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Ethics in medicine - Archer USMLE step 3
 

Ethics in medicine - Archer USMLE step 3

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Archer USMLE step 3 Ethics lecture notes. These lecture notes are samples and are intended for use with Archer video lectures. For video lectures, please log in at ...

Archer USMLE step 3 Ethics lecture notes. These lecture notes are samples and are intended for use with Archer video lectures. For video lectures, please log in at http://www.ccsworkshop.com/Pay_Per_View.html

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    Ethics in medicine - Archer USMLE step 3 Ethics in medicine - Archer USMLE step 3 Presentation Transcript

    • Ethics in Medicine Archer Online USMLE Reviews www.ccsworkshop.com All rights reserved. Archer Slides are intended for use with Archer USMLE step 3 video lectures. Hence, most slides are very brief summaries of the concepts which will be addressed in a detailed way with focus on High-yield concepts in the Video lectures. These slides are only SAMPLES
    • Confidentiality
      • Physicians cannot tell anything about their patient without the patients permission.
      • Getting a consultation is permitted only if the consultant is bound by confidentiality.
      • The physician must BREAK CONFIDENTIALITY in the following cases..
      • If the patient is threat to self or others
      • Duty to warn and duty to protect
      • Suicide ,homicide or abuse cases
      • Infectious diseases are treated as threat  At first encourage the patient to work with you to tell the person who is at risk  if pt still refuses then you should breach confidentiality
      • STD’s – have to inform the sexual partner  try to figure out a way and make the patient and partner to come to the office  if it does not work, you should report to public health and allow contact tracing
      • “ However, confidentiality, like other ethical duties, is not absolute. It may have to be overridden to protect individuals or the public or to disclose or report information when the law requires it. The physician should make every effort to discuss the issues with the patient. If breaching confidentiality is necessary, it should be done in a way that minimizes harm to the patient and that heeds applicable federal and state law” ( ACP Ethics)
      • “ Sometimes, a physician receives information from a patient's friends or relatives and is asked to withhold the source of that information from the patient  The physician is not obliged to keep such secrets from the patient  The informant should be urged to address the patient directly and to encourage the patient to discuss the information with the physician”
      • “ The physician should use sensitivity and judgment in deciding whether to use the information and whether to reveal its source to the patient. The physician should always act in the best interests of the patient.”
    • Case Study
      • 45 year old man is hospitalized with gastroenteritis. You get paged by the nurse saying the family is on the phone and wishes to speak with you. When put through, the family wants to know what illness it is and how he is doing. you will... a) Tell the family the condition of the patient and take time to answer their questions b) Ask the family to come in the next day so you can tell them in person as you are busy right now c) Refer the family to the nurse educator so she can do a better job d) Refuse to answer the family's questions until you have had a chance to confer with the patient.
    • Medical Records
      • Medical records should contain accurate and complete information.
      • Ethically and legally, patients have the right to know what is in their medical records.
      • The physician must release information to the patient or to a third party at the request of the patient. Information may not be withheld because of nonpayment of medical bills.
      • Physicians should retain the original of the medical record and respond to a patient's request with copies or summaries as appropriate unless the original record is required.
      • To protect confidentiality, information should be released only with the written permission of the patient or the patient's legally authorized representative, or as required under applicable law.
      • If a physician leaves a group practice or dies, patients must be notified and records forwarded according to patient instructions
    • Case Study
    • Disclosure
      • Disclose the information to pt whenever it is considered material to the patient's understanding of his or her situation, possible treatments, and probable outcomes.  this information often includes the costs and burdens of treatment, the experience of the proposed clinician, the nature of the illness, and potential treatments.
      • However uncomfortable for the clinician, information that is essential to and desired by the patient must be disclosed.
      • Upsetting news and information should be presented to the patient in a way that minimizes distress
      • If the patient cannot comprehend his or her condition, it should be fully disclosed to an appropriate surrogate
      • Should you admit your mistake?  ALWAYS DISCLOSE THE ERRORS YOU HAVE COMMITTED TOO!!! That might not only reduce the risk of lawsuit but builds trust in relationship.
    • Religious beliefs
      • Be accepting of benign folk medicine practices.
      • Your goal is to make the patient comfortable.
      • Ask the pt’s religious beliefs if you are not sure. If possible participate in them because religion is a source of comfort to many.
      • Patients who pray and who are prayed for have better outcomes.
      • Refusal of blood products by a competent jehovah’s witness pt is acceptable.
    • If pt request alternative medicine?
      • “ The physician should encourage the patient who is using or requesting alternative treatment to seek literature and information from reliable sources. The patient should be clearly informed if the option under consideration is likely to delay access to effective treatment or is known to be harmful. The physician should be aware of the potential impact of alternative treatment on the patient's care. The patient's decision to select alternative forms of treatment should not alone be cause to sever the patient-physician relationship. “
    • Disability Certification
      • Disability evaluation forms should be completed factually, honestly, and promptly.
      • Physicians will often find themselves confronted with a patient whose problems may not fit standard definitions of disability but who nevertheless seems deserving of assistance (for example, the patient may have very limited resources or poor housing). Physicians should not distort medical information or misrepresent the patient's functional status in an attempt to help patients.  Doing so jeopardizes the trustworthiness of the physician, as well as his or her ability to advocate for patients who truly meet disability or exemption criteria
    • Informed consent
      • Always obtain informed consent. This requires that the pt has received and understood 5 pieces of information.
      • Nature of procedure
      • Purpose of procedure
      • Benefits
      • Risks
      • Availability of alternatives
      • Informed consent can be oral, written consent can be revoked orally at any time.
    • Exceptions to informed consent
      • Emergency
      • Waiver by patient
      • “ Competence” is a legal term
      • Patient does not have “capacity”  meaning the patient attempts suicide, pt is grossly psychotic and dysfunctional, pts physical and mental state prevents simple communication.
      • If you are unsure, assume that pt is competent
    • Withholding/ Withdrawing Care Ethical concerns
    • Withdrawing Care
      • Withdrawing and withholding treatment are equally justifiable, ethically and legally.
      • Do not withhold Rx because of the mistaken fear that if they are started, they cannot be withdrawn.  This practice would deny patients potentially beneficial therapies.
      • Instead, use a time-limited trial of therapy to clarify the patient's prognosis. At the end of the trial, you can hold a conference to review and revise the treatment plan
      • Some health care workers or family members may be reluctant to withdraw treatments even when they believe that the patient would not have wanted them continued  You as a physician should try to prevent/ resolve these situations by addressing with families their feelings of guilt, fear, and concern that the patient may suffer as life support is withdrawn.
    • Incompetent Patient
      • If a pts condition is life threatening and the physicians believe that the pt lacks the capacity to decide, emergency facilities have a policy to override refusals of life saving therapy by incapacitated patients.
      • Also consider this if pt is suffering mental disorder like infections that makes her dangerous to herself, involuntary treatment for mental disorder may also be justified.
      • If the pt is legally competent they have absolute right to refuse. You have to withhold care even if it is life saving.
      • “ Patients without decision-making capacity have the same rights concerning life-sustaining treatment decisions as mentally competent patients. Treatment should conform to what the patient would want on the basis of written or oral advance care planning. If these preferences are not known, care decisions should be based on the best evidence of what the patient would have chosen (substituted judgments) or, failing that, on the best interests of the patient. “
      • Always Discuss “ADVANCED care planning with the patient!
      • You are called to obtain surgical consent from an 84-year-old man who is hospitalized after suffering a right femoral neck fracture, for repair of that fracture. The patient has a long history of multi-infarct dementia and major depression. He lives with his daughter and her husband. They report to you that he lost his footing while walking and suffered a fall. There was no loss of consciousness and no evidence by history that the fall was syncopal in nature. You read the psychiatric evaluation in his chart that notes that the patient, despite some dementia, confusion, and odd mannerisms, is competent to make his own medical decisions and fully understands the nature of his condition. When you enter the room to obtain consent from the patient for surgery, he responds with situation-inappropriate responses, fails to make eye contact with you, and is not oriented to place or time. The patient has no power of attorney or health care proxy listed in his medical record. The most appropriate course of action is to
      • A. call a family member to consent for the patient
      • B. consent the patient for surgery, he has been cleared by psychiatry
      • C. consent the patient for surgery with a note explaining his condition in the chart
      • D. do not consent the patient for surgery
      • E. perform your own competency test on this patient
      • A 67-year-old woman has suffered a massive subarachnoid hemorrhage. The patient was well until three days prior when she had a sudden loss of consciousness. After emergent transport to the local hospital where her trachea was intubated and a CT scan disclosed a large grade 4 subarachnoid bleed, she was transferred to the intensive care unit. Over the past 72 hours her condition is unchanged. She in nonresponsive to deep painful stimulus, there is no dolls' eye or gag reflex, and corneal blink reflex is absent. She has had no narcotics, analgesics, or paralytics. There is discord present within the family about whether to withdraw care. The husband desires care to be withdrawn whereas the children want to continue maximal supportive care. You explain that the most important determining factor in helping to direct future care is
      • A. the decision of a court appointed legal guardian
      • B. the decision of the medical and nursing team taking care of the patient
      • C. the husband's wishes given that he is the health care proxy
      • D. the opinion of the hospital ethics committee
      • E. the patient's previously expressed wishes regarding life support if known
    • End of life Care
      • Do nothing to actively assist the pt to die sooner.
      • Allowing the pt is die is acceptable ,active killing is unacceptable.
      • Do all you can to reduce the pts suffering ex by giving pain medication.
      • Patients decide when treatment stops not the physicians.
    • Medical Futility
      • If there are no treatment options i.e. the pt is cortically dead and the family insists on treatment – if there is nothing that the physician can do; treatment must stop.
      • If physician thinks that continued treatment is futile – the pt shows no improvement , but surrogate insists on continuing treatment – the treatment should continue.  but refer to ethics committee
      • “ In the unusual circumstance that no evidence shows that a specific treatment desired by the patient will provide any benefit from any perspective, the physician need not provide such treatment.”
      • “ The more common and much more difficult circumstance occurs when the treatment will offer some small prospect of benefit at a great burden of suffering or financial cost, but the patient or family nevertheless desires it  If the physician and patient (or appropriate surrogate) cannot agree on how to proceed, there is no easy, automatic solution. Consultation with colleagues or with an ethics committee may be helpful.  Timely transfer of care to another care provider who is willing to pursue the patient's preference may resolve the problem. Infrequently, resort to the courts may be necessary. ““
    • Issues With Minors
    • Case study
      • A 17-year-old girl comes to the office for a complete physical examination before going off to college. You have been the physician for her and her brother since birth, and for both her parents for the past 20 years. The patient has been very healthy and has had all of her immunizations. Her mother is always in the waiting room as you obtain the history and perform the physical examination. The patient admits to you that she has had her first sexual experience after the prom a few weeks ago. After she tells you this she becomes very worried that you will tell her mother. At this time you should
      • A. advise her to tell her mother herself so you will not have to tell her
      • B. explain that you will not bring up the issue but that you cannot lie if the mother specifically asks if her daughter is sexually active
      • C. perform a pelvic examination and obtain a Pap smear specimen
      • D. tell the patient that your conversations with her will remain confidential
      • E. try to convince her to talk about these issues with her mother
      • Explanation:
    • Ans.D
      • In establishing and maintaining a good physician-adolescent relationship, the physician should tell the patient that their conversations will remain confidential. This way, the adolescent will be able to trust the physician and will be willing to discuss issues, such as sexuality, that they do not want their parents to know about, but that may affect their health.
      • An exception to the confidentiality rule is the duty to warn and protect a third party from violence or infectious conditions, such as tuberculosis and syphilis.
    • Issues with Minors
      • Children less than 18 yrs are minors and are legally incompetent.
      • Parents cannot withhold life or limb saving treatments from their children.
      • If they refuse
          • Immediate emergency  treat
          • Not immediate , but still critical  refer to ethics committee or seek court intervention. The child is declared a ward of the court and court grants permission. Eg:- juvenile diabetes
          • Not life or limb threatening  listen to parents.
          • Childs refusal is irrelevant unless pt is an emancipated minor
    • Emancipated Minors
      • Statutes in every state  known as minor consent statutes/ medical emancipation statutes  authorize minors to consent to care based either on their status or based on the specific service they are seeking.
      • The following are the categories of minors authorized to consent to medical care
          • emancipated minors (sometimes defined as those who are married, who are pregnant, who are parents, who have served in armed forces, are living apart and financially independent from their parents)
          • married minors;
          • minors in the armed forces;
          • mature minors;
          • minors living apart from their parents ( if older than 13 yrs) ;
          • high school graduates;
          • pregnant minors
          • minor parents.
      • The idea behind this is that because these minors are no longer under effective parental supervision, parental consent is not a sensible precondition to accessing care.
    • Services which don’t need parental consent
      • There are some health services for which any minor can give consent. The various services for which minors are authorized to give consent in one or more states in the USA are: • emergency care; • prenatal care; • contraceptive services; • abortion; • diagnosis or treatment of venereal or sexually transmitted diseases; • diagnosis or treatment of reportable, infectious, contagious or communicable diseases; • HIV/AIDS testing or treatment; • counseling or treatment for drug- or alcohol-related problems; • collection of medical evidence or treatment for sexual assault; and • in- or outpatient mental health services.
      • “ If a patient who is a minor requests termination of pregnancy, advice on contraception, or treatment of sexually transmitted diseases without a parent's knowledge or permission, the physician may wish to attempt to persuade the patient of the benefits of having parents involved , but should be aware that a conflict may exist between the legal duty to maintain confidentiality and the obligation toward parents or guardians  Information should not be disclosed to others without the patient's permission . In such cases, the physician should be guided by the minor's best interest in light of the physician's conscience and responsibilities under the law. “ ( ACP Ethics )
    • Case Study
      • 1) ] A 4-year-old boy has just had his second generalized tonic-clonic seizure in a 4 month period. You have recommended starting an anticonvulsant. The parents have concerns about the recommended medication and would prefer to wait and see if their son has more seizures. Your next step would be: A) Comply with parents wishes B) Start anticonvulsants C) refer to ethics committee D) seek legal advise from hospital attorney E) Seek court support to start the patient on medications
      • Ans. A ( Not life threatening)
    • Case Study
      • A 6-year-old with a fractured forearm is brought to the emergency room by her baby-sitter. Both the baby-sitter and emergency room staff have attempted to reach her parents to get their consent for treatment without success. Your next step: A) Await for the parents to call back B) Keep trying to reach the parents C) Refer to ethics committee D) Take a consent from patients baby sitter before treatment E) Get an x-ray of the forearm and treat the fracture appropriately
      • Ans E. Pain and possibility of deformity
    • Case Study
      • 9 year old girl is brought to the ER for a foot infection which looks serious. She needs IV antibiotics and debrideent, or you know that her foot is in danger of amputation. the mother refuses consent for antibiotics and debridement. You discuss the need for immediate treatment and the risks in the presence of a witness. But mother still refuses the treatment. Your next step: 1) order the antibiotic and the debridement, overruling the mother. 2) Get an emergency court order 3) get an emergency ethics consult 4) agree with the mother and not give the treatment
      • Ans. 1  limb threatening
    • Case Study
      • 10 year old girl who is a Jehovah's witness is brought to the ER after a car accident. She needs IV fluids and transfusions. The mother refuses consent for fluids and transfusions, saying its against her religion. Your next step: 1) order the fluids and transfusions, overruling the mother. 2) Get an emergency court order 3) get an emergency ethics consult 4) agree with the mother and not give the treatment
    • Ans. A
      • If there is a clear and imminent threat to life, and a delay in treatment is likely to lead to the death of a child  healthcare professionals can overrule parents without judicial review (eg, in this case of a blood transfusion for a Jehovah's witness child with life-threatening bleeding after a MVA).
      • When differences of opinion arise between health care providers and parents and if there is time to obtain judicial review  Practitioner must first try to explain and convince the parents. If this fails, practitioners should approach courts for guidance and authority.
    • Sexual Relations Patient – Physician, Previous patient, Pediatrician – child’s parents
    • Case study
      • One of your 27 y/o female pt who is recently divorced has been making approaches towards you. She is one of the most beautiful women among your patients. She requests that you go for a date with her the following weekend. Your response should be: A) Tell her that you will transfer her to your friend's care so that you can get involved with her. B) Tell her its unethical for a physician to get involved with his own patients so you will not entertain such a thing C) Tell her you could go for a dinner this weekend but you will not get sexually involved as that part is unethical D) Tell her its not appropriate for her to make such advances towards her physician E) Tell her you could definitely get involved with her provided she signs a paper releasing you from any liability
    • Current Patient - Physician
      • It's unethical for a doctor to become sexually involved with a current patient, even if the patient initiates it
      • Ans. b
    • Case Study
      • 2) Lisa was one of your patients 2 years ago. While Lisa was in NJ she has been your regular patient for her depression. She trusts and respects you a lot. She even told you earlier that she would be very lucky if she could date a person like you at least once in her lifetime. She is a beautiful 25 year old whom any man would like at a first sight. You have lost contact with Lisa and she has not been your patient for past 2 years because she moved to Florida. She happens to meet you incidentally at a mall and requests that you go for a date with her the following weekend. Your response should be: A) Tell her that since she no longer your patient you can get involved with her. B) Refuse her proposal because its not ethical for you to do it C) Tell her you could go for a dinner this weekend but you will not get sexually involved as that part is unethical D) Tell her its not appropriate for her to make such advances towards her past physician E) Tell her you would definitely get involved with her provided she signs a paper releasing you from any liability.
    • Past patients
      • Relationships between patients and physicians may also include considerable trust, intimacy, or emotional dependence.
      • The length of the former relationship, the extent to which the patient has confided personal or private information to the physician, the nature of the patient's medical problem, and the degree of emotional dependence that the patient has on the physician, all may contribute to the intimacy of the relationship.
      • The extent of the physician's general knowledge about the patient (i.e., the patient's past, the patient's family situation, and the patient's current emotional state)  is also a factor that may render a sexual or romantic relationship with a former patient unethical
    • Past Patient
      • “ A sexual relationship with a former patient is unethical if the doctor "uses or exploits the trust, knowledge, emotions or influence derived from the previous professional relationship."
      • Ans. b
    • Case Study
      • You are a busy pediatrician in the city. 6 year old John has been your patient for past 3 years. John's mother Mary brings him to your office for a recent upper respiratory infection. You treat John appropriately but he gets to be admitted to the hospital for serious pneumonia. You continue to treat John at the hospital. One evening Marissa calls you and requests that you go out for dinner with her because she is feeling so alone and has been getting quite attached to you. Which of the following is most appropriate statement? A) You can go out with Mary because she is not your patient and you have never treated her in the past B) You may want to avoid going out with her because she might cling to you later on C) You should avoid relationship with her because there is potential for adverse effects on professional judgment and family member behavior concerning the patient's health. D) You should consult your colleague to take his advise on this issue
    • Pediatricians – Relations with child’s family
      • Pediatricians should maintain appropriate professional boundaries with the families of their patients
      • There is an inherent risk of exploitation for patients or family members who depend on the knowledge and authority of the physician
      • The success of the doctor-patient or doctor-parent relationship depends on the ability of the patient or family member to trust the physician completely.
      • Patients and family members legitimately expect to feel physically and emotionally safe in professional relationships with physicians.
      • They should not feel vulnerable to romantic or sexual advances while receiving medical care for themselves or their children.
      • Children should be free from concern that their treatment may be compromised by a nonprofessional relationship between a parent and their physician
    • Pediatricians – Relations with child’s family
      • “ The clinical judgment of physicians who become intimately involved with a patient or family member may become clouded and they may breach their professional responsibilities”.
      • Ans. C
    • Duty to Warn & Protect
      • The concept of a duty to warn and protect achieved widespread exposure following Tarasoff I and Tarasoff II .
      • In Tarasoff I,  If the clinician obtained information from his patient that an identified victim was at risk  he has a duty on the part to warn the intended victim, even if that meant breaking confidentiality.
      • Tarasoff II extended the concept  “ the duty to protect supersedes the duty to warn”  meaning “warning in itself may not ultimately be sufficient to protect the victim”
    • Reporting of Incompetent Colleague
      • Health care professionals who pose risk to patients must be removed from patient contact. Types of risk – infectious diseases, substance abuse, depression and incompetence.
      • Ask them to take time off, get them into treatment, contact their supervisors if necessary
      • HIV infected worker meets obligation to inform appropriate parties and modify work.
      • Always patient comes first.
      • “ Physicians provide medical care to health care workers, and part of this care is discussing with those workers their ethical obligations to know their risk for such diseases as HIV or viral hepatitis, to voluntarily seek testing if they are at risk, and to take reasonable steps to protect patients. The physician who provides care for a seropositive health care worker must determine that worker's fitness to work. In some cases, seropositive health care workers cannot be persuaded to comply with accepted infection control guidelines, or impaired physicians cannot be persuaded to restrict their practices. In such exceptional cases, the treating physician may need to breach confidentiality and report the situation to the appropriate authorities in order to protect patients and maintain public trust in the profession, even though such actions may have legal consequences . “
    • Case Study
      • A 33-year-old man with AIDS is brought by ambulance to the hospital after collapsing on the street. Paramedics resuscitated and intubated the patient for ventilatory support and transported him to the hospital while in an incoherent, agitated state. Physical examination and laboratory studies confirm an extensive pneumonia involving the entire left lung. Shortly afterwards, his designee demands that the patient be taken off the ventilator. The designee produces a copy of the patient’s living will indicating the patient wishes no life support and that his designee is to make all medical decisions if he becomes incapacitated. The patient’s previous hospital record contains a copy of the same living will. Which of the following is the best course of action?
      • ( A ) Maintain the patient on the ventilator
      • ( B ) Contact the patient’s parents
      • ( C ) Contact the hospital’s attorney
      • ( D ) Remove sedation and wean the patient
      • ( E ) Provide sedation and pain medication and extubate the patient
    • Ans. E
      • Unless there is evidence that a patient was not mentally competent when executing a living will, had a change of mind, or named another health care proxy to make medical decisions forhim or her, a designee has the right to make medical decisions on behalf of a patient, including termination of ventilatory support.
      • The patient has the right to make decisions about his own health care (principle of autonomy).
      • Ethically, there is no difference between withholding or withdrawing medical care
      • Although discontinuing mechanical ventilation may carry emotional repercussions, it is ethically no different than making the initial decision not to ventilate the patient. Bringing the patient’s parents into decision-making is contrary to the patient’s wishes. Although the parents are not prohibited from visiting the patient (unless he directed otherwise), the legal right to make decisions has been assigned to the designee and is not bound by a family relationship. If the patient executed the will properly, there are no grounds for the hospital attorney to take the matter to court. It is unlikely a court will consider the case.
      • The patient directed that no life support should be utilized, and delaying removal from the ventilator in an attempt to avoid resulting death does not comply with the patient’s wishes. If the patient is in pain or agitated and comfort medication is removed, the physician likely is acting in an unethical and, in some legal jurisdictions, an illegal manner
    • Duty to warn and protect
      • The counselor / doctor should call the police and should also try in every possible way to notify the potential victim of the potential danger.
      • First try to detain the patient making the threat. Next , call the police and finally notify and warn the potential victim.
      • All 3 actions should be taken or at least attempted.
    • DNR Status Verbal statement, Living will, Substituted judgment, Doctrine of durable attorney
    • DNR
      • DNR refers only to cardiopulmonary resuscitation. Must continue with ongoing treatments.
      • DNR discussions should always occur early in treatment . Explore the pts reasons for not wanting CPR. CPR is done in the absence of DNR order.
      • They are made by patient or surrogate (if the patient is incompetent)
      • A competent patient has every right to refuse even life saving hydration and nutrition.
      • If patient is INCOMPETENT physician may rely on the following –
      • Advance directives can be oral
      • Living will – written document expressing wishes
      • Health power of attorney – surrogate decision maker, speaks with patients voice. It beats all other decision rules.
      • When SURROGATE MAKES DECISION for pt the following should be used –
      • Subjective standard – it is actual intent , advance directive of pt. refers to what did the pt say in the past?
      • Substituted judgment – it says who best represents the pt? what would patient say if he/she could make a decision. If the pt is unable to decide a decision maker who is the best representative of the patients wishes must be substituted.
      • Best interests standard – used if the pt has always been incompetent or no one knows the pt well enough. Weighs the burden versus benefits. The issue here is not who makes the decision…but all persons applying the best interest standard should come to the same conclusion.
      • A 94-year-old man is transferred from his nursing home to the hospital because of an altered mental status over the past 10 days and little oral intake. His past medical history is significant for diabetes mellitus, coronary artery disease with 2 prior myocardial infarctions, congestive heart failure with an ejection fraction of 20%, and chronic renal insufficiency. He was diagnosed with a renal-cell carcinoma metastatic to the brain, lungs, and liver 1 month ago. His temperature is 37.8 C (100 F), blood pressure is 89/54 mm Hg, pulse is 128/min, and respirations are 36/min. His heart is tachycardic with a 2/6 systolic ejection murmur, lungs have coarse breath sounds bilaterally, and his abdominal examination is benign. It is felt that the patient will require endotracheal intubation in order to survive. However, the patient is transferred with a living will that was written up after his diagnosis with renal-cell carcinoma, which states that he does not want any extraordinary measures taken to prolong his life. Before a do not resuscitate (DNR) order is written, his son arrives and says that everything medically possible should be done in order to save his father's life. The most appropriate management at this time is to
      • A. call a family meeting and discuss with the son and any other family members why he or they would like to override the wishes of his father with regard to his terminal care
      • B. call the nursing home and have the patient transferred back
      • C. intubate the patient and admit him to the intensive care unit
      • D. politely ask the son to leave the room and start the patient on a morphine drip to keep him comfortable in his final hours
      • E. tell his son that there is no way you are going to listen to him or do anything to prolong the patient's life beyond the wishes set forth in the living will, then transfer the patient to hospice care
    • Ans.A
      • When a patient can no longer speak for himself or herself, it is always a very difficult ethical dilemma, when a close family member wants to override the wishes set forth by a patient in a living will. The best course of action is to get the appropriate parties together to have a logical discussion about why or why not, the wishes of the family member should be honored.. The original decision is often better thought out at a time of less emotional stress. Whereas, at a time when a patient may die, the family will often change their decisions about care, when the fear of losing a loved one is staring them in the face.
      • What will end up transpiring after a logical and calm discussion with the family will often vary. It is always desirable to honor the wishes of a living will. However, you never know when extenuating circumstances may exist. It is important to treat the patient and the family with the utmost respect. Telling the son that you won't listen to him (choice E), is inappropriate. Similarly asking the son to leave the room (choice D), politely or not, is also not appropriate.
    • Organ Donation
      • “ Another issue concerns who should make the organ request  Under federal regulations, all families must be presented with the option of organ donation when the death of the patient is imminent. To avoid conflicts of interest, however, those who will perform the transplant or are caring for the potential recipient should not be involved in the request. Physicians caring for the potential donor should ensure that families are treated with sensitivity and compassion. Previously expressed preferences about donation by dying or brain-dead patients should be sought. However, only an organ procurement representative who has completed training by an organ procurement organization may initiate the actual request. This can include physicians, if they have received specific training “
      • DON’T ACCEPT GIFTS FROM PHARMA
      • ACCEPTABLE THINGS INCLUDE EDUCATIONAL SEMINARS
    • END