fandarast
Forum Junior
Topics: 15
Posts: 53
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1. An 84-year-old man is under your care for severe dementia. He develops urosepsis requiring transfer to an acute care facility for intravenous fluids and intravenous antibiotics. He has no advance directive and his children are split as to what they believe their father wishes to be regarding his care. His brother wants to hold all therapy. His son and two nieces wish to do everything. The rest of the family is in the middle. What should you do?
A. Do everything
B. Hold everything
C. Seek court intervention
D. Make an ethics committee referral
2. A 32-year-old woman comes to see you for evaluation for an elective termination of pregnancy (abortion) and a tubal ligation. She is accompanied by her husband who is the father of the child. The husband is very disturbed because this is the first time that his wife has been pregnant and he very strongly wishes to become a father. He tells you that this has been a constant topic of discussion between himself and his wife and that she has repeatedly agreed to have children. In fact it was so important in the relationship that her agreement to have children was put into a pre-nuptial agreement which she signed. The patient is very clear that she wants the termination of pregnancy and the tubal ligation to proceed. What should you do?
A. Refer to another physician
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B. Ask for a court order before proceeding
C. Ask for evidence of the legal resolution of the pre-nuptial agreement prior to
proceeding
D. Do the tubal ligation only after she delivers the baby
E. Do the abortion but not the ligation
F. Proceed with both procedures as requested
G. Proceed with the procedures only if the husband consents
3.A 57-year-old man is involved in a motor vehicle accident leading to head trauma severe enough to meet brain death criteria. As the emergency department physician, you find an organ donor card giving consent to donate all available organs. His family arrives including the wife who says that one of his organs was to be sold to pay for their living expenses. What should you do about his organs?
A. Allow the sale of the kidneys and discard the rest
B. Sell the kidneys and put the rest up for open donation
C. Honor the organ donor card exclusively and put all the organs up for free donation
D. Defer any involvement on your part and ask the organ donor network for family consent for free donation
4.On a routine Wednesday morning you’re in your office beginning to see a new patient. The patient is very angry, impatient, and hostile. As you say hello the response from the patient is “I’m not going to take any crap from you, doctor. I understand how you all are. I know all you care about is money. You’re going to do what I tell you, or I’ll sue you”. You cordially ask the patient what her medical problems are, but besides a headache, the only response you can get is that the patient is extremely upset and seems angry with you, despite the fact you have only just met. No matter what you say, the patient is hostile and threatening. You’re wishing you had never met the patient and you would prefer not to be her doctor. What should you do?
A. You must take care of the patient
B. Consult your attorney
C. Take care of her for a few visits and see if it gets better
D. Inform the patient that you cannot accept her as a patient
E. You must take care of her until you find her another doctor
Edited by fandarast on 11/11/07 - 09:00 AM
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| Doc750
transfer:step 3 prison
Topics: 52
Posts: 634
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1. B
2. F
3. C
4. C? I still think it's A. It's your job to determine why the patient is upset with you. And if there is any cause then address the issue and reassure the patient. Not pawn it off on someone else.
Edited by Doc750 on 11/11/07 - 09:20 AM
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Experience is a hard teacher because she gives the test first, and the lesson afterwards.
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| fandarast
Forum Junior
Topics: 15
Posts: 53
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Sorry for problems with editing the questions, doc 750. Now all the pieces are there and you can look at them again. Unfortunately none of your answers are correct.
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| fandarast
Forum Junior
Topics: 15
Posts: 53
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Here are the correct answers as they are given in online companion of Conrad Fisher's Kaplan USMLE Medical Ethics book:
1- D
2- F
3-D
4-D
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| Doc750
transfer:step 3 prison
Topics: 52
Posts: 634
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can u please post his explanations.
thanks! 
___________________
Experience is a hard teacher because she gives the test first, and the lesson afterwards.
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| me007
Forum Guru
Topics: 72
Posts: 799
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#2 - F - bcs it's her body and she is free to decide what to do with it.
#4 - D for sure, the doc is not a prisoner, why shoud he listen all this and take care of that person.
#1 - cant find qs and choices.
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| fandarast
Forum Junior
Topics: 15
Posts: 53
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1- Make an ethics committee referral
When there is no clear advance directive and the family doesn't agree on what the patient wanted for himself or herself, then the right anwer is to refer to the ethics committee and finally the courts.
Here is a list of the various kinds of consent, with the most desirable listed first:
- Direct patient wish verbalized by the patient
- Formal advance directive such as a proxy or a living will
- Oral advance directive
- United group of family and friends
- Group of family members disagreeing on what the patient would have wanted
In cases where there is no living will or proxy and the family members are not in agreement, the next step is to "encourage consensus," "request discussion," or "talk with the parties involved." If consensus is not possible, you should refer the case to the hospital ethics committee. The last step to pursue in the absence of a clear consensus is referral to the courts or "sick judicial intervention."
For example, the Terry Schiavo case ended up in the court because her husband and several of her friends said the patient told them that she never wanted to be maintained in a persistent vegetative state. The patient's parents atated that she never said that. The ethics committee does not have direct legal power and their decisions are not always universally binding. If the ethics committee is unable to build consensus, or the involved parties ignore the ethics committee, then judicial intervention is necessary.
2- Proceed with both procedures as requested
A woman has the right to proceed with a tubal ligation or any other form of sterilization procedure at her own discretion. The husband has no right to interfere with her right to choose her own reproductive potential. Spousal consent is neither sought nor involved in sterilization procedures. Though there may be a potential civil penalty for violating a pre-nuptial agreement, the pre-nuptial agreement has no impact in the care of a physician for his patient. The father of a child has essentially no rights over an unborn fetus. Untile the time of delivery, the child is considered exclusively a part of the mother's body. There is some modification of this standard of care in terms of second- and third - trimester abortion. In the second trimester there is some limitation on the free access to abortion and there is some negotiation with the physician required. Third-trimester abortion can only be freely done if there is a threat to the life of the mother. abortionnever require the consent of the father.
3- Defer any involvement on your part and ask the organ donor network for family consent for free donation
The sale of solid organs is entirely prohibited. Only renewable tissue such as sperm, blood and unfertilized eggs can be legally sold. Though there is an organ donor card found on the patient, the family should still be asked to consent for the donation. The status of an organ donor card is not absolute. The family can overrule a donor card indicating a desire to consent for donation. The physician and patient care team should not, however, be the ones involved in obtaining consent for organ procurement. This is considered a conflict of interest. Even though the patient is brain dead and therefore legally dead, it would be potentially problematic for the patient's family to perceive that the caregivers were also trying to obtain organs for donation. In addition, the success rate of a trained organ procurement team from the organ donor network has a far higher rate of success at obtaining consent.
4- Inform the patient that you cannot accept her as a patient
A physician isn't legally or ethically obligated to accept every patient. The doctor-patient relationship is entirely voluntary on both ends. Neither party can be forced to enter it. Contrary to a common misconception, a patient isn't automatically entitled to have a doctor automatically agree to treat him. The issue is much easier in the case described in which the relationship has not truly begun. If you have an established relationship with a patient then you must give the patient written notice that you're ending the relationship in advance of discontinuing treatmnet in order to give him time to obtain a new caregiver. It's not considered discrimination to decline entering into the doctor-patient relationship for circumstances such as interpersonal difficulties. It would be discrimination and therefore unethical to refuse to treat a patient for on the basis of race, gender, ethnicity, sexual preference, or HIV status. However, although it would be considered unethical to refuse the patient in these cases, it's not illegal. You cannot ba legally compelled to provide care, to a patient you don't accept. The same way they can't be compelled to accept a physician they don't want. This includes emergency care as well.
Edited by fandarast on 11/11/07 - 12:43 PM
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