Family Medicine Ethics.pdf

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A primary care physician is caring for a 77 year old patient with stage I V ovarian cancer, diagnosed 1 year prior to the current visit. She has been through numerous attempts at chemotherapy which were unsuccessful and after long discussions with family, she has chosen to participate in hospice care . On arrival, her vitals are within normal limits, she has a flat affect, but otherwise a normal physical exam . Within a minute of the encounter she eagerly asks the physician to give her "something to end it all."

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Which of the following is the most appropriate next step for the physician?

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A. Call the patient's daughter, who holds her power of attorney, and explain her mother's request so that the patient can have additional support at home

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B. Discuss with the patient her feelings and identify why she is asking for life-ending medication

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C. Provide the patient with a prescription for narcotics and anxiolytics to make her more comfortable

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D. Refer her to an outpatient palliative care physician to discuss options for her request E. Refer the patient to a psychiatrist, because how she is feeling may not be consistent with the normal grieving process

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The correct answer is B. 910/o chose this . Taking time to understand a patient's emotions and reasons for asking for life-ending measu res is the correct answer. Understanding why the patient has made such a r equest w ill help add ress the underlying problem . A is not correct. 2% chose this . Calling the woman's daughter without her permission violates patient privacy righ ts and should not be the physician's next step. The physician should discuss the problem w ith the patient and call family members only with the patient's permission . Physician Privacy

C is not correct. 4% chose this. Physician-assisted suicide is illegal throughout much of t he United States w ith the exception of several states . The physician should not provide the patient w ith medication that is intended to be life ending . Assisted suicide Suicide Physician United States

D is not correct . While it would certa inly be an option to refer the patient to outpatient pa lliative care, you wou ld first want to explore her specific feelings and thoughts around her request. Only after fully understand ing her wishes wou ld you consider additional input f rom palliative care (for a patient is al ready on hosp ice) . Palliative care Hospice Outpatient

E is not correct. 30/o chose this. Before immediately referrin g the patient to another physician, it is most appropriate to understand her emotional state and identify her underlying problem . Physician

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Item: 1 of 18 QID: 23214

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Physician Privacy

C is not correct. 4% chose this. Physician-assisted suicide is illegal throughout much of t he United States w ith the exception of several states . The physician should not provide the patient w ith medication that is intended to be life ending . Assisted suicide Suicide Physician United States

D is not correct. While it would certa inly be an option to refer the patient to outpatient pa lliative care, you wou ld first want to explore her specific feelings and thoughts around her request. Only after fully understand ing her wishes wou ld you consider additional input from palliative care (for a patient is al ready on hosp ice) . Palliative care Hospice Outpatient

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E is not correct. 30/o chose this. Before immediately referrin g the patient to another physician , it is most appropriate to understand her emotional state and identify her underlying problem • Physician

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Bottom Line: When physicians receive a request for euthanasia, an appropriate response is to cla rify the patient's request and attempt to understand why he or she is making the request. Only after th is discussion is made and patient perm ission is given shou ld additional providers or fam ily members become involved . Euthanasia

References: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed pp 115-116

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Item: 2 of 18 QID: 22759

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A 79-year-old woman is in the early stages of Alzheimer d isease. She has some m ild recent memory loss and difficu lty w ith everyday motor tasks, which has been prog ressive over 2 years . She has no living will and has not designated a durable power of attorney in the event that she becomes incapacitated .

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Which of the following statements r egard ing advance di rectives in patients with early Alzheimer disease is true?

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A. Fam ily members shou ld be allowed to decide on futu re t reatment plans

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B. It is impossible for these patients to make decisions regarding their health care due to loss of self-identity

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C. Patients generally do not have a sufficient level of executive function to designate a hea lth ca re proxy

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D. Substituted judgment should be applied to determ ine the patient's proxy

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E. The physician shou ld discuss the importance of advanced directives w ith respect to the patient's prognosis

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The correct answer is E. 78% chose this. Due to the relentlessly progressive nature of Alzheimer disease, it is important for patients to have a liv ing will or durable power of attorney. However, this does not need to occur before the onset of disease because the majority of patients still have the capacity for self-determination at the t ime of diagnosis . Treatment decisions are likely to be more in line with the patient's desires if the patient is involved early in deciding who should serve as a proxy. The physician should have a discussion with the patient regarding disease course and prognosis as soon as possible . Alzheimer's disease Advance healthcare directive Power of attorney Physician

A is not correct. 7% chose this. Fam ily members shou ld be involved in the discussion about future car e, but the patient should decide who will ult imately make treatment decisions.

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Family (biology)

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B is not correct. 30/o chose this . Patients with early Alzheimer disease still retain executive function and self-identity, and should be allowed to make health care decisions and select a proxy .

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Alzheimer's disease Executive functions

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C is not correct. 5% chose this. Patients with early Alzheimer disease still retain executive function and self-identity, and should be allowed to make health care decisions and select a proxy .

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Alzheimer's disease Executive functions

D is not correct. 7% chose this. Substituted judgment comes into play when a health ca re proxy is faced w ith a decision for an incompetent patient when that patient did not make any specific requests pertaining to the situation . Substituted judgment cannot be used to choose a health care proxy. Healthcare proxy Proxy marriage Proxy (climate) Proxy server

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Family (biology)

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B is not correct. 30/o chose this . Patients with early Alzheimer disease still retain executive function and self-identity, and should be allowed to make health care decisions and select a proxy.

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Alzheimer's disease Executive functions

C is not correct. 5 % chose this . Patients with early Alzheimer disease still retain executive function and self-identity, and should be allowed to make health care decisions and select a proxy. Alzheimer's disease Executive functions

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D i s not correct. 7 % chose this . Substituted judgment comes into play w hen a health care pr oxy is faced w ith a decision for an incompetent patient when that patient did not make any specific requests perta ining to the situation . Substituted judgment cannot be used to choose a hea lth care proxy. Healthcare proxy Proxy marriage Proxy (climate) Proxy server

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Bottom Line : Due to the relentlessly progressive nature of Alzheimer disease, it is important for patients to have a liv ing will or durable power of attorney. The physician shou ld have a discussion with the patient regarding disease course and prognosis as soon as possible. Alzheimer's disease Power of attorney Advance healthcare directive Physician

References: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed p 115

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A 32-year-old woman presents to her primary care physician's office complain ing of dysu ria, urgency, and frequency. The ~~AI physician prescribes an antibiotic for a presumed urinary tract infection . A few hours later, the pharmacist contacts the physician's office because she notices that the amount of antibiotics the physician prescribed is 10 times the usual dose given for urinary tract infection . The physician admits that she was distracted by having so many patients wa iti ng to be seen and must have accidentally added an extra zero .

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What is the most appropriate next step for the physicia n?

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A. Ask the pharmacist to send the patient back to the clinic for a reevaluation and a new prescription

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B. Call the patient to explain what happened and apologize for the error, then fax a new prescription to the pharmacy

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C. Fax the pharmacy a new prescription and avoid discussing the error with the patient to ma intain the patient's trust

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D. Have the pha rmacist explain the error to the patient wh ile you remain on the phone as w itness, then have the pharmacist dose the medication correctly

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E. Thank the pharmacist and r eturn to seeing patients; the pharmacist w ill tell the patient about the error

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The correct answer is B. 880/o chose this . The physician has an obligation to fully disclose any errors made in patient care . The most effective and responsible way to do this is to call the patient immediately, explain what happened, and apologize . This is particularly easy in this case because no harm was done. Furthermore, acknowledgment of an error and an apology can help the physician avoid litigation . Physician Lawsuit

A is not correct. 5% chose this . Even though no harm was done with this error, it is appropriate and responsible to inform the patient about the error and to correct it without having the patient repeat an entire evaluation . Cis not correct. 1% chose this. Faxing the pharmacy a new prescription is appropriate . However, the physician should also inform the patient of the error.

The trust in a patient-doctor relationship depends on honest communication . Pharmacy Physician

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D is not correct. 4% chose this. It is the physician's responsibility to disclose the error directly to the patient . Physician

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E is not correct. 20/o chose this .

It is the physician's responsibility to disclose the error directly to the patient; she should not rely on someone else to do so . Physician

Bottom line:

The physician has an obligation to fully disclose any errors made in patient care . The most effective and responsible way to do this is to contact the patient immediately, explain what happened, and apoloqize . Lock

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Physician Lawsuit

A is not correct. SOfo chose this. Even though no harm was done w ith this error, it is appropriate and responsible to inform the patient about the error and to correct it without having the patient repeat an entire evaluation .

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Cis not correct. 1% chose this. Faxing the pharmacy a new prescription is appropriate . However, the physician should also inform the patient of the error. The t rust in a patient-doctor relationship depends on honest commun ication .

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Pharmacy Physician

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D is not correct. 4% chose this. It is the physician's responsibility to disclose the error directly to the patient .

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Physician

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E is not correct. 20/o chose this .

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It is the physician's responsibility to disclose the error directly to the patient; she should not rely on someone else to do so .

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Physician

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Bottom line: The physician has an obligation to fully disclose any errors made in patient care . The most effective and responsible way to do this is to contact the patient immediately, explain what happened, and apologize . Physician

Ref er en ces: FA Step 2 CK 9th ed p 129 FA Step 2 CK 8th ed pp 116- 117

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An 87-year-old woman r eturns to the hospital for the fourth t ime this year. She has severe peripheral vascular disease from her diabetes, and she had a femoral-popliteal bypas:s this past spring . Since then she has been living in a nursing facility, and her mental status has been waxing and wan ing . She is a pleasant elderly woman who recognizes her family members. However, although the attending physician introduces himself daily, the patient never remembers the physician's name, and usually forgets who her attending physician is. During this hospitalization, the patient becomes unstable and is moved into the intensive care unit. Because a Do Not Resuscitate (DNR) form does not exist, the physician asks the family about the patient's desires . The patient's son presents signed and witnessed documentation that indicates he is the designated health care proxy. He is rea dy to sign the DNR/Do Not Intubate form, saying that, "I don't want her to suffer anymore. The past 9 months have been so difficu lt. She's not the woman she was just a year ago, and she wouldn 't want to live this way."

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Which of the following is the appropriate next step?

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A. Continue to treat the patient until the patient recovers enough and is able to sign a DNR form on her own . B. Find another r elative to corroborate the patient's desires

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C. Go to the ethics committee with this issue

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D. Help the son fill out the DNR form

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E. Take the son to court

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The correct answer is D. 810/o chose this. The patient has designated her son as her hea lth care proxy. Because she is no longer able to make decisions on her own, the physician must lega lly follow the decisions of the hea lth care proxy.

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Healthcare proxy

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A is not correct. 7% chose this . If it is possible for the patient to survive this episode with a little assistance from a respirator, the physician may inform the health care proxy of this and try to convince him to wait a few days to make a decision. However, the physician must ultimately honor the son's decision as the health care proxy.

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Healthcare proxy

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B is not correct. 70/o chose this. The son is the patient's designated health care proxy. He thus has the authority to make decisions for the patient, and corroboration from a relative is not necessary. Healthcare proxy

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C is not correct. 40/o chose this.

This situation is straightforward and does not need the involvement of the ethics committee . Ethics National Health and Medical Research Council

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E is not correct. 10/o chose this . The son has documentation that would hold up in a court of law. Going to court would not be helpfu l in this situation . Bottom line: A patient's duly designated health care p roxy has the authority to make decisions on the patient's behalf. Healthcare proxy Proxy marriage Proxy (climate)

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Healthcare proxy

A is not correct. 7% chose this. If it is possible for the patient to survive this episode with a little assistance from a respirator, the physician may inform the

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health care proxy of this and try to convince him to wait a few days to make a decision . However, the physician must ultimately honor the son's decision as the health care proxy.

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Healthcare proxy

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B is not correct. 70/o chose this. The son is the patient's designated health care proxy. He thus has the authority to make decisions for the patient, and corroboration from a r elative is not necessary.

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Healthcare proxy

C is not correct. 4% chose this. This situation is straightforward and does not need the involvement of the ethics committee . Ethics National Health and Medical Research Council

E is not correct. 10/o chose this . The son has documentation that would hold up in a court of law. Going to court would not be helpfu l in this situation .

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Bottom line: A patient's duly designated health care p roxy has the authority to make decisions on the patient's behalf. Healthcare proxy Proxy marriage Proxy (climate)

References: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed p 115

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A 75-year-old man with no advance directives has a diagnosis of metastatic lung cancer confirmed on multiple biopsies and CT scans . The man's wi fe finds him unresponsive in bed and calls an ambulance. The man is intubated by the paramedics, and a CT scan in the emer gency department shows hern iation of the bra in stem through the foramen magnum . After a lengthy discussion with the patient's physicians, the man's wife decides to withdraw ventilatory support with the understanding that her husband will likely die .

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Which of the following is the correct term for the withdraw al of support in this setting?

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A. Involuntary active euthanasia

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B. Palliative sedation

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C. Passive euthanasia

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D. Physician-assisted suicide E. Voluntary active euthanasia

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The correct answer is C. 580/o chose this. Passive euthanasia is defined as the w ithdrawing or w ithhold ing of life-sustain ing medical treatment(s) from a patient, with the patient's informed consent. A health proxy can also provide the informed consent. Examples of such treatments include mechanical ventilation, artificial nutrition, or vasopre ssor s. Passive euthanasia is legal in the United States and most other developed countries. Th is is the correct answer for this v ignette, in wh ich the patient is wholly dependent on the mechan ical ventilator for his re spiration and his proxy makes the informed decision to w ithdraw this life-susta ining treatment . Mechanical ventilation Euthanasia Informed consent Medical ventilator Vasoconstriction Developed country Nutrition Feeding tube United States

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A is not correct. 140/o chose this . Involuntary active euthanasia is the administration of med ication or an intervention w ith the intent to cause death in a patient who is competent to consent but did not. Involuntary active euthanasia is illegal. This is not the correct answer because no additional medication or intervention was administered, and it was not involuntary (ie, the patient's proxy provided consent) .

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Euthanasia

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B is not correct. 120/o chose this. Palliative sedation is the administrati on of medication with the intent to reli eve pain, shortness of breath, or another symptom w ith the incidental consequence of respiratory depression that may result in the patient's death . The important featu re is that the physician has no intent to increase the risk of the patient's death . Although not a form of euthanasia, it is sometimes referred to as indirect euthanasia . Palliative sedation is lega l in the Un ited States and most other developed countries. Th is is not the correct answer because the patient in the question vignette is not receiving palliative sedation, but a life-sustaining treatment is being terminated .

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Hypoventilation Palliative sedation Sedation Euthanasia Pharmaceutical drug Dyspnea Symptom Palliative care Physician Major depressive disorder Depression (mood) United States

D is not correct. 3% chose this. Physician-assisted suicide (PAS), also known as physician-assisted death, is defined as when a physician provides medication and a prescription to a patient, at the patient's request, knowing that the patient intends to use them to commit suicide . In the United States, PAS is legal in Oregon, Montana, Washington, Vermont, and California . PAS is not the correct answer Lock

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referred to as indirect euthanasia . Palliative sedation is legal in the United States and most other developed countries. This is not the correct answer because the patient in the question vignette is not receiving palliative sedation, but a life-sustain ing treatment is being terminated .

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Hypoventilation Palliative sedation Sedation Euthanasia Pharmaceutical drug Dyspnea Symptom Palliative care Physician Major depressive disorder Depression (mood) United States

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D is not correct. 3% chose this. Physician-assisted suicide (PAS), also known as physician-assisted death, is defined as when a physician provides medication and a prescription to a patient, at the patient's request, knowing that the patient intends to use them to commit suicide . In the United States, PAS is legal in Oregon, Montana, Washington, Vermont, and California . PAS is not the correct answer because neither the patient nor his wife requested a medication to end the patient's life .

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Assisted suicide Vermont Montana Euthanasia Oregon United States California Physician

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E is not correct. 13% chose this. Voluntary active euthanasia (VAE) is defined as the intentional administration of a medication or an intervention to cause a patient's death with his or her informed consent. VAE is illegal in the United States. VAE is not the correct answer because there is no additional medication or intervention being given to this patient.

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Euthanasia Informed consent Pharmaceutical drug United States

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Bottom line: Passive euthanasia is defined as the w ithdrawing or w ithholding of life-sustain ing medical treatment from a patient, after the patient (or the patient's proxy) has given informed consent. It is legal and ethical in the United States . Euthanasia Informed consent United States

References: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed p 116

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An 84-year-old man has been hospita lized with pancreatit is in the setting of an alcoholic binge. He has been evaluated and determined incapable of making his own medical decisions . He has never been married and does not have a living will. A During a previous hospital stay, the patient signed a document giving durable power of attorney to his next-door neighbor. The patient's nephew arrives at the hospital and demands that his uncle be admitted to an alcohol r ehabilitation center. A close friend of the patient pu lls the physician aside and r eveals that the nephew has been estranged from his uncle's side of the family for several years .

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What is the most reliable source for determining this patient's health care wishes?

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A. Durable power of attorney

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B. Friend of 35 yea rs

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C. Medical team

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D. Nephew

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E. Personal physician

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The correct answer i s A. 880/o chose this. The person given durable power of attorney is responsible if a living will has not been made . However, in an acute medical decision situation without an appointed durable power of attorney, spouse, adult ch ildren, parents, adult siblings, friends, and personal physicians can be in charge of medical decisions . Order of medica l decision making when the patient is incapacitated: Living will-> power of attorney-> spouse - > adu lt children - > parents - > adult siblings-> friends - > personal physicians.

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Advance healthcare directive Power of attorney Attorney at law Attorneys in the United States

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B is not correct. ]Ofo chose this . The friend would be able to help with an acute med ical decision if no other family member cou ld be contacted but the friend is not the best choice for making medical decisions in this situation given the patient's history.

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C is not correct. 20/o chose this . The current medical team is not responsible for determ ining the patient's healthcare wishes in this situation . The medical team is responsible for contacting the appropriate person in order to assist in decision making . D is not correct. 2% chose this . The nephew is not a first-degree relative and therefore does not take precedence over the other available persons in this situation . Consanguinity

E i s not corr ect. 1 0/o c hose th is. The personal physician would be the last step in the order of decision making for th is patient. Physidan

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Advance healthcare directive Power of attorney Attorney at law Attorneys in the United States

B is not correct.

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chos e this .

The friend would be able to help with an acute medical decision if no other family member cou ld be contacted but the friend is not the best choice for making medical decisions in this situation given the patient's history. C

is not correct. 20/o chos e this .

The current medical team is not responsible for determining the patient's healthcare wishes in this situation . The medical team is responsible for contacting the appropriate person in or der to assist in decision making . D is not correct. 2% chos e this . The nephew is not a first-degree r elative and therefore does not take pr ecedence over the other available persons in this situation . Consanguinity

E is not correct. 1 0/o c hose th is . The per sonal physician would be the last step in the order of decision making for th is patient. Physician

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Bottom line : The per son given durable power of attorney is responsible for medical decisions if a living will has not been made. Power of attorney Advance healthcare directive lawyer

References: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed p 116

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An 89-year-old woman is diagnosed with metastatic breast cancer to the lungs, bone, and brain. Four months after diagnosis, the patient is admitted to the hospital with excruciating bone pain and changes in her mental status .

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What term refers to the adm inistration of morph ine to reli eve this pain w ith the incidenta l consequence of causing r espiratory depression and death?

6

•7 •8

A. Indirect euthanasia B. Involuntary active euthanasia

•9 • 10

C. Nonvoluntary active euthanasia

• 11

D. Passive euthanasia

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E. Volunt ary act ive euthanasia

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• 15 • 16 • 17 • 18

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The correct answer i s A. 480/o chose this. The adm inistration of morph ine or other medications to r elieve pain with the incidental consequence of causing respiratory depression leading to death is know n as indirect euthanasia and is legal everywhere in the United States. Hypoventilation Morphine Euthanasia

~1ajor

depressive disorder Depression (mood) United States

5 6

7 •8 •9

B is not correct. 1 30/o chose th is. Involuntary active euthanasia involves intentionally giving medications or interventions to cause a patient's death w hen the patient is competent to consent but does not . Euthanasia

• 11

C is not correct. 100/o chose this . Nonvoluntary active euthanasia involves providing these med ications or interventions to a patient who is incapable of consent.

• 12

Euthanasia

• 13

D i s not correct. 240/o chose this . Passive euthanasia is the withholding or withdrawing of !fi fe-susta ining treatments to let a patient die.

• 10

• 14

• 15

Euthanasia Euthanasia in India Passive euthanasia

• 16

E i s not corr ect. SO/o c hose th is . Voluntary active euthanasia is defined as the intentional administration of medication or of an intervention to cause a patient's death with their informed consent .

• 17 • 18

Euthanasia Informed consent

Bottom line : The adm inistration of morph ine or other medications to r elieve pain with the incidental consequence of causing respiratory depression leading to death is know n as indirect euthanasia. l-lvnn\/g.ntil::atinn Mnmhin,c. l=uth::an::ac:;i::a M::ainr

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Involuntary active euthanasia involves intentionally giving medications or interventions to cause a patient's death when the patient is competent to consent but does not.

3

Euthanasia

4

5 6

7 •8

C is not correct. 100/o chose this. Nonvoluntary active euthanasia involves providing these medications or interventions to a patient who is incapable of consent. Euthanasia

•9

D is not correct. 240/o chose this . Passive euthanasia is the withholding or withdrawing of lute-sustaining treatments to let a patient die .

• 10

Euthanasia Euthanasia in India Passive euthanasia

• 11

• 12

E is not correct. SOlo chose this .

Voluntary active euthanasia is defined as the intentiona l admin istration of medication or of an intervention to cause a

• 13

patient's death with their informed consent.

• 14

Euthanasia Informed consent

• 15 • 16 • 17 • 18

Bottom line: The administration of morphine or other med ications to relieve pain with the incidental consequence of causing respiratory depression leading to death is known as indirect euthanasia . Hypoventilation

~1orphine

Euthanasia Major depressive disorder Depression (mood)

References: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed p 116

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An 86-year-old man presents to his family physician for an annual check-up . His only medica l cond it ion is hypertension controlled with a diuretic and a ~-blocker. He has had regu lar screen ings for colon cancer and prostate cancer. He lives w ith his wife, who is 82 years old and also in good health . When the physician asks the patient about advance directives, he states that he has been putting it off because he is healthy and does not want to think about death . When encouraged, the patient responds that if he were to become incapacitated, he would want his wife to make medical decisions for him . What type of advance directive is the patient describing?

•8 •9

A. Durable power of attorney

• 10

B. Instructional directive

• 11

C. Living will

• 12 • 13 • 14

D. Medical futility E. Values history

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The correct a nswer i s A. 620/o chose t h is. Durable power of attorney is a type of advance directive that goes into effect if a patient becomes incapable of making medical decisions . In that event, the designated proxy assumes legal responsibility for all decisions regarding the patient's care. Although the durable power of attorney transfers decision-making capacity to another individua l, the choice of proxy must be made while the patient retains his or her own decision- making capacity. In cases such as Alzheimer's disease, for instance, it is imperative that the health care proxy be designated early in the course of the disease, before dementia makes it impossible for the patient to do so .

•9

Alzheimer's disease Advance healthcare directive Healthcare proxy Power of attorney Dementia

• 10

B is not correct. 2 2 0/o chose t h is. Instructional directive is a modification of a living will , in which the patient decides on a certain treatment modality given several specific clin ical scenarios . The scenarios may include coma with no chance of recovery, coma with chance of partial recovery, advanced dementia with concurrent term inal ill ness, and so forth .

• 11

• 12 • 13 • 14

• 15 • 16 • 17 • 18

Dementia Advance healthcare directive Coma

C i s not corr ect. 100/o chose this . A living will also goes into effect if a person becomes incapacitated. However, instead of designating a second party to make decisions, it allows an individual to describe what measures should be taken given certain medical cond it ions. However, these desires are often vague and apply to the dying patient, not one who is simply demented or otherwise medically stable and incapacitated. In most states, living wills carry moral weilght, but individual decisions must still be made for each specific clin ica I situation . Advance healthcare directive

D is not correct. 4 % chose this. Medical futility refers to situations in which treatment would not achieve the desired outcome for a patient. The determination of futility rests on the treatment goals for the patient, which can vary between individuals, particu larly among family members and physicians . The patient in the vignette is not in a medical situation in which medical futility would be a concern. Lock

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decisions, it allows an individual to describe what measu r es should be taken given certain medical condit ions. However, these desires are often vague and apply to the dying patient, not one who is simply demented or otherwise medically stable and incapacitated . I n most states, living w ills carry moral weilght, but individual decisions must still be made for each specific din ica I situation . Advance healthcare directive

D i s not correct. 4 % chose this. Medical futility refers to situations in which treatment would not achieve the desired outcome for a patient. The determination of futility rests on the t reatment goals for the patient, w hich can vary between individuals, particu larly among fam ily members and physicians . The patient in the vignette is not in a med ical situation in which medical futility would be a concern .

•9

Futile medical care

• 10

E i s not corr ect. 2 0/o c hose th is . A values history makes use of a questionna ire in which the patient outlines certain beliefs that may be helpful in determining how he or she would want to die. The areas of inquiry often include religious beliefs, views on independence and autonomy, and attitudes concerning health and hea lth ca re prov iders. These quest ionnaires ar e often helpfu l for patients, but it is unclear how the information shou ld gu ide physicians in t r eatment decisions .

• 11

• 12 • 13 • 14

• 15 • 16 • 17 • 18

Bottom Line : Durable power of attorney is a type of advance directi ve that goes into effect if a patient becomes incapable of making medical decisions . In that event, the designated proxy assumes legal responsibility for all decisions r ega rding the patient's care. Advance healthcare directive Power of attorney Attorneys in the United States Attorney at law Lawyer

References: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed p 116

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A 33-year-old man who has AIDS is brought to the emergency department after he collapses outside his apartment. On admission, he is unconscious, his blood pressure is 149/99 mm Hg, heart rate is 115/min, respiratory rate is 9/min, and oxygen saturation is 84% . The patient is intubated and intravenous fluids are started . The patient is found to have Pneumocystisjiroveci pneumonia and his current CD4+ cell count is <170/mm 3 . The patient's brother arrives and states that the patient has expressed w ishes to withhold treatment at this stage of his disease . Assuming the patient rema ins unconscious, which of the following would best dictate the next step in management?

8 •9 • 10

A. A signed advance directive from 2 years ago stating that the patient wishes to refuse all treatment

• 11

B. A statement by the patient's brother indicating that the patient wishes to pursue any and all life-saving interventions

• 12 • 13

C. A statement by the patient's primary care physician indicating that the patient wishes to refuse treatment

• 15

D. An acquaintance to whom the patient granted power of attorney for the duration of his previous hospital stay 2 weeks ago requests that interventions be withheld

• 16

E. Initia l paperwork for an advance directive in conjunction with the brother's statement

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F. The brother's statements alone are sufficient to withhold new interventions, but ventilation and fluid treatment should continue

• 14

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5 6 7 8 9 • 10 • 11

• 12 • 13 • 14

• 15 • 16 • 17 • 18

The correct answer is A. 440/o chose this . A patient and family have the right to withhold treatment for ventilation, antibiotics, or fluids . There is no distinction between w ithholding and withdrawing life-supporting treatment. However, when the patient is not conscious, it is important to confirm the patient's wishes through prior legal documentation and to ensure that the relative is aware of the most recent decisions of the patient. Antibiotics

B is not correct. ] Ofo chose this . In the absence of a signed legal document, the patient's fam ily and friends are the first line of contact for decision-making regarding the patient's management. The order of precedence is usually 1) spouse, 2) adult children, 3) siblings, 4) other family members, 5) friend, 6) health care providers (in absence of other decision-makers) . C i s not correct. 4 % chose this. Although the patient's primary care physician may be ca llled upon to help make choices in management after family members

have been contacted, the physician's prior interactions with the patient alone are not enough to withdraw care . Primary care physician Primary care Physician

D i s not correct. 180/o chose this . Power of attorney can be granted by the patient to any person for a specific period of time, or permanently (durable power of attorney) . A person previously granted power of attorney holds no special decision-making rights once that specific period of t ime (previous hospitalization) has ended . Power of attorney Attorney at law Attorneys in the United States Lawyer

E i s not correct. 15% chose this. "Initial paperwork" signifies that the document had not yet been completed . The advance directive does not become a legal document until it is signed . Any prior paperwork may be used to help a power of attorney. Advance healthcare directive Power of attorney Attorneys in the United States Attorney at law

F is not correct. 120/o chose th is. T hA

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have been contacted, the physician's prior interactions w ith the patient alone are not enough to withdraw care .

2

Primary care physician Primary care Physician

3

D is not correct. 180/o chose this. Power of attorney can be granted by the patient to any person for a specific period of time, or permanently (durable power of attorney) . A person previously granted power of attorney holds no special decision-making rights once that specific period of time (previous hospitalization) has ended .

4

5 6

Power of attorney Attorney at law Attorneys in the United States lawyer

7 8 9 • 10

E is not correct. 15% chose this. "Initial paperwork" signifies that the document had not yet been completed . The advance directive does not become a legal document until it is signed . Any prior paperwork may be used to help a power of attorney. Advance healthcare directive Power of attorney Attorneys in the United States Attorney at law

• 11

• 12 • 13

F is not correct. 120/o chose this . The patient has the right to refuse life-supporting treatment. Withholding and withdrawing life-supporting care from a patient are currently considered ethically identical.

• 14

• 15 • 16 • 17 • 18

Bottom Line: A patient and family have the right to withhold treatment for ventilation, antibiotics, or fluids . However, when the patient is not conscious, it is important to confirm the patient's wi shes through prior legal documentation to ensure that his or her health care proxy is aware of the patient's most recent decisions . An advance directive accomplishes this. Healthcare proxy Advance healthcare directive

References: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed p 115

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A 76-year-old nursing home resident with Alzheimer disease is seen by the primary care physician because of incidents of ~~AI difficulty swallowing . After physical examination, the physician suspects esophagea l obstruction and would like to schedule the patient for upper endoscopy. The patient has been determined to lack capacity in making health care decisions . His surrogate, his 50-year-old son, is out of the country and cannot be located, but has signed a waiver to relinquish his right to informed consent. How should the primary ca re physician best proceed?

8 9

• 11

A. Explain the nature of intervention, the ind ications, risks, and benefits, and the potential alternatives to the patient and then obta in the consent from him

• 12

B. Find another surrogate to sign the consent

• 13

C. Obtain permission from the eth ics committee

• 10

• 14

• 15 • 16

D. Schedule the patient for the procedure E. Wa it to obtain consent from the son

• 17 • 18

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The correct answer is D. 510/o chose this. Informed consent can be waived if the patient or the patfi ent's surrogate has signed a waiver to the right. The physician can proceed with the procedure .

6

Informed consent Physician

7

A is not correct. 7% chose this. The patient has been determined to be incapacitated and thereby unable to interpret the information provided about his condition and possible treatments. Therefore a signed form of informed consent from the patient is not valid .

4

8 9 10 • 11

• 12 • 13

Informed consent Manually coded language

B is not correct. 180/o chose this. The surrogate has signed the waiver and therefore is allowing the physician to perform/order appropriate tests for the patient. It is not necessary to find another surrogate . Physician Waiver

• 14

• 15

C is not correct. 150/o chose this .

• 16

The surrogate has signed the waiver to informed consent. The physician does not need permission from the ethics committee . Informed consent Ethics Physician

• 17 • 18

E is not correct. 90/o chose this . Although it would be ideal to discuss the care plan with the son, given the situation and the presence of the waiver, it is not necessary to wait and obtain consent from the son .

Bottom line: Informed consent can be waived if the patient or the patient's surrogate has signed a waiver to the right. Informed consent

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Informed consent Physician

A is not correct. 7% chose this.

4

The patient has been determined to be incapacitated and thereby unable to interpret the information provided about his condition and possible treatments. Therefore a signed form of informed consent from the patient is not valid .

5

Informed consent Manually coded language

6

8

B is not correct. 180/o chose this. The surrogate has signed the waiver and therefor e is allowing the physician to perform/order appropriate tests for the patient. It is not necessary to find another surrogate.

9

Physician Waiver

10

C

7

is not correct. 150/o chose this.

• 11

The surrogate has signed the waiver to informed consent. The physician does not need permission f rom the eth ics committee.

• 12

Informed consent Ethics Physician

• 13

E is not correct. 90/o chose this . Although it would be idea l to discuss the care plan w ith the son, given the situation and the presence of the waiver, it is not necessary to wait and obtain consent from the son .

• 14

• 15 • 16 • 17

Bottom line:

• 18

Informed consent can be waived if the patient or the patient's surrogate has signed a waiver to the right. Informed consent

References: FA Step 2 CK 9th ed p 126 FA Step 2 CK 8th ed p 114

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An 84-year-old woman suffering from terminal breast ca ncer is hospitalized and intubated due to pneumonia. Her cli nical condit ion worsens/ and 1 week later her hea lth care proxy decides to w ithd raw care and offer comfort measures on ly. Her family requests that she be given high doses of morphine to ensure that she will not be in pain. Her physicians agree to this 1 even though they know that opioids may further depress her respirations .

~~AI

5 6 7

The physicians' w illingness to treat this patient with potentially fatal drugs for palliative purposes is an example of wh ich principle?

8 9 10

· 11

A. Autonomy B. Dereliction C. Double effect

• 12 • 13 • 14

D. Malpractice E. Physician-assisted suicide

• 15 • 16 • 17 • 18

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The correct a nswer i s C. 540/o chose t h is. "Double effect" is the ethical principle that states that a palliating treatment is acceptable even if it may hasten death because the intended effect is to relieve the patient's suffering. In this case, opioids may cause respiratory depression and hasten the patient's death after extubation; however, this is ethically acceptable because of the importance of providing palliative comfort measures for the patient. Hypoventilation Opioid Intubation Tracheal intubation Palliative care Major depressive disorder Depression (mood)

8 9 10 11

A i s not correct. 190/o chose t his. Autonomy is the principle stating that physicians must respect the indiv id ual rights and opinions of their patients. Although this applies in all cases, this case is not specifically a case of autonomy. Individual and group rights

• 12

• 15

B is not correct. 1 30/o chose th is . Dereliction is one of the four elements of a malpractice s1u it. The physicians in this case are not committing malpractice. After discussion with the patient's family and consideration of the patient's rights and wishes, the physicians are acting in accordance w ith sound ethical principles .

• 16

Malpractice Medical malpractice

• 17

D i s not correct. 3% chose this . The physicians in this case are not committing malpractice; after discussion with the patient's fam ily and consideration of the patient's rights and wishes, the physicians are acting in accordance with sound ethical principles .

• 13 • 14

• 18

Malpractice Medical malpractice

E i s n ot cor rect. 1 0% ch ose this . The physicians in this case are offering opioids as a palliative measure, not a treatment intended to hasten the patient's death . This case, in which the patient lacks capacity and her family and physicians decide to w ithdraw care, is not an example of suicide. Lock

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this applies in all cases, this case is not specifically a case of autonomy. Individual and group rights

3

B is not correct. 130/o chose this.

4

Dereliction is one of the fou r elements of a malpractice s1uit. The physicians in this case are not committing malpractice. After discussion with the patient's family and consideration of the patient's rights and wishes, the physicians are acting in accordance w ith sound ethical principles.

5 6 7 8

Malpractice Medical malpractice

D is not correct. 30/o chose this.

9

The physicians in this case are not committing malpractice; after discussion with the patient's family and consideration of the patient's rights and wishes, the physicians are acting in accordance with sound ethical principles .

10

Malpractice Medical malpractice

11

E is not correct. 10% chose this.

• 12 • 13 • 14

• 15

The physicians in this case are offering opioids as a palliative measure, not a treatment intended to hasten the patient's death . This case, in which the patient lacks capacity and her family and physicians decide to w ithdraw care, is not an example of suicide . Opioid Suicide Palliative care

• 16 • 17

Bottom line:

• 18

"Double effect" is the ethical principle that states that a palliating treatment is acceptable even if it may hasten death because the intended effect is to relieve the patient's suffering .

References: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed pp 115-116

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A ped iatrician sees a 14-year-old girl who comes in for her yearly physical with her mother. When the mother steps outside ~~AI while more history is taken, the girl says that she is sexua lly active and would like to be tested for sexually transmitted diseases; however, she is afra id that her mother will find out.

4

5

Which of the following is the most appropriate response?

6 7 8

9 10 11

• 12 • 13 • 14

• 15 • 16 • 17

A. Inform your patient that you can perform tests for Chlamydia and gonorrhea, but HI V testing w ill require consent from her parents

B. Inquire if the patient is an emancipated m inor; only if she is living on her own, financially independent, or married may she obtain these tests on her own C. Reassure the patient that th is conversation is confidential and that testing for sexually transmitted diseases will not require parental consent D. Tel l her that being sexua lly active comes with a lot of responsibi lity and if she is not yet willing to be honest with her parents, she should absta in

E. Tel l her that you w ill agree to do the testing and maintain confidentiality, unless her parents ask and you have a positive result

• 18

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The correct a nswer is C. 920/o chose t his.

5

In general, minors have the right to confidentiality when requesting testing for sexually transmitted diseases . Some states may vary on HIV testing in particular, but overall minors are not required to get consent from their parents when requesting these tests.

6 7 8

9

HIV Diagnosis of HIV/AIDS Sexually transmitted infection Confidentiality

A is not correct. 2% chose this .

10

In some states, HIV testing may require additional disclosure when performed for a m inor, but in most it does not. The child may receive all tests confidentially.

11

H!V Diagnosis of HIV/AIDS

12

B is not correct. 2% chose t his . The patient may receive screening for sexually transmitted diseases confidentially, regardless of whether or not she has been emancipated .

• 13 • 14

• 15

Sexually transmitted infection Emancipation of minors Emancipation

• 16

D is not correct. 1 Ofo chose this . Though this statement may be true, it does not speak to the patient's question .

• 17 • 18

E is not correct. 30/o chose th is. Though sharing such information w ith parents may be important, for the physician to do so against the patient's wishes is a v iolation of patient-physician confidentiality. Physician Confidentiality

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HIV Diagnosis of HIV/AIDS Sexually transmitted infection Confidentiality

A is not correct. 2% chose this.

4

In some states, HIV testing may r equire additional disclosure when performed for a minor, but in most it does not. The child may receive all tests confidentially.

5

H!V Diagnosis of HIV/AIDS

6

8

B is not correct. 20/o chose this. The patient may receive screening for sexua lly transmitted diseases confidentially, regardless of whether or not she has been emancipated .

9

Sexually transmitted infection Emancipation of minors Emancipation

10 11

D is not correct. 1 Ofo chose this. Though this statement may be true, it does not speak to the patient's question .

12

E is not correct. 30/o chose this .

7

• 13 • 14

• 15

Though sharing such information w ith par ents may be im portant, for the physician to do so against the patient's wishes is a violation of patient-physician confidentiality. Physician Confidentiality

• 16 • 17 • 18

Bottom line: In general, m inors have the right to confidentia lity when requesting testing for sexua lly transmitted diseases . Sexually transmitted infection Confidentiality

References: FA Step 2 CK 9th ed pp 126-127 FA Step 2 CK 8th ed pp 114-115

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A patient in the clinic has a positive HIV test, first by enzyme-linked immunosorbent assay antibody assay and then ~~AI confirmed by Western blot. She is married, has three children, and is sexually active w ith her husband . After explaining what the results mean, she is advised that it is important for the husband to be informed of these test results. She appears stunned and frightened by this suggestion, and does not want to tell him . She also requests that you maintain her patient confidentiality and not disclose the resu lts to him yourself. What is the most appropriate course of action?

8

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12 • 13 • 14

• 15 • 16 • 17

A. Contact the husband directly and suggest he stop in for an appointment, so that he can be informed of the resu lts of the test B. Inform the patient that it wou ld be unethical for her not to tell her husband and therefore you would no longer be involved in her medical care C. Reassure her that she can legally not inform her husband or other sexual contacts who have been potentially exposed D. Report the resu lt to the public health department and encourage the patient to inform her husband E. Send an anonymous letter informing the husband of the exposure

• 18

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The correct answer is D. 880/o chose this. HI V is a reportable disease . In many states and cities, t here are partner-notification laws such that individuals who test positive for HI V may be legally obligated to tell their sex or needle-sharing partners . Some health departments require physicians to report the name of such partners even if t he patient refuses to report that information . The best choice in this case is to notify the hea lth department and encourage the patient to inform her husband and any other sex partners . HIV Disease surveillance

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A is not correct. 6% chose this. Going behind the patient's back is inappropriate; however, in some states there are laws that protect the physician from lega l liabi lity for breach of confidentiality if they do inform third parties of HIV exposure . The physician is protected, however, on ly after efforts by the physician have failed to convince the primary patient to disclose th is information to his or her sexual contacts.

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HIV Physician legal liability Confidentiality

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B is not correct. 20/o chose this . It is inappropriate to not provide the patient with medica l care because of her decision, even if the physician feels that it may be unethical. Physicians may be asked to provide medical ca re for criminals and inmates, and should be able to provide unbiased med ical opinions and provide appropriate medical care rega rdless of the decisions that a patient makes outside of the hospital or cli nic. In this case, inform ing the husband is an important public service, but should not impede the physician from continuing to ca re for the patient.

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Physician

C is not correct. JO/o chose this. Although a physician should be fam iliar with the laws governing medicine, it is genera lly good practice to avoid providing nonmedical expertise to patients. In this example, it may not be the case that the patient "can legally not inform" her sexual ,..."""'""+-:=.,-t-e

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be unethical. Physicians may be asked to provide medical care for criminals and inmates, and should be able to provide unbiased medical opinions and provide appropriate medical care regardless of the decisions that a patient makes outside of the hospital or clinic. In this case, inform ing the husband is an important public service, but should not impede the physician from continuing to ca re for the patient. Physician

C is not correct. 3% chose this. Although a physician should be familiar with the laws governing medicine, it is generally good practice to avoid providing nonmedical expertise to patients. In this example, it may not be the case that the patient "can legally not inform" her sexual contacts. In fact, many states have laws that requ ire HIV affected ind ividua ls to inform their sexual contacts and failing to do so could be considered a crime . HIV Physician Medicine

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E is not correct. 10/o chose this. If the patient refuses to inform her husband, then depending on the state there might be other avenues by which sexual partners may be contacted . Sending an anonymous letter informing the husband of the exposure, however, wou ld likely damage the doctor-patient and husband-wife relationships .

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Bottom Line: Protecting patient confidentiality is crucial. However, in some states there are laws that protect the physician from lega l liabi lity for breach of confidentiality if he or she informs third parties of HIV exposu re when the infected patient refuses to do so despite repeated attempts at persuasion . HIV Legal liability Confidentiality Physician

References: FA Step 2 CK 9th ed pp 129-130 FA Step 2 CK 8th ed p 117

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A 16-year-old girl comes to see her pediatrician alone, complain ing of itchy, greenish vag ina l discharge for 4 days . When questioned about her sexual practices, the patient blushes and adm its that although she is usually careful about using condoms, she was at a party recently where she drank too much and forgot to insist that her boyfriend use a condom . After disclosing th is information, she suddenly looks alarmed and says, "You're not going to tell my parents th is, are you? They don't know that my boyfriend and I have sex, and they wou ld kill me." In addition to gently rem inding the patient about safe sex, how shou ld the pediatrician respond?

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A. "Although th is is not generally my practice, I will make an exception for you because you are a long-stand ing patient. However, as your physician I do not approve of your refusa l to tell your parents about your habits" B. "I really wil l need to tell your parents because now that you have had unprotected sex I need their consent to do an HIV test" C. "I'm sorry, but because you are under 18 years old I legally have to share your medical history with your parents if they ask me" D. "Un less you agree to tell your parents about your sexual activ ity, I cannot treat you for your vag inal infection" E. "Although I would encourage you to be open and honest with your parents, your health is most important, and everyth ing you tell me about your sexua l practices is completely confidential"

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The correct answer is E. 94% chose this. Minors requesting treatment for sexually transmitted diseases are entitled to complete confidentiality. Minors can consent to treatment under these following ci rcumstances . Court-ordered emancipation : A child under the age of 18 who lives independently without the support of parents and makes his or her own day-to-day decisions may petit ion the court for emancipation . If granted, the minor w ill have the same legal rights as an adult, including the right to consent to (and refuse) medical treatment Situationa l emancipation : Depend ing upon the particu la r state, minors who are or have been married, are themselves parents, attend college away from home, are members of the military, and other similar situations may be al lowed to consent to treatment on their own behalf. States may also grant minors the ability to consent to treatment where no parent or guardian is immediately available and a delay in t reatment may result in harm to the minor.

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Type of treatment: Minors are often allowed to consent to treatment for such things as substance abuse, mental health car e, and birth control

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Birth control Sexually transmitted infection Abolitionism in the United States Mental health Confidentiality Substance abuse Health care

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A is not correct. 2% chose this. The physician must r espect the confidentia lity righ ts of all minors, and it would be inappropriate to imply that an exception is being made for this particular patient.

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Physician Confidentiality

B is not correct. 10/o chose this. Minors have the right to confidential treatment and screen ing for sexual ly t ransmitted diseases . Parental consent is not necessary for minors to receive th is screening . Sexually transmitted infection

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The physician must respect the confidentiality rights of all minors, and it wou ld be inappropriate to imply that an exception is being made for this particular patient. Physician Confidentiality

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B is not correct. 1 0/o chose this. Minors have the right to confidential treatment and screening for sexua lly transmitted diseases . Parental consent is not necessary for minors to receive this screening . Sexually transmitted infection

C is not correct. 2% chose this. Minors have the right to confidential treatment and screening for sexua lly transmitted diseases, and thus the physician has no legal obligation to share this portion of the patient's history with her parents . Physician Sexually transmitted infection

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Dis not correct. 1 % chose this. Minors requesting treatment for sexually transm itted diseases are entit led to complete confidentiality, Physicians are legally and eth ically prohibited from withholding treatment.

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Sexually transmitted infection

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Bottom line : Minors requesting treatment for sexually transm itted diseases are entit led to complete confidentiality. This also appli es to pregnancy and drug and alcohol abuse . Alcohol abuse Alcoholic beverage Alcohol Sexually transmitted infection Pregnancy

References: FA Step 2 CK 9th ed p 129 FA Step 2 CK 8th ed p 117

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A 74-year-old man with metastatic lung cancer presents to his primary care physician to discuss treatment options and end-of-life issues . He states that he wishes to select his brother to make decisions about his health care in case he is no longer competent.

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What form of legal document best addresses this patient's wishes?

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A. Advance directive B. Competency document

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C. Durable power of attorney

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D. Informed consent

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E. Living will

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The correct answer is C. 690/o chose this. A durable power of attorney is a legal document that allows an individual to authorize another person to make legal decisions for h im/her when the individual is no longer able to do so. Power of attorney Legal instrument Attorney at law

A is not correct. 180/o chose this.

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An advance directive is a spoken or written decision with instructions and preferences for medical treatment. This patient desires his brother to make decisions instead of predetermined written decisions in a legal document.

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Advance healthcare directive Legal instrument

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B is not correct. 30/o chose this. A competency document does not exist. D is not correct. 3% chose this.

Informed consent is the permission given by a person before surgery or other kinds of treatment. The patient, or a parent or

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guardian, must understand the potential risks and benefilts of the treatment and lega lly ag ree to accept those risks.

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Hyperkalemia

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E is not correct. JOfo chose this . A living w ill is the most widely used written advance diredive . Typically, a living will takes effect if the person is termina lly ill w ith no chance of recovery, and outlines the desire to withhold heroic measures .

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Advance healthcare directive Tenminal illness

Bottom line: A durable power of attorney is a legal document that allows an individual to authorize another person to make legal decisions for the patient when he or she is no longer able to do so . Power of attorney Legal instrument Attorney at law

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A is not correct. 180/o chose this.

An advance directive is a spoken or written decision with instructions and preferences for medical treatment. This patient desires his brother to make decisions instead of predetermined written decisions in a legal document. Advance healthcare directive legal instrument

B is not correct. 30/o chose this.

A competency document does not exist. D is not correct. 30/o chose this. Informed consent is the permission given by a person before surgery or other kinds of treatment. The patient, or a parent or guardian, must understand the potential risks and benefilts of the treatment and legally ag ree to accept those risks.

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Hyperkalemia

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E is not correct. JOfo chose this.

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A living will is the most widely used written advance diredive. Typically, a living will takes effect if the person is terminally ill

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w ith no chance of recovery, and outlines the desire to withhold heroic measures .

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Advance healthcare directive Terminal illness

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Bottom line: A durable power of attorney is a legal document that allows an individual to authorize another person to make legal decisions for the patient when he or she is no longer able to do so . Power of attorney Legal instrument Attorney at law

References: FA Step 2 CK 9th ed pp 128-129 FA Step 2 CK 8th ed pp 115-116

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A 93-year-old woman comes to the emergency department after tripping in her yard . She complains of right hip pa in and ~~AI inability to ambulate . The physician notes that her right leg is shortened and externa lly rotated . Her past medical history includes hypertension, hypercholesterolem ia, and multiple myeloma diagnosed 2 years ago . Per hospital procedure she is asked to designate a person as a health care proxy. The physician asks the patient to explain back to him what she has just been told about what this documentation entails. Which of the following statements indicates that the patient has understood what a health care proxy is?

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A. "A hea lth care proxy is the family member I pick to make my medica l decisions"

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B. "A hea lth ca re proxy knows my wishes about medica l decisions; if I can no longer make decisions for myself, he or she will make decisions in my place"

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C. "Designating a health care proxy means I no longer make any decisions regarding health care for myself"

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D. "Designating a health care proxy means that from th is point forward he or she has access to all my medical information " E. "Even if I am in good mental and physical health, I cannot override decisions of my hea lth care proxy"

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The correct answer is B. 920/o chose this. A health care proxy or durable power of attorney is a designated person who, in the event that the patient cannot make decisions for him- or herself, would make medical decisions in lieu of the patient. Healthcare proxy Power of attorney Proxy marriage Health care Attorney at law Attorneys in the United States Lawyer

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A is not correct. 5% chose this. A health car e proxy does not have to be a fam ily member. Healthcare proxy Proxy marriage

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Cis not correct. 1% chose this. As long as the patient is competent, he or she wil l continue to make medical decisions on her or his own unless he or she concedes this right to his or her health care proxy. Healthcare proxy Proxy marriage Proxy (climate)

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D is not correct. 2% chose this. A health car e proxy does not have free access to the pati ent's med ica l information unless he or she is making decisions for the patient. Healthcare proxy Health care Proxy marriage

E is not correct. OO/o chose this. As long as the patient is competent, he or she wil l continue to make medical decisions on her own unless she concedes th is right to his or her health care proxy. Healthcare proxy Proxy marriage Proxy (climate)

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A health care proxy does not have t o be a fam ily member. Healthcare proxy Proxy marriage

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Cis not correct. 1% chose this.

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As long as the pati ent is competent , he or she wil l continue to make medical decisions on her or his own unless he or she concedes th is right to his or her health care proxy.

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Healthcare proxy Proxy marriage Proxy (climate}

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D is not corre ct. 20/o chose this. A health care proxy does not have free access to t he pati ent's med ica l information unless he or she is making decisions for t he patient.

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Healthcare proxy Health care Proxy marriage

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E is not correct. OOfo chose this.

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As long as the patient is competent, he or she wil l continue to make medical decisions on her own unless she concedes th is right to his or her health care pro xy.

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Healthcare proxy Proxy marriage Proxy (climate}

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Bottom line : A health care proxy or durable power of attorney is a designated person who, in t he event that t he patient cannot make decisions for him- or herself, would make med ical decis ions in lieu of the pati ent . Healthcare proxy Power of attorney Proxy marriage Health care Attorney at law Attorneys in the United States Lawyer

Refere n ces: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed p 116

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A 97-year-old man was adm itted to the hospital because of weakness and rectal bleeding for the previous 24 hours. ~~AI Question ing reveals a decrease in stool caliber over the past several months . Examination reveals a nontender mass in the left lower quadrant. Stool heme is positive. Serum hemog lobin is 8.8 g/d L. Further work-up reveals colon cancer, Duke stage D. The patient's spouse and only child are no longer living, but the patient's 50-year-old granddaughter pleads with the physician not to inform her grandfather of the diagnosis, stating that he is an anxious man and that she wants him to enjoy his remaining t ime .

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Which of the following is the most appropriate next step"

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A. Agree not to reveal the diagnosis to the patient

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B. Ask the granddaughter to obtain other family members' opinions and try to reach consensus

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C. Ask the patient how much information he wants to know

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D. Request a consult from the hospital's ethics team

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E. Request psychiatric evaluation of the patient

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The correct a nswer i s C. 9 1 0/o chose t h is. With rare exceptions, patients are entit led to know their diagnosis and pr ognosis, even if they ar e old, their condit ion is probably terminal, and they have anxious personalit ies and/ or psychiatric diagnoses. Exceptions to the physician's obligation to discuss the diagnosis with the patient include the pr evious r equest of the patient to not be informed or the belief of the physician that disclosur e would severely harm the patient. Physician Prognosis Mental disorder Classification of mental disorders

A i s not correct. 4 % ch ose this. It would be unethica l to acquiesce to the family's request. If nondisclosure is the patient's request as well, then the physician w ill be able to honor it . Physician

13

B is not correct. 2 0/o chose t h is. Even if the entir e fam ily wants to keep the diagnosis fr om the patient, if the patient him- or herself wants to be informed, the physician is obligated to tell the patient the diagnosis.

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Physician

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Dis not correct. 1% chose this. Rarely will consultation be a corr ect answer on a USMLE examination . The physician has the information needed to act and should do so .

12

16 17 • 18

United States Medical Licensing Examination Physician

E i s n ot correct. 20/o c hose th is. Psychiatric evaluation is not warranted at this t ime . All physicians can judge decision-making capacity, and if the patient has the capacity to decide w hether he or she wants to be informed of the diagnosis, the obligation then exists to abide by that w ish. Psychological evaluation Psychiatry

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Physician

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B is not correct. 2 0/o chose this . Even if the entire fam ily wants to keep the diagnosis from the patient, if the patient him- or herself wants to be informed, the physician is obligated to tell the patient the diagnosis.

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Physician

Dis not correct. 1 % chose this. Rarely will consultation be a correct answer on a USMLE examination . The physician has the information needed to act and should do so . United States

~1edical

Ucensing Examination Physician

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E i s n ot corr ect. 2 0/o c hose th is. Psychiatric evaluation is not warranted at this t ime . All physicians can judge decision-making capacity, and if the patient has the capacity to decide whether he or she wants to be informed of the diagnosis, the obligation then exists to abide by that wish . Psychological evaluation Psychiatry

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Bottom Line : Patients are entit led to know their diagnosis and prognosis . Exceptions to the physician's obligation to discuss the diagnosis w ith the patient include the patient's previous request to not be informed or the physician's belief that disclosure would severely harm the patient. Prognosis Physician

References: FA Step 2 CK 9th ed pp 128; 126 FA Step 2 CK 8th ed p 116

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In a Florida commun ity medical center, a 76-year-old man receives a diagnosis of advanced-stage sma ll cell lung cancer. ~~AI He is widowed and the patient has not told his only son of the diagnosis, because the son lives outside of the United States and the patient does not want to burden him . The patient requests that his physician administer a medication to end his life, because there is "no point in living anymore."

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Which of the following is the appropriate decision?

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A. Physician admin isters the agent at the patient's request B. Physician checks w ith the legal health care proxy and then administers the agent

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C. Physician does not adm inister such an agent, but is willing to provide the agent to the patient for self-administration

13 14

D. Physician does not adm inister such an agent, but prescribes it to the legal health care proxy to admin ister it to the patient instead

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E. Physician refrains from administering or providing such an agent

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The correct answer i s E. 8 3% chose this. Euthanasia is the intentional ending of a person's life to facilitate a merciful death . It typically involves a caregiver administering a lethal agent. Although it is ethical to provide pain relief and palliation to a patient, even if this treatment speeds up his or her death, euthanasia is illegal and opposed by the American Medical Association Code of Medica l Ethics. Physician-assisted suicide involves a caregiver providing or prescribing a lethal agent for the patient to administer on his or her ow n accord . Physician-assisted suicide is currently illegal in most states, but is an option given to individuals by state law in Oregon, Vermont, Washington, and Californ ia. It is also an option given to ind ividuals in Montana v ia court decision.When a patient r equests euthanasia, a physician should be concerned with comorbid psych iatric ill ness, and should ensure the patient has adequate social support and symptom control, especially pain medication .

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Euthanasia American Medical Association Assisted suicide Comorbidity Palliative care Montana Mental disorder Symptom Social support Analgesic Caregiver Physician Suicide

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Medical ethics Oregon Pharmaceutical drug

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A i s not correct. 3% ch ose this. This is the incorrect answer, physician-assisted suicide is il legal in most states, including the state of Florida. The physician should not administer the agent at the patient's request.

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Assisted suicide Suicide Florida Physician

B is not correct. 4 0/o chose this. This is the incorrect answer. I n Florida, it is illegal for a physician to administer such an agent at the patient's request, even w ith the support of the legal health care proxy. Healthcare proxy Florida

C i s not correct. 6 0/o chose this. This is the incorr ect answer. I n Florida, the physician should not provide such an agent for the patient to self-admin ister. Florida Physician

D is not correct. 4 % chose this. This is the incorrect answer. I n Florida. it is illeaal for a ohvsician to orovide such an aaent to the health care oroxv to aive to Lock

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This is the incorr ect answer, physician-assisted suicide is il legal in most states, including the state of Florida. The physician should not administer the agent at the patient's request.

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Assisted suicide Suicide Florida Physician

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B is not correct. 4 0/o chose this .

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This is the incorr ect answer. I n Florida, it is illegal for a physician to administer such an agent at the patient's request, even w ith the support of the legal health care proxy.

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Healthcare proxy Florida

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C

is not correct. 60/o chos e this .

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This is the incorr ect answer. I n Florida, the physician should not provide such an agent for the patient to self-admin ister.

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Florida Physician

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D is not correct. 4 % chos e this . This is the incorr ect answer. I n Florida, it is illegal for a physician to provide such an agent to the health care proxy to give to the patient.

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Healthcare proxy Florida

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Bottom line : Although it is ethical to provide pain relief and palliatiorn to a patient, even if this treatment speeds up his or her death, euthanasia is il legal in most states in the Un ited States. Euthanasia Palliative care Pain management United States Ethics Analgesic

References: FA Step 2 CK 9th ed p 128 FA Step 2 CK 8th ed p 116

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