
    • Answersand ExplanationsNecessityofInformingthePatientofOtherTreatmentOptions45. (d) He will win becauseyou did not inform him of the risks andbenefitsof alter-native therapy to surgery.Patientshavethe right to befully informed about the risksand benefitsof therapyandalsoaboutalternativetherapies.He cannotmakean informeddecisionif hehasnot beeninformedaboutthe alternativeto the main coursein therapy.Theabsenceof adverseeffectsdoesnot eliminatethe needto tell him the risksof theraovaswellasthebenefits.oralConsentlsValid46, (e) Takeconsent for the blpass over the phone and have a second person confirmthe consent.An oral consent is equal to a writtcn consentif it is valid and provable.The validity oforal consent has nothing to do with the severity of the procedure. If you improperlytake consent for a minor procedure you are liable for damages.If you take a properconsentfor major surgery it is valid even if it is oral. It is important to have asmuchdocumentation of the consent aspossible.The secondperson speakingto the proxyon the phone is a valid way of confirming the consent.A secondperson should evenlvitness consent in person. There is no limit on what can be consented to by oralconsent.lt is simply a matter of establishingproof of the consentso no one can denyit later if there is an adverseeffect of the procedure.
    • I(API"ANJanrlvurcundExplanationsMFDICALOnlyaCompetentPatientCanRefuseEmergencyLifesavingprocedures+2. (b) Givethe blood.only a fully consciouspatientcanrefusea lifesavingblood transfusion.you do nothavedirectevidenceofthe patientswishesfor himserf.you cannotassumethatwhattheparentsaresayingiswhathewould havewantedfor himself.If hewereawakehemayverywell sayhe thinks his parentsreligiousbeliefsarecrazyand hewantstheblood.He maysayhe agreeswith then. Becauseyou haveno clearideaof whatthepatientwantedfor hirnself,you mustgivethebJood.Consentis impliedin an emer_gencyprocedureunlessthereis a contemporaryrefusalby a consciouspatient.youcannotwait for a court hearing.Thepatientwill diein the meantime.RefusalsMadeWhenCompetentAreValidWhenCapacitylsLost48. (d) You cannot give the blood.The patient has given you a clear advancedirective both orally and in writing. youInusthonor her wishcseren if sheloescapdcity.lf thiswerenot true no onc i,ouldhave to honor a personslast w I and testament when he or shedied. rf this were herwill and shewasdesignatingwhat shewanted done with her property after death youcannot reassignher property basedon what the husband wanted. The most intimateproperty a person hasrsher own life and body.
    • AnswersandExplanationsIr55Harm:IntentNotRelevant49. (e) Theresidentandhospital areboth liablefor harm to the Datient.Harmexistsevcnifit isunknownto thepersonactedupon.Thetntentlonofthe per_sonmakingtheerror doesnot actuallymatterin termsof assessingbothmalpracticeaswellasharmto thepatient.In thiscase,boththeresidentandhospitalareguiltyofharmandpotentiallyliablefor damagesfor resultingin aninjury to the patientthatwereavoidable.Thenursesandthe pharmacistcanalsobeheldliable.If a manufac_turersellsyou a carthat is unsafeandyou sustaininjury theyarestillliablefor dam_agesbecauseit istheirresponsibilityto ensurethesafeqrof theproductstheysellyou.If I own arestaurantandyou getfoodpoisoningaccidentallyfrom unsalefood or anemployeewho did not washhishands,thenI amliabre.I amnot absorvedofliabilityfortheharmjustbecauseI did not intendharmandam in,,goodwill,,towardyou.I stillharmedyou.Thesameis true of a medicationerror.RoleofRiskManagement50. (e) Tominimize the legalrisk to the hospital from litigationRiskmanagementis the term appriedto the portion of the hosprtaladministrationthatevaluatespotentiallegalliability to theinstitution.Theroleof risk managementrsto try to intervenein acutecarein a waythat protectsprimarily thehospitalfromlawsuits.Riskmanagementmayleadto bettercareandcommuntcationin theserviceof reducingthechancethatapatientor theirfamilywill engagein legalactionagainsttheinstitution.!l!!p veorcer
    • Ionr*"r, andExplanations51.lnformedConsentProtectsAgainstLiability(d) Helosesit becausethepatientwasfully informed aboutthe risksandbenefitsof both alternatives.Thekeyissuein termsof liability for adverseeffectsto patientsiswhetherthepatientwasfully informed of the risksof the therapybeforethe treatmentwasgiven.If amajor adverseeffector evendeathoccurred,but the patientknewand understoodthisandstillchoseto proceed,thenthereisno liability.Thepatientwasfully informedof what could happen.If a minor adverseeffectoccurredsuchashair lossandthepatientwasnot fully informedthatthiscouldoccur,thenthereiswrongdoing.Again,the issueis whetheror not the patientgaveconsentor hadthe opportunity to makeanotherchoice.The patientsfamily doesnot needto be informed.The patientmust be informed.IRtsapprovalalonedoesnot shieldyou from liability.The keyissueis whetherthepatientwasgiv€nthe opportunity to makea freechoice.A man is buying a car.The one in the storehe chooseshasa cup holder he likes.Theydelivera car with a much betterengine,but without a cup holder.The dealeris liablebecausethe customermustbegivena choice.Maybebewill only buy a carwith acupholderhelikes.Youcannotsay,"Thiscarwithout thecupholderisamuchbettercar."It dependson beinginformed,not on what occurs.I(API.AN MEDICAL
    • AnswersandtxplanationsIt57itsNecessityofKnowingRisksofDeferringTherapy(e) You lose becauseyou did not inform the patient of the serious consequencesofforgoing angioplasty.In order for a patient to make an informed consent for a procedure, he must knowthe risk of not having the procedure done. In this caseyou did not document thatyou told the patient that a person with an acute ST segment elevation myocardialinfarction who fails to reperfusewith thrombolytics hasa markedly increasedrisk ofdeathwithout angioplasty.You only informed him of the risks (hematoma, coronaryrupture) but not the benefit (decreasedmortality) of the procedure. He was not fullyinformed and therefore you are liable.ln the sane way that failing to inform a patient of the risk of harm from doing theprocedure is mandatory, you must also inform of the risk of harm when you dontdo the orocedure.DutyofPatientsto InformtheStaffofMedicalProblems53. (e) Shelosesbecauseshe did not inform the nurses shewas dizzy or lightheaded.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 standardof care to leavea patient unescorted on the toilet if she does not offer a complaint.There would have been malpractice and liability if the patient had informed thenursesthat shewas dizzy and in need of assistanceand they did not provide it. Thepatient has a responsibility to inform staff of medical conditions that would have animnact on her care.:ntI aodedne.n,ked.les.lrhMEDICALt(AptA tt
    • I(API.AN/onr*"r, andExplanationsRevealingaMedicationError54, (c) Apologizeand tell the patient that you forgot to reorder the antibiotics,butthat he will be all right,Medicalerrorsare one of the most difficult issuesin the ethicalmanagementofpatients.Therearefewabsoluterulesin termsof disclosureandit is oneofthe mostembarrassingissuesto dealwith. Thereis very little acceptanceof evenan honesterror on the part of the patient,the physician,or our physicianpeers.Nevertheless,the ethicaldirection is clearthat you should revealthe error to the patient.Thepatienthasan absoluteright to be fully informed abouthis own care.This meansit is his right to knorvandyour duty to inform aboutanyerror in careevenif thereis no demonstratedharm.Thepatientsright to know is more important than yourembarrassmentoverthe error.Thegreatestobstacleto informing the patientis fearof lossof credibilityandthepotentiallossof confidenceof thepatientin your competence.Thepatientmaychooseto severthe relationshipandsometimesto engagein litigationif thereispotentialharm.Youmuststill tellhim thedetails;it ishisrightto know.If you bring your carfor repairandthe mechanicmakesa n.ristakein the repair,youareentitledto klow. Thecarisyour propertyandno onehasa right to mismanageyour propertywithout 1ourknowledge.Themostpersonalform of propertyis yourown bodv.DisagreementsBetweenResidentsandAttendings55. (e) Bring the disagreementto the chiefof service.Your first duty is to the patient;however,you cannotdamagethe physician/patientrelationshipbetweenthe privateattendingand the patient.Youcannotjust changetherapyon someonespatientwithout his knowledge.It would be inappropriatetogo outsideyour localhierarchywithout first appealingprivatelyto the chiefof ser-vice.The chiefof servicehasthe authorityin an institution to intervenein qualityof careissues.MEDICAL
    • Answersandexplanations/ ts9cs,butAbsoluteRightofpatientstoViewTheirOwnRecords56. (d) Shehas the right to her own records even without giving a reason.The patient doesnot havetorh"."n.*,ro.i.;;;;;;".L:;:."XJTili*J.lliHlili:,::iiJ.::i:::H,,i:withheldfrom thepatientfohealth-careinformation caranyreasonincludingnonpaymentofbills. Thepatient,sstrons,thatr,i,u..,ary,ffi,ll"*,:"i::fffi,.i:.iT.#j:;i:T,:seekthe parient,sapprovalin_orderfr. th.;;;.;-"*rT ,n" parient,srecords.You,asa physician,requirergetacopvorther..-j, ,.",il,lllnTlll,r:,1,1*thepaticntinorderforvoutoOwnershipofMedicalRecords57. (c) Theinformation is the propertyofrhepatientand the physicalpaperor elec_tronic recordis (heproperty of ,f," f,.utit _.*" p.olil,Thehealth-careprovidercanotherhcalth-carep.ouro.rr, o,ototto"copiesof the medicalrecordto thepatientorclinic,or hospital.H.".., ,1r"o::l:-1fll:" 1:-is thepropertvofthe phvsician,care..l.heinformation in thereorrgtnalrecordalwaysremainswith the provider ofpatientis entitled,. "...r, .f ;:tisthepropertyof thePatientandthat iswhy theent ofr mostronest-reless,:. Theneansthereyours fearcom-rgageright, YounageFourientnge3 t Oter-lityI(API.AN MEOICAL
    • Answersand ExplanationsChangingInaccuraciesintheRecord58. (e) Write anewnotewith the current dateandtime.The two methodsof correctingerrorsin documentationareto placea singlelinethroughthe originalerror,write in the newinformation,andaddyour initialsortoplaceanentirelynewnotewith thecurrentdateandtime.Usethefirst methodifyoufind the error immediatelyand the timing is the same.The reasonnot to remove,erase,or usecorrectionfluid on the error is to maintaincredibiliry lf you alterthenotein anunacceptableway,thenthethoughtprocess-includingthemistake-can-not befollowed,Youmustneverbackdate/postdateanote.Youcannotrewritehistoryby tryingto makeit looklikc anotewritten todaywasreallywrittenyesterday.Alwaysusethe currentdateandtime for whatyou write in the chart.InformedConsentMandatoryforSututring59. (c) Wait for the consent of at least one parent.Proceduresthat are emergenciesdo not need any infomed consent from a parent inorder to begin the treatment. We do not want a childs health to suffer just becauseno one is presentto give consent at that moment an emergencyoccured. Neighborscannot give consent.Only parents or legal guardians can give consent for proceduresfor minorsj however you do not need both parents to sign consent.You would onlyseek a court-appointed guardian if there were no identifiable parents. This Patientcannot give consent becausche is a minor, which in rnost statesis defined asbeingunder age 18. Ily definition, minors are considered incomPetent except on areasoforal contraceptives,STDs,prenatal care,and rehabilitation or detoxification for sub-stanceabuse,[APLAN) METTCAL
    • Parentalconsentis not requiredto treata minor for illnessessuchassexuallytrans_mitted diseases(STDs),prenatalcare,contraception,HIV or substanceabuse.Aminor is definedasa personunderthe ageof 1g.parentalconsentis requiredfor allfbrmsof treatmentotherthan ththiscase,arthoughcervicitisis";::",1j.::ffi:11H|.T,::-::"";T:T:|J.:leventrying to noti4, the parents.Wewant to lowerthe barriersto the careof thesediseases.In otherwords,wepreventmoreSTDsandunwantedpregnanciesbygrant_ing a minor full accessto this form of care.The ..q.,ir"_"rr, for"parentalconsentmakesthe minor lesslikely to comein for care.LessSTD treatmentmeansmoretransmission.Lesscontraceptivemanagementmeansmore unwantedpregnancies.Thereis no consensusnationallyon parentalnotificationfor aborhon.somestatesrequireit andsomedont.UrgentBloodTransfusionintheChildofaJehovah,sWitness61. (c) Giveblood to the child but not to the fatherAny competentadult may refusetherapyof anykind, includingthe lifesavingones.The sameis not true for a minor. Minors cannotrefuseurgentlifesavingtherapy.That is why the fathermay refi:sefor himself,but not for the child.This questiondoesnot addresswhetherthe child wantsthe blood or not. The child,swishesin amatterof urgent,lifesavingtherapyarenot relevantto theproperethicaltreatmentofthe child.A 12-year_oldchild,by definition,is treatedasiou would an incompetentadult Thatis,you arehappyif theyareagreeable,but youwill still dowhatyou thinkis right anpvay.In a legalsense,a minor child is like your dog.you arehappyif hedoesntbarkduringthetreatment,but youwill not changeyourmethodof treatmentbasedon hisopinion.you do not needa courtorderin thiscasebecausethedirectionis clearandwellworkedout.you savethe life of the child;don,twait.STDinaMinor60. (a) Ceftriaxone/azithromycinnowin a singledose.AnswersandExplanationsrA PlAll MEOtCAT
    • AnswersandexplanationsIt6lrgle Iineals or tord if youremove,alterthe.e--can-: history: AlwaysItent 11-l)ecauseighbors:eduresld onlypatients beingreasofrr sub-STDinaMinor60, (a) Ceftriaxone/azithromycin now in a single dose.Parental consent is not required to treat a minor for illnessessuch assexuallytrans-mitted diseases(STDs), prenatal care, contraception, HIV, or substance abuse.Aminor is defined asa person under the ageof 18.Parental consent is required for allforms of treatment other than thesewith the exception of emergencytreatment. Inthis case,although cervicitis is not an emergency,shecan receivetreatment withouteven trying to notiry the parents.We want to lower the barriers to the care of thesediseases.ln other words, we prevent more STI)s and unwanted pregnanciesby grant-ing a minor full accessto this form of care.The requirement for parental consentmakes the minor lesslikely to come in for care. LessSTD treatment means moretransmission. Lesscontraceptive management means more unwanted pregnancies.There is no consensusnationally on parental notification for abortion. Some statesrequire it and some dont.UrgentBoodTranslusionintheChildofa)ehovahsNitness61. (c) Giveblood to the child but not to the fatherAny competentadult may refusetherapyof anykind, includingthe lifesavingones.The sameis not true for a minor. Minors cannotrefuseurgentlifesavingtherapy.That is why the fathermay refusefor himseli but not for the child.This questiondoesnot addresswhetherthe child wantsthe blood or not. The childswishesin amatterof urgent,lifesavingtherapyarenot relevantto theproperethicaltreatmentofthe child.A 12-year-oldchild,by definition,is treatedasyou would anincompetentadult.Thatis,you arehappyif theyareagreeable,but youwill still dowhatyou thinkis right an1way.In a legalsense,a minor child is like your dog.Youarehappyif hedoesntbarkduringthetreatment,but youwill not changeyourmethodoftreatmentbasedon hisopinion.Youdo not needacourt orderin thiscasebecausethedirectionis clearandwellworkedout.Yousavethe life of the child;dont wait.I(API.AN) MEDICAL
    • Inn.*urs undExplanations!!l!!p ueorcar-r52Thereisno needfor apsychiatricevaluationbecausethefatherwasclearlycompetentandit doesntmatterwhatthechildsays.Intravenousiron will not work fastenough.The casesmust be clearand unequivocal.Occasionally,a 17 year_oldchildwithleukemiathat will likelybefatalanl.wayis allowedto refuseatransfusionor chemo-therapy.Thissortof caseisfar,fardifferent.A 17_year_oldiscloseto alegaladult,thediseaseis not sudden,andthe treatmentwill likelynot changeoutcome.Thebottom line is that parentscannotrefuselifesavingtherapytbr a child.PrenatalCareinaMinor62. (a) "Iwill give you the care you need and keep it conffdential.,,Prenatal careis one of the exceptionsto the general rule of parental notification andconsent for the treatmcnt of minors. you do not haveto inform either the parentsofthe patient or the father of the baby. This conficlentiality also extends to protectingthe patielrt even if the parents were to ask.The patient has a right to privacy for herprenatal care.EmergencyTreatmentofaMinor63. (d) Perform the appendectomy.The patier.rtdescribedin this casehas acute appendicitis and needsan urgent proce_dure, Allltappendectom).must be perfor-.d u, ,oon u, possiblern acute appendicitis.You cannot allow harm to thc patient becauseyou are momentarily unable to contactthe parents.Intravenous antibiotics alone are insufficient to treat acute appendicitis.Agamr you cannot harm the child becausethe parents are not able to be locatedatthis moment. Only a parent or legalguardian can consentto a proceclureon apatient.Neighbors, aunt and unclcs, grandparents, and babysittersaurrnu, gru. consentfor achild that is not their own. Minor children cannot consent to an appendectomy.
    • AnswersandExplanations]t65cmpetentt enough.rild withr chemo-rdult,theon andentsoftecting.orherIOCe-icitis.ntactcitis.rd atrent.b r aEmancipatedMinor64, (d) "Iwill give you the isotretinoin asrequested,,,This patient, although a minol is a special exemption known as an..emancipatedminor." This category appries to persons who are under the age of rg but who areindependent 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 supportingthrough their own independent means such astheir own job. A large portion of thedefinition of an emancipated minor has to do with the patient being self-supportingand living independently. There is no definite age.utoff fo, _h.r., someone may beconsideredan emancipated minor The agevaries by statebut is usually at either agel5 or 16.An emancipated minor is capableof consenting to any medical procedure.All minors can consent to prenatal, contraception, HIV:STD, and substanceabusecare.An emancipated minor is one that can consentto any form oi careor procedureasif he or shewasan adult.65. (a) Provide the pain medications asappropriate but not the means to end his lifePhysician-assistedsuicide is always considered unacceptable. The patient is notacutely depressedso antidepressantsare unnecessary.This form of reasoning doesnot need an inpatjent psychiatric evaluation. Try never to refer patients on boardquestions for anything. There is no,,specialist,,that can certii/ a patient as a goodcandidatefor assistedsuicide.Thereis an cthicalimperativefor the physicianto pre_servelife. Consequently there are no acceptablecircumstancesin which a patient canact as an assistantin suicide- There is significant concern that putting the power toend lit-ein the hands of the physician is an uncontrollable power that woulcl easilybesubject to abuse and indiscrirpersonsin,.,..dort,"at,.,,..,tnil:"rT,::::*;t:";"1,:,il:1,H.-J"irff[::::suicideon demand.Rementberthattheboardsarenottestingyourpersonalopinionsaboutwhatyou think ought to beacceptable.fhey aretestlig tne bestconsensusofthe lawandpracticeguidelines.5{!!P ueorcnr
    • Innr*"r, undExplanationsYoumaypersonallyagreewith physician-assistedsuicideor disagreethatfirsttrimes_ter abortionsareacceptable.Justdo not choosetheseasthe answersto thetestques-tions.Forty nine or 50 stateshavelawsthat makephvsician-assistedsuicideillegal.Theexperimentin the statcof Oregonwherephysician-assistedsuicideislegaldoesnot hold true for anyother placein the United States.Hence,on a nationalexami-nation,you must go wjth what would betrue in the majority of cases.In addition,despitewhateverlawstherearecurrently,all physicianprofessionalgroupsconsiderassistedsuicideunethical.LethalInjectionAlwaysUnacceptable66. (e) Youtell hirn tirat under no circumstancescanyou participatein euthanasia.Underno circumstancesis it ethicalfor a physiciarto participatein euthanasia.Thedifferencebetweeneuthanasiaand physician-assistedsuicideis that euthanasiaisameansof deathadministeredto the patientby another.physiciansarenot ethicallypermittedto destroylife.This istrue evenif thereisa law authorizingit. Thehigherethicalduty of thephysicianto preservelife supersedesstatelaw.Euthanasiaisunac-ceptableevenif acompetentpatientrequestsit. physician-assistcdsuicideisclifferentfrom euthanasiain that the physicianprovidcsthe patientI,ith the meansto endtheir own lives.In physician-assistedsuicide,the patientadministersthe meansofendingtheir life. In euthanasia,the physicianadministersthe meansof death.Bothof theseareunacceptable.This is markedlydifferentfrom giving pain medicationsor othertherapythat inadvertentlyendsthe patient,slife.If the only wayto controta personspain and sufferingcompletelyis to givemedicationsthat inadvertentlyoIunintentionallyshortenthepatientslife,thisisacceptable.Thisissor:netimesreferredto asterminalsedation.Theprimary issueisoneofintent. In euthanasia,theprimaryintent is to endlife.In terminalsedation,theprimary intent is to relievesuffering.!APLAN) MEDtCAT
    • mes-ues-egal.loesmt-ion,derSubstanceAbusing-Resident67. (e) Reporthim to the chairpersonor program director of his department.Thereportingof a potentiallyimpairedphysicianis an ethicalduty that cannotbebypassed.Althoughyou haveanabsoluteduty to protectthepatientsunderhis care,you shouldfirst go to the personin the tableof organizationto whom the residentreports.Tellingyour deanof studentsis inappropriatebecausethe deanof studentsdoesnot supervisethe resident.Tellingthe deanof studentswould beappropriateifthermpairedpersonwasanotberstudent.Forphysicians_in_trainingthe first stopistheir programdirectoror departmentchair.For attendingphysiciansit can be thedepartmentchairor themedicaldirectorofthe hospital.Forattendingphysiciansnotreportrngor working for localauthorities,makethe reportat the higherlevelof thestatelicensingboardor the mechanismsin placefor impairedphysicians.It is fruit_lessto gostraightto theimpairedperson.It islikereportingchildabuse.Ifthe personwho is impairedadmitsit to you,you must still report centrallyto makesureof thefollow-upandresolution.If theydenytheproblemyou muststill do thesame.If you noticc the impairmentand do not report it, then you becomeliablefor anyharm that might happento a patient.DementiainAttending68. (d) Reporthim to the statelicensinsboard.Reportsof physicianimpairmentshouldgo first to the localsupervisorypersonnel.If this is eitherunsuccessfulor not applicablethenreport it to a higherlevelsuchasa statelicensingboard.Tcllingyour own divisionheadis inapproprratebecausethatpersonsupervrsesyou,not thepotentiallyimpairedphysician.AnswersandexptanationsIr6t!(d pLAr) MEDTCALlealy:rtIt
    • t65Ionr*"r, andExplanationsfA?LAN) MEDTcALBehaviorAbnormalitiesNotAffectingPatientCare69. (d) Do nothing.Your responsibilityfor reporting physicianimpairment restsonly with reportingabnormalitiesthat mayaffectpatientcare.If thereareno abnormalitiesin her abilityto makemedicaldecisionsand supervisejunior houseofficersthento report detailsof a physicianspersonallife would only bepotentialslander.Lossof reputationis aseriousissuefor aphysician.Otherphysiciansandpatientswill not wantto useaphysicianwhom theythink isof low moral characterevenif herrnedicalcareisfine.Youdo not haveto agreewith, condone,or approveofthe behavioryou witness.However,therehasto beevidenceof medicalimproprietyin orderfor it to beworthy of beingreported.The Committeeon PhysicianImpairmenthelpsphysicianswith substanceproblem.Thisisbeforetheydriveor mar.ragepatientswhileintoxicated.If aph,vsicianisimpairedandtakescareof patientswhileintoxicated,thenthephysicianshouldbereportedto thelocalchiefof serviceor Departmentof Health.RightNottoAcceptPatients70. (a) It is both legaland ethical.Thereisno legalor ethicalmandateto carefor anypatientwho comesto seeyou.Thephysician/patientrelationshipmustbeenteredinto voluntarilyon both parts.Hence,if thephysicianspracticeisfull, thereisno obligationto acceptnewpatients.It wouldbeunethicalifthe physicianwereto acceptsomepatientsbasedon arbitrarypersonalpreferencesand rejectothersfor the sane reason,althoughthis is not illegal.Forexample,it wouldbeunethicalto acceptor rejectpatientssirnplyon thebasisof race,gender,or religionunlessit hadto do with a specificareaof expertisesuchasbeinga gynecologistrejectingmalepatients.Althoughit is courteousto nake a referraltoanothcrphysicianthereis no obligationto arrangefor carefrom anothcrphysician.This is entirelydifferentfrom a casein which a patientwasalreadyunderthe careofa physician.In this case,aphysicianmustarrangefor appropriatetransferto anotherphysicianscareasheendstherelationship.Oncehavingacceptedresponsibilityfor apatientthereisfar lessfreedon on thepartofthe physicianto breakthatrelationship.To ceasefrom providingcareto an ill patientrvithoutappropriatetransferof carcisboth anunethicalandillegalactioncharacterizedaspatientabandonment.
    • AnswersandexplanationsI167DutytothePatient,GagOrdersNotValid,HMO71. (a) Fully inform the patient about the risks and benefitsof bone marrow trans-plantation,Yourprimary duty isalwaysto thepatient.Oneof the uniqueelementsof thephysi_cian/patientrelationshipisthatits ethicalboundariestranscendordinaryrulesof theworkplaceandinstitutionalrules.Assuch,you cannotwithhordinformationfrom apatientif that information mayleadto benefitfor the patient.ln orderto makean"informedconsent,"the patientmustbefully informed.Thepatrentcannotbefullyinformedifhe hasnot heardofthe options.It isnot appropriatefor lou to backawayfrom educatingyour patientby transferringcareunlessit is for anareaoutsidevourexpertise.Thereis no needto encouragelitigationunderanycircumstances.It is not ethicalto tell a patientabouta potentialtherapyonly if he asksaboutit. Itis our duty to inform him. "Gagorders,preventingthe educationof patientsabouttreatmentoptionsarealwayswrong.The patientscannothayeautonomyoverthechoiceof treatmentof theirbodyif theyarenot awareof theoptions.Beneficencetothe patientalwaysoutweighsinstitutionaldirectives.
    • 16l I AnsuersandExplanationsI(APTAN) MEDICALPhysicialRefusingtoTreatHIVPatientsforaProcedure72. (e) Referthe patient to anothercardiothoracicsurgeon.Thepatienthasaveryclearneedfor coronarybypasssurgerywith three-vesseldiseaseand left ventricularfirnction.Thebottom line point to this questionis aboutwhatyou do for patientswho needa particularprocedurewhenthe physicianis refusingto do the right thing.Ar.rswersb, c, and d involveswitchingthe patientto anotherform of therapy,which is inadequate,comparedwith surgery.This is unacceptable.Youcannotforcethe surgeonto operateagainsthiswill. Althoughit is unethicalforaphysicianto refusecareon thebasisof race,gender,ethnicorigin,anddiseasessuchasHI4 you cannotlegallyforceaphysicianto takecareofsomeonetheydo notwantto. Thephysician/patientrelationshipthat must beenteredinto voluntarilyonbothparts;hence,it is unethicalto refuseto treata patientsolelybasedon you dislikeordiscomfortwith HlV-positivepersons,but it is not illegal.The chiefof servicemayhavethe power to removeor suspendhospitalprivilegesand to fire someoneforunethicalbehavior,but thechiefof servicedoesnot havethe abilityto forcea physi-cianto performaprocedure.Whena patientneedsaprocedurethatyour consultantwill not do,thenthe right actionisto find thepatienta doctorwho will do therightthing. Although this casewasframedin terms of HIV, the answerof referringtoanotherphysicianwould be the sameno matterwhat reasonthe physicianhadforrefusingto do theprocedure.SexualRelationsbetweenPhysicianandPatient73. (d) "I cannotdateyou andbeyour doctor-maybe in the future wecandate,afteryou getanotherdoctor."Sexualrelationsbetweenaphysiciananda currentpatientareneverethicallyaccept,able.At the very least,the physician/patientrelationshipmust stop.The patientmust transferher careto anotherphysician.This is to avoidan abuseof powerinthe relationshipand to keepclearboundaries.Relationshipsbetweena psychiatristandapatientaregenerallyneveracceptableevenafterthephysician/patientrelation-shiphasstopped.It doesnot matterwho initiatestherelationship.Thereis no ethicsboardin placeto actasa datingservicefor physicians.E!-
    • AnswersandExplanations]169liseaset whatfusingrotherrtable.:al for; suchwantbothke ormaFe forhysi-itant-ight8 t oI fort -csterntinist74 (c) Herpes simplexThe primary purpose of reportir.rgdiseasesto the Department of Health is to be ableto interrupt a cycle of transmission. hr addition, we wish to know the epidemiology of diseasesin order to assessresourceallocation and the successof interventionprograms. Finally, for infectious diseaseswe report seltsitivity patterns in order toguide appropriate ernpiric therapy in the future. For instance,we track the sensitivityof gonorrhea resistanceto quinolones in order to assesswhether we can continue tousequinolones en.rpiricallyto treat patients into the future. We report salmonella sothat we can identify and eliminate the source of the infection such as a resta[rantclosed or contaminated food discarded.We report tuberculosis so that the contactscan be PPD skin-testedand the sourcepatient isolateduntil noninfectious.Measlesnotification is important sothat we can assesswho needsvaccincsin order to Dreventfurther spread.Herpesdoesnot need any ofthese intervcntions. Herpes spreadsonlythrough intimate contact. It cannot spreadthrough contaminated food ar.rdwater likesalmonella.Herpes cannot be effectively eraclicatedfrom the entire bod1..In betweenoutbreaks,herpes is dormant in the body anclthe outbreaks only shorten rvith abor-tive therapy such as acyclovir. Peopleofien harbor asymptomatic gonorrhea, whichcan be detectedand eradicated.There is no isolation for hcrpes and there is n. effcctive vaccine.TuberculosislsolationandIncarceration75. (d) Remove the patient from his job asa bus driver and incarcerate him in a hos-pital to take medications.lhepatients right to privacy and autonomy ends when the public,s right to safctyis 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 themedications through a nasogastric tube, but you do have the right to rcmove thepatientfrom hisjob and put him in a hospitalwherehe cannotinfectothersuntil hissputum is free of acid fastbacilli. This is not just bccausehc hasa job asa bus driver,rvhichhasa lot of contactwith the public.TB incarcerationis not the samcasbeingarrested.It is part of the Departmentof Health,not the crimial justicesystenr.yogo to a hospital where the only rvay to get out is to take the medications antl haveclean sputum. You do r.rotgo to a jail.MDICAL
    • I(A PLA I.IIonr*"r, andExplanationsMEDICAIPartnerNotificationforSyphilis76, (d) The Department of Health will send a letter or call the contacts and let themknow they have a serious health issue.They will test and treat the partners butwill not revealhis name.The need to keep the population free from diseaselimits the patientsri€lht to privacy.You have a duty to the other contacts he may have infected. However, in order torespectthe patients privacy, the Department of Health has never revealedthe nameof the source patient, no matter how rnr.rchthey are asked.They make the originalnotification by phone or mail but only reveal the specific diseasein person. If thepatient wont revealthe namesof his contacts,you haveno means to force him to doso.You cannot incarcerateor arrest a patient becausehe will not revealthe namcsofhis contacts.Physician0bjectingtoPerformingAbortions77. (e) Refer the patient for the abortion,Patients have the legal right to safe and effective abortions. This right is universalwithin the first trimester and no hrrther evaluation or rsaiting period is required.Theright to abortion after the first trimester (12 weeks) is lesscleat and extenuatingcircumstancessuch asa risk to the life ofthe mother from the pregnancyor whether theconceptiolr is a product of sexual assaultare also considered. The criteria for readyaccessto abortion becomeslessclear after the first trimester asthe fetus progressesiniL.developmentlowardbccominga viahleinlant.
    • 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 objectioncan cover your refusal to do the procedure personally but you do not have the rightto refuseto refer her to the care she neeclsasyour patient. Although a physician hasthe right to refuseto enter into the physician/patient relationship before it hasbegun,once you have entered into the relationship you are obligated to provide the carethepatient needs.Hence, you cannot just terminate the physician/patient relationshipat the moment the patient needs a form of care you disagreewith. you cannot askfor a four-week waiting period especiallywhen the patient presentsat eight weeksofpregnancy and this wait will bring her past the first trimesterIfthe patient hasclear decision_making capacity,there is no needto obtain a psychologicalevalualion.ParentalNotificationforAbortion78. (e) Stronglyencourageher to discussthe issuewith her parents.Althoughcompetentadurtshaveanunfetterecrlegalright to abortionwithin thefirsttrimester,this right is not universalfor a minor. A minor is generallydefinedasapersonbelowthe ageof 18.Thenecessityof parentalconsentor at leastnotificationisamired issueacrossstatesnationally.Somestatesrequireparentalnotificationandsomestatesdo not. Hence,asaboardexamination,whichisgivennationally,thereisno singleclearanswerUnlikethebarexaminationfor lawyers,physicianstakevirtu_ally no statespecificexamination.4renyou passUSMLEor the Boardof InternalMedicine,it isvalidin everystate.The only thing that is alwaysclearis that we shouldstronglyencouragethe patientherselfto havethe discussionwith her parents.Many of the boardswill want ananswerindicatingdiscussionbeforeactionsoyou will betrainedinto trying to buildconsensus.Evcnif you arewithin your rightsto walk up to a brain_deadpatientandremovetheventilatorwithout consentof the family,theboardswiI alwavswantvouto answer"cliscusswith the famiiy,first if that is oneof the options.AnswersandExplanationsIl 7 lI(APLAN MEDICAL
    • 172Innr*"r, undExplanationsSterilization-HusbandDisagrees79. (a) Referfor the tubal ligation asrequestedby thewife.Although it is preferableto haveconsensus,thereis absolutelyno spousalconsentrequiredfor sterilizationproceduresof eitherpartner.Thefallopiantubesarelocatedwithin the body of the woman;henceit is a matter of her right to autonomyoverher own body that shehasthe right to the sterilizationprocedureif that is whatshedesires.The number of childrenthat a patienthasbearsno impact on the accept-ability of the sterilizationprocedure.If this were true, it would be equivalenttolegallymandatingthat everywoman must reproduce.In other words,"Wewill tieyour tubes,only aslongasyou haveput themto gooduse.Firstfulfill your biologicalpotential,and then we will sterilizeyou."This is unacceptablereasoning.A womanhasa right to choosewhat to do with her own body.If a man buysa new carbutchoosesneverto driveit, that is his right. If he choosesto throw out the car,thatishisright.Youcannotmandatethathedrivethecarbecausethecarisnew.Youcannottell him hemustkeepthe carbecause"youmight changeyour mind later,andwantto gofor a drive."Aslongasthereisno evidenceofpsychiatricdisturbanceor incapacityto understandher medicalissues,a psychologicalevaluationis not necessary.PaternalConsentforAbortionNotNecessarv80. (e) You sayyou have an absolute duty to the mother to honor her wishes no matterwhat his personal feelings are.A woman hasa right to choosewhat to do with her own body. Undelivered babiesorfetusesdo not havelegalstanding asan independent person to bring a suit to preventits termination. Until the moment of delivery,the embryo is consideredan extensionof the womans body. Shedoes not need consent from the father of the child or anymember of the family. Her ability to consent to the termination is equal to her con-scntfor a bre.r"tbiopsyor a legamputation,!?r-,yD reorca.
    • AnswersandexplanationsIt7tAlthough a fetusmaygeneticay containhalf the geneticerementsof both parents,it is the femalethat mustgo throughthe deliverni"".., ,fr. *o_an hasa,,right ofownership,overanyundeliveredchild becauseit inhabl,, i". nra"ThirdTrimesterAbortion8I. (d) Legallyyou canonly do it if her life is at risk.Abortion during the third trimesteris the nost controversialareaof reproductiverights.Thereis no automati(Duringthethirdtrimeste.,tierriil,tsl:;::J:1ffi,fil.TiJi:,",,r;,;::i:1::::tational age(six months) can potentiallysurviveintact with a deliveryalthoughitwould havea greaterrisk of complications,..onau.y to p.._"rr.u, The SupremeCourt hasconsistentlyIeft exceptionsfor the possibilityof uior,_n ln later stagesof pregnancyif the life of the mother is at risk.you ."nrroa"rH.ully freelyabort apotentiallyviable fetusunlessthereis a very significan;";;;r",r", crrcumstancesuchasrisk to the motheror a fetussod.""1;p;.;ll; "0""r_, ,n", fetaldemiseis certain.As for a court ordet the court cancaryorproression"i,;;;;;.;r-,#r.i::#li:l?11*1.,f.T,#::;T,;"i,1:it legal to perform euthanasia onunethicartodosoeven_,,h".;;f :.d:;;l : :H,,r*:tr;.1,1"1jl jj.lrl:lfltllt*,1 ont:t:tanparticipatingin anexeculion.Thecondemnejisunderacourtorder to die and it is legal.However,it is unethical for a physician to partrcipate, asaphysician, in an execution.I(API.AN) MEDICAI
    • 174 Answersand ExplanationsVictimObjectstoReporting82. (b) You will report the injury only with his consent.The rules on the reporting of domestic violence are much lessstrict than those onreporting child abuseare.This is becausea competent adult hasthe voluntary choiceof reporting the injury themselvesin the vast majority of cases.In additiolt, you can-not violate the patients right to autonomy by specifically doing sonething that hasexpressivelybeen refused. For children there is mandatory reporting becausechil-dren do not have the abilily to defend themselves.Minors, by definition, are deemedincompetent except for a few exceptions like sexually transmitted diseases(STDs).Children are not, therefore, consideredto have autonomy that can be violated.This patient is being physically abused. As an adult Patient with the capacity tounderstand his medical problems, he hasthe right to refusecareand protection fromreporting the injury if that is what he wants.AttemptedSuicide-NeedforEmergencyProcedure83. (b) Performthe surgery.This patientsinjury is,in a sense,the sameasa Purposefuldrug overdose,jumpingoffa bridge,or trying to shoothimself.Inthiscase,thecarisalargegun.Althoughanadultpatientwith the capacityto understandhis medicalcarecanrefusetreatnentthis is not the sameasallowingPatientsto kill themselves.Peopleactivelytrying tokill themselvesare,by definition,not consideredcompetent.The right to autonomlendsjust shortof condoningactivesuicide.lt isassumed,in thiscase,thatthesuicideattemptwasperformedwhileundertheintolerableemotionalburdenofrecentlyhav-ing found hehadcancer.An assumptionismadethatwhenacutelife stressorsleadapatientto attemptsuicidethattheyaretemPorarilyincompetentandPsychotherapyor psychopharmacologymayhelphim. lf you reviewthe questionyou will seethatthe caseneverstatedthat the cancerwasincurable,progressive,or evenfatal.l!!!!!) ueotcrt-
    • Answersand ExplanationsYou cannot let a patient kill himself rvhile under acute psychological distresssuch asdepression.You cannot wait for a court order tbr energency surgerv in a henorrhag-ing patient. The familys consent is not necessary.It is nice to have,but does not alterthe reasoning stated above.If I was trying to commit suicide, it would rot matter ifmy family comes by and says,"Itsokay, lct him die." You still have to intervene toprevent the active suicide.NotEthicaltoParticipateinPhysicalTorture84. (e) You cannot participate in the purposeful torture of a prisoner.Physiciansare never ethically allowed to participate in the torture of anyone.This istrue even if there is a court order directing you to do so. It would not be ethical toassaultsomeone or murder someone even if there is a court order. The physiciansduty to the patient transcends duty to ordinary institutional structure. This is trueeven if the prisoner has been convicted of the crime. We cannot have our duty topatients flexible basedon urhether they havebeen accused,arrested,charged,on trial,or convicted. It is always unethical to participate in the purposcful injury whetherphysical or psychological of a prisoner. There is no releaseyou can obtain from asuperior or an institution that makesunethical behavior ethical.The physician cannotlater justifu participation in torturc under the rubric,"Iwas only follorving orders."DutytoReportInlurytoPrisoners85. (a) Reportthe injuries assignsofpossible torture.You havea duty to protectthe rvelfareof all patientsunderyour care.This includesprisoners.Failingto report the injury makesyou an acconpliceor in somesenseparticipatoryto the injury becauseyou did nothing to preventthe nextinjury. Thisduty transcendsyourpresenceeitherin or out ofthe military.It wouldbethesameasfinding evidenceof childabuse.Youareamandatedreporter.Youareliableif youfailto report aninjury to achild thatyou suspectof beingabuse.If thereisa subsequentinjury to the child,thosewho fail to report the first injury areliablefor helpingtocausethesubsequentinjury byfailingto reportthefirst.Thesameistruefor evidenceof torture to prisoners.Youhaveanethicalduty to reportevenifthe injury turnsoutnot to havebeensecondaryto rorture.
    • Answersand ExplanationsHence,in terms of torture and child abuse,the physiciansethicaldutyistoreportpossibleepisodes.Thereisno obligationto onlyreportepisodesthatareorovento beepisodesof abuseor torture.FutileTreatment86. (e) Recornmendthat dialysisnot beperformedYou are not required to administer any form of therapy that you feelwouldbeYoudo not havcto performthedialysisif it will not leadto anysignificantthepatient.Thisis true evenif the family isrequestingthatyouperformtheAlthough,in practice,it is extremelydifficult not to honora familyswishestoform any therapy,there is no legalor ethical requirement to do so.In thiscas€,the pcrsistent vegetativestate,there is multiorgan failure associatedwithno chance of survival. Hence, dialysis woulcl not be prolonging this patientswould only be prolongingthe dyingprocess.In this case,doingdialysiswouldcallybethesane asthe family requestingkidneytransplantation.AdultwithCapacityRequestingWithdrawalofVentilator87. (a) Removetheventilator assherequests.Any adult patient with the capacity to understand her mcdical problemshasright to do what shewishesvrith herown body.Althoughtheren.raybeandistinction on the part of the caregiversand familv betweenrvithholdingofcarewithdrawal of care,there is no ethicalor legaldistincrion.This prtientshewill die and it is her legalright to havethe ventilatorremovedif shewishes.court orderis not necessarybecausethis typeof casehasbeenlegallyworkedoutthe pastin other cases.The consentof the family and the prory arenotbecausethe patient is alert and able to communicate her own wishes.Thecareprory only becomesresponsiblefor decisionmakingwhenthepatientlosescapacityto speakfor herself.Youshouldnot evenconsulttheproxyandthewhen the patientis alert unlessit is at the requestof the patient.Sedationispropriate. We cannot just sedatepeople when we do not like their decisions.Younot havethe right to forceanyform of therapyon a competentpatient.Thisbediff-erentonly if thc personwereacutelysuicidal.!!l!!p rueorcar
    • AnswersandExplanationsI177ect andalwavsAdultwithCapacityRefusingLifesavingChemotherapy88. (d) Honor the patientswishesThepatientis an adult who hasthe capacityto understandthe risksandbenefitsoftherapy.Consequentlyshehasthe right to refuseor accepttherapyor alrl part ofthe therapythat sheseesfit. psychiatricevaluationwould only be necessaryif therewereevidenceof depressionand possiblesuicidalideation.psychiatryevaluationisalsousefulsometimesif the patientscapacityto understandher medicalconditionis unclear.If the patientclearlyunderstandsher issuesor is crearlyunableto under-standthen a psychiatricevaluationis unnecessary.The court has no standinstoappointa guardianto overrulean adult with the capacityto understandher issues.Radiotherapyis not adequatetherapyfor stageIII lymphoma.In addition,you can_not substituteanothertherapywithout thepatient,sconsent.Riskmanagementisaninstitutior.ralagentwhoseroleisto minimizethe risk of litigationfor theinstitution.Theywould not be necessaryhereaslong asyou haveadequatelydocumentedthepatientsmentalcapacityandthe refusalof therapy.DepressedPatientRefusingTherapy89. (a) PsychiatricevaluationThis patientis severelydepressedwith vegetativesignsof depressionsuchasweightchange,anhedonia,and sleepdisturbance.It is important to evaluateand treatdepression,which n.raybe a temporary condition, prior to withholding therapywithout which the patientwill likely die. In atldition,the shortnessot breathmavindicatehypoxia,which maybeinterferingwith thepatient,scapacityto understandtheir medicalcondition.yorrdo not want to sedatea patientwho needsto speaktoa psychiatrist.In addition,simplysedatinga patientwho is refusingtherapymaybeconstruedassimplymakinghim unableto refusetherapy.Thefamily,sopinion doesnot changetheprimary duty to thepatientto assurethatthereasonfor therefusalofpotentiallylifesavingtherapyis not simply untreateddepression.Ethicscommitteeevaluationismostusefulwhenapatientdoesnot havethecapacityto understandhismedicalconditionandthe family membersarein disagreement.A DNR orderdoesnot absolveyou of theneedto treatthe patient,sotherconditions.futile.fit foralysis.) Per:sidesrtiallyi f e . ; rethi-thernalandnds; . Al r naryth-lheilvLP-doLld!(AptAN) MaDrcAr
    • 178|nns*ersandExplanationsRefusalofAtificialNutrition;DisagreementwiththeProxy90. (d) Do not placeanyform of tubefor artificial nutrition or hydration.Your primary duty is to the patientrvhospecificallytold younot to placeanyof tube for artificial nutrition. Although the proxy hasthe abilitv to ovettr{ein the famllyin tems of decistonmaking,shecannotoverrulethepatien.Is$.thepaperdocumentationdid not specificallymention J-tube,thepatientgavelouaclearoral adrzancedirectire and that tr the abnJute ruJe )oumut stitk bf tlno nal.terwhatacout ortheclhjcsconnjtlcend//tal Hkough Xj,floal ighl /0xrttffto acceptapatrent,you cannotethicallytransferthecareof apatientto someonewhowill goagainstthepatientswishesjust becauseyou feeluncomfortable.Oraladvancedirectivesareharderto provebut theyarestillvalid.Thisistrueevenwhenthepatientlosesthecapacityto makedecisions.Ifwe did not honorapatientswishesafterlosingcompetence,no onewouldbeableto makealastwill andtestament.A personswillis,in essence,aproxydirectingthefinancialandpropertywishesofthe patient.Deathistheultimatewayoflosing capacityto makedecisions.A person,sadvancedirectiveisatbrm of will directingwhathewishesdonewith themostpersonalpropertyapatientcanhave:his own life andbodv.MEDICALP
    • AnswersandexplanationsI179mleha:ProxyasUltimateDecisionMaker91. (a) Honor the prory and do not intutrateThehealthcareprorTistheultimateciecisionmakerin allmattersofhealthcare.TheprorTisthe designeeby thepatientto deternine andimplementthepatient,swishesin the eventthat a patientbecomesunableto makedecisions.lt doesnot matterifeverysinglepersonin the univaccurateryknowsthe*,,h.,,;T;"T;,:"::ffi:#:T:Jjlj5:Xil:.i:.jLTtrmebecausetheprory isthepersondesignatedbyihe patientto makejudgmentsforthepatientt care.Theprory islikethe.r..uto. ofu will.Atit ol,gi ..,,n."nru, ugr".-ment with the family is not necessarysometimesthe questionscontainan answerchoicethat says"encouragediscussions,,amongstthe family and proxy or,,seekagreement."When that answerbetterroseekconsensus"J;J:"H::1,il,ili:,liH:T,.ili!1,i*,*LiJievaluationisnot necessaryifeither thereisapro-xywho t"o_, ,i. a"nni,. wishesofthepatientor, whenthereis no pror:7,whenthereis agreementamongstthe family,Neurologyconsultationis not necessaryfor the samereason.It islike voting.Ifyou havealetterfrom a personwith their prorl, ballotfor aneiec_tion,it doesnot matterwhatotherpeoplethink,you castth" ]rot.th. pnt,.rrtwanted.Not thevotethat his motherthinksis bestfor him. Wh.r, u purr..r,Oo.u_entsclearwishes,theproxy is like a mail carrierdeliveringthe .e.or.l of th. patientt plan forhimself.I(API-AN MTDICAL
    • t(Aat-ANl80]onr*urcandExplanationsNoProxy,DisagreementamongstFamily92. (a) Encouragediscussionamongstthe family.When thereis no clearevidenceof a patientswishesfor himsell we must seekth€bestevidencewecanfind ofwhat judgmentthepatientwouldmakefor himselfwereheawakeandcommunicative.ln practicethisis not a problemaslong asthefamil,vmembersall agree.In addition,when thereis disagreement,particularlywhenthefamilymembersareconsideredto haveequal"weight"thenwemustfirst try to seekconsensusby encouragingdiscussion.Only if this is not fruitful shouldan outsidethird partysuchasthecourtsbesought.All necessarytherapyshouldcontinuewhiletheevidenceof the patientswishesis collected.NoProxy,DisagreementamongstFamily,NoConsensus93. (e) Pursue an ethics committee evaluation.When there is no clear evidence of the patients wishes,then you must seekthe best"substituted judgment." The physician mLrstseekout what the patient would harewished for herself and you"substitute"the judgment of the caregiversor family forwhat the patient would have wanted for herself had shebeen awake.When a reach-able consensusby discussion is not possible then an evaluation by the ethics committee is appropriate to seekconsensus.This is the weakestform of decision makingbecauseit carries the least precision. If a clear agreement still is unreachable thenreferral to the courts nay be necessaryto achieve clarity and objectively weight theevidencethat the different family members bring forth. This is what happened in theTerry Schiavocasein which the patients husband wasjudged by the courts asbriningthe best evidence that he and others had the most accurateknowledee of what thepatient wanted for herself.If there is no family available then the ethics committee and physicians wouldmake decisionsbasedon the judgment of what would be in the best interestsof theParrent.MEDICAL
    • AnswersandexplanationsIt 8 leekthellf werefamilyIen theto seekrutside: whileTerminalSedation,PalliativeCare,"Double-Effect,94. (b) It is acceptableaslong asthe patient understandsthe risks.Yourprimary duty to a patientwith a terminal condition and intractablepain isto relievesuffering.lt is unacceptableand unethicarto leavehim to suffer.As ronsashe understandsthat the pain medicationsmay havethe ,double_eftect..of bothrelievinghispain andpossibleshorteninghislife andheagreesthenit is acceptable.It isthesameasperforminga riskTsurgicalprocedurein whichthepatientconsentsto a lifesavingsurgeryknowing thereis a risk of possibledeath.This is the sameascardiacbypassgraftingin which the surgerywill prolonglife if successful,but hasa risk of deathfrom the procedure.This is the sameasa bonemarrow transplanta_tion ir.rwhichthepatienthasaverysignificantrisk of death,but mustdo it in orderto preventdeathfrom leukemia.A DNR order aloneis not a wayof avoiclingrisk.Physician-assistedsuicideis illegalin virtualy alljurisdictions.you cannotpurposelyendthepatients life.Theprimary issueistheintentof thephysicianin givilrgthepainnedications.If theprirnaryaim is to relievesufferingand thereis an inadvertentshorteningof life asanadverseeffect,thenit is acceptable.If theprimary intentis to endhisIifewith themedicationsthenit is unacceptable.The directstatementof the rJ-S.supremecourt is "thestatepermitsphysicianstoadministermedicationto patientsin terminal conditionswherethe primary intentisto relicvepain,een whenthemedicationissopowerfulasto hastendeathandthepatientchoosesto receiveit with that understandins.,: besthavey forach-:om-kingihenthethelrngtheuldlheI(A.PLAN MEDICAL
    • r82Innr*"r,undExplanationsValidityoftheLivingWill95, (c) Remove the tube and the ventilatorAll adults of sound mind have the right to do what they want with their own bodv.The patient has left a clear advancedirective of what she wanted clearly stating shedoes not want ventilator managemcnt if there is no hope of recovery. It does notmatter what the risk manager,the rest of the family, or even the husband wants.Allthat matters is what the patient wanted. To treat a patient for anything without herconsent is legally equivalent to assaultand battery. In this case,ifyou leavethe venti-lator in placeyou are"mugging"the patient. This caseis extremely clear becausetheadvancedirective is in writing and specifiesthe precise medical intervention that isbeing refusedby name. A court order is unnecessarybecausethe courts do not havethe authority to treat a patient againsther will.The vast ma.jority of stateshaveactual statutessayingthat a living will is a valid formof advancedirective that absolutelymust be honored. All 50 stateshavelawsdeclaringthe validity of advancedirectives.ln the three statesthat do not have specific livingwill statues,there is caselaw and legal precedent showing that the living will must behonored. lt is clearer if we take the word"living"out of the reasoning and view thepatients body as a house in which the husband brings in a will directing what shewants done with her house.It the document is valid then you must honor it no matterwhat the rest of the family or the courts say.!!!!p rurorcrr
    • AnswersandExplanationsIt85body.rgshes nots.Allt herend-: theat islaveThereis no limitation on whatfamilycanwithdrawthat is uniteclin agreeingon thewishesof the patient.Thc difficultiesarisewhenth" f"_ify ,piir, ,r, their opinion asto what the patientlyanted.The bestform of advance,ti;*i;; " a prorT with anagentthat hasthe patient.swishesfor herselfwritten o,,, n,rda"r.r,O"a by specificproccdure.ln otherwords,ir.rsteadofsaying,,noh.roi. ,rraurur.ri,i,e pror:7says.,nomechanicalventilation,no nasogastrictube placement,and no artificial nutrition.,,This is thc patientspeakingfor hersel| It is c]ear"rJP...rr". i ** areno ]imitson what can be withdrawn or withheld.When this i, ;.;;;;*,, then the familyor frienclsmust describewhar the patient would have-;; ;. herserfhad shebeenableto speak.In thiscaserhefamilyactsasa subs,irri. i"i,fr. luag_ent of thei,lljll_T:::1"::.substitutedjudgmentisnotassooda,up.oltir,.*,,. ,hereisnocreardocumentation.Thefanily is statingwhattheybelievearethepatient,swishesfor themselves.Thisis the casein this<lueition.Be.""r. ri.1. "r. ," "greement,thereisnoproblem.Theycandoanythingincrudingpullingor, ii" .ra.rr_n*r tubeandstoppingnasogastrictubefceding.The pivotalpoint is that the family is conveyingwhat they understandthe patientwould wish for herself,not what they think is i*,,, ,., ,i. O"l*nt. The lastformof decisionmaking fbr a patientwithout d..irio; _aki;;:ip".,r1, ""0 withour aproxyrsprople makingajudgmentof what theythint ll;ii tt i U..t i,rterestsof thepatient.Thisform of decisionmakingof the,,bestinteres,iironiura i, ."L* thereisno documentationof thepatient,swishes(liing ,ill), ""d ll; ;;;;yTheorderof directivesarrangedfrontrtrongerttoweakeslir:1. Adult wirh capacity_No limit on what canbewithdrawn/withheld2. No capacity,but with pro{, that statesin writing thepatient,swishes_No limita_tionNoCapacity.NoProxy.NoLimitationonWhatCanBeWithdrawnbyFamilyinConsensus96. (e) Norhing3. No capacitSno prory,but written wishesfrom thepatient_No limitationsrrmrngi.gbeheheet(ll!!P rureorcnr
    • t84 j onr*"r, andExplanationsM E D I C A L4. No capacity, no proT, no written wishes, but family united in knowingthepatients wishes (essentiallya verbal advancedirective)-No limitationWhen there is no proxy and no living will and the family is not in agrecment,thenanarbitration processshould occur starting with an institutional ethics committeeandsometimes ending in the courts.AdultwithCapacityWantstoStopArtificialNutrition97. (a) "Iwill get that tube out right away,sir."An adult patient with the capacity to understand his mcdical problems hasthe rightto stop any form of therapy he wants to. This patient gives the reason that he isuncomfortable, however, the patient does not have to give you any reason.He canjust say,"Ido not want it," and you must stop. There is no evidence of psychosisordepressiondescribed in the caseso there is no reasonto doubt the decision makingcapacity of the patient.4hen the patient has the capacity to understand, the wishes of the faniily, thecourts, or the pro)!l. are not relevant to what you haveto comply with in terms of thepatients care.There is a big difference between not complying with a patients wishes for himselfand not agreeing with the decision. You do not have to agree with a conpetentpersonswishesfor himsell but you do have to comply with them.Removing tube feeding in a person who needsthe nutrition hasa different emotionalfeeling for many caregiversbecauseit seemslike denying basiccomfort. Nevertheless,there is no legal or ethical distinction. Tube feedingsare a medical intervention thatcan stop like any other at the discretion ofthe patient. You cannot force-feeda patientasainsttheir will.cIIE II(APLAN
    • AnswersandrxplanationsIt85the CompetentAdultWantstoStopDialysis98. (f) "AlthoughI disagree with your decision, I will stop the dialysis."An adult with the capacityto undcrstandthe effcctsof his decisions(rn st()p ryforn of therapy evenif it rvill lead to his death.Stopping dialysisis not a form of phy-sician assistedsuicideor euthanasia.Eutltanasiamcansgiving a medicationthat willkill the patient. The primary clifferenceis one ofintent. Passivedying from stopping amedical treatment is cntirely at the discretion of the patient provided that the personis not acutelyclepressedanclsuicidal.By dcfinition, a suicidalpatient is decmednotto be competent.This casespecificallystatesthat the patient is not depressed.Although there may bc an emotiolal difference betwcen stopping therapy and everstarting in the first placc, there is no legal difference.Therc is no ethical or lcgal dif-ferencebetrveenwithholding and withrlrawing a treatmcnt. All that matters is rhatyou are adhering to a competent adults clcar wishesfor his own cire.lf I am painting your houseblue and halfivaythrough the job you insistthat I paintthe housered,I must comply rvith your wishes.I canttell you,"Sorry,onceI starttopaint, I dont stop urtil thejob is clone.Your wishesarelessimportant than mine."Itis your housc.You can do what you want $ith it.AdultwithoutCapactityandaVagueLivingWill99. (a) Continue both for now.fhemajor difficulty with the living rcill is that it is often rot clear and specific interms of what it means.The phrase"noheroic measures"is not sufficientlyclearasan advancedirective to stop a ventilator that thc personslife is dependcnt upon, Youalsodo not larow if the patientswisheshavechangcclsincethe lastvisit. As far asyouknow, the paticr.rtsfamiJy may appear any minutc and saythe patient wants to be ona ventilatoraslong asit is not permanent.lheymay say"noheroicmeasurcs"neantdialysisand organ transplantationin the mind ofthe paticnt.A DNR order docsnotfrean ren]ovea ventilator.DNI{ just meansno cardiopulmonaryresuscitationeffortsin the eventof the patientsdeath.anLndhtis.n)rI(AIIAN M E D I C A L
    • 185]onr*"r, and ExplanationsIf the advancedirective is not clear,particularly concerning basicnutrition, then 1oushould continue therapy until it becomesclear If you think that what is bestfor thepatient is to rernovethe ventilator and he dies,what happens when you find out thatthe Alzheimers diseaseis mild memory impairment and"noheroic measures"in thepatients nind meant no chenothcrapy or surgery?Continue therapy until the situ-ation is clear.In absenceof a spccific directive to stop, you should continue.DefinitionofHealth-CareProxy100. (c) To communicate and carry out the wishes of the patientThc health careproxy is the agent of the patient to carry out the patients wishesfortheir mcdical treatmcnt in the event that shelosesthe capacity to make decisionsforherscll The prori:yis not an agent of the physician. The proxy should be the primaryperson to be the substitute for the judgment of the patient. ln other words, whatwould the patient want if shewere able to speak?The reasonit is called a health-careproll. is to distinguish it from a financial executor.lhepower of the health careprorT hasno impact on the finarces of the patient. They do not pay the bills for thepatient.The most important issueis that the primary role of the health-care agent or proxvis not there to statewhat the prorT thinks is bestfor the patient, but what the patientwanted. The prory is like a mail carrier. lf the patients wishesare like a letter to thephysician, the prory is there to deliver it.I ( A P L A N M T D I C A L
    • AnswersandExplanationsI187n you)r thet thatn thesitu-PregnantAdultwithCapacityl0l. (a) Honor her wishes;no transfusion.The pregnancyhasno impact on the ability of a competentadult,sright to refusetherapv.As long asthe fetusis insideherbody,the fetusdoesnot havethe indepen-dent rights of a person.The fetusis consideredthe sameasher body.personhoodfor the fetusis only a considerationafterthe delivery.The sameanswerwould betrue evenifshe werein herthird trimesterofpregnancy.Theconsentofthe fatherisirrelevant.Thefatheris not the onereceiyingth.-t.nnrfurinn. Do not seekhis opin_ion.Thecourtscannotorderefusing.r a comPetentpersonto receivea medicaltherapysheisOralAdvanceDirectivesAreBindingI 02, (e) Remove the IV lines and stop blood draws asthey wish.There is no limitation on what can be withdrawn from a patient,s care based on aclear advancedirective. In this casethe advancedirective is oral. A written advancedirective is preferablebecauseit is easierto prove. fhis is especiattyimportant whenthere is disagreementamongst the family members. In this case,the wife and eightchildren are in uniform agreementon what the patient stated he wanteclfor himself.There is no ethical or legal distinction betweenwithholding and withdrawing care.An_ethicscommittee is important when there is disagreementon what the patient,swisheswere judicial interventionrvould be necessaryifthe physrciansdisagreedwiththe prognosis of the patient. In other words, ifthe fu-ily _u.rt"a "u.rything stoppedbecausethey believed there would be no recovery but the physicians believed thermpairment was temporary, then judicial jnrervendon for a court order might benecessaty.forforrrylatLrerelevrt!f!!p r,,|eorcrr
    • tsBN-13: 978-1-4195-4209-110: 1-41954209-5fl[ilfl[i