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You are called to see a 75-year-old man who has metastatic lung cancer because of hypoxia, hypotension, and mental status changes. He has been your patient for many years and he has told you multiple times that he does not want to be placed on a respirator for any reason. On multiple occasions after his wife died, he has explained to you that if he was ever in a situation where mechanical respiration or any heroic measures should become necessary, that he would prefer to simply be made comfortable and be "allowed to go." He has a living will, which states that if he was in a terminal condition he does not want any life sustaining treatments including hemodialysis, intubation, and cardiac resuscitation. Rather, he wants comfort care only. His two daughters and three sons are all present in the room with you. They explain to you that they are very upset by their father's condition and that they want to place him on a ventilator to help him get through this episode. You explain that their father did not want aggressive medical care at the end of life, but the family insists on intervention. They threaten to sue you for malpractice if he dies. His temperature is 37.0 C (98.6 F), blood pressure is 75/40 mm Hg, pulse is 130/min, and respirations are 29/min. Physical examination shows a cachetic man in moderate respiratory distress. He is extremely disoriented and agitated and appears to be in pain. The most appropriate course of action at this time is to
A. ask the family to leave and inject a lethal dose of morphine in accordance with the patients wishes
B. do not intubate patient but administer morphine and dopamine together to alleviate his suffering while maintaining his blood pressure
C. do not intubate the patient but administer morphine for comfort even though this might lower his blood pressure and respiratory rate and hasten the patient's demise
D. contact the hospital ethics committee to decide on the proper course of action
E. intubate the patient for now; when the situation is more stable discuss the patient's end of life wishes with the family
tx to relieve pain and suffering even if such tx may hasten a pcte`s death.
Agree, the intent is to relieve suffering and the medication is titrade for that purpose.
Explanation: The correct answer is C. This patient has a living will, which states that if he was in a terminal condition he wants only comfort care. He has also clearly stated his wishes to you in the past. Intubation of this patient is clearly against his wishes. Starting morphine may cause respiratory suppression or worsen his hypotension which might hasten death. The potential to hasten death is an acceptable risk if the primary intention is to decrease patient suffering. Ideally, the patient's wishes should be clearly explained early in his hospital course.Injection of a "lethal dose" of morphine (choice A) is not acceptable management of this patient since its only purpose would be to hasten death. As stated above, it is acceptable to use a drug that may hasten death if the primary intention is to decrease suffering. Asking the family to leave and then injecting a lethal dose of medication is clearly not acceptable management.Any time you start morphine on a patient you need to be aware of the possibility of worsening hypotension. Morphine is a mild vasodilator and therefore acts as a preload reducer. In this patient, hypotension already is prominent prior to starting morphine. Starting dopamine with the morphine (choice B) is not appropriate in this case since most physicians agree that, in this patient, starting vasopressors would constitute "heroic" measures.Contacting the hospital ethics committee (choice D) is not appropriate in this patient. This patient needs immediate medical attention. There is no time for meetings now. Intubation of this patient now (choice E) is clearly against the patient's documented wishes. To ignore a patient living's will and end of life issues is clearly wrong and would make completion of advance directives meaningless.
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