Core ethical principles - informed consent - consent of minors- decision making capacity

Question 1

core ethical principles

Answer 1

1. autonomy
2. beneficence
3. nonmaleficence
4. justice

Question 2

core ethical principles - AUTONOMY

Answer 2

Obligation to: 1.to respect patients as individuals (truth-telling, confidentiality). 2. to create condtitions necessary for autonomous choice (informed consent). 3.to honor their preference in accepting or not accepting medical care

Question 3

core ethical principles - BENEFICENCE

Answer 3

Physicians have a special ethical (fiduciary) duty to act in the patient’s best interest

Question 4

Beneficence may conflict with

Answer 4

1. autonomy (an informed patient has the right to decide)

2. what is best for society (traditionally patient interest supersedes)

Question 5

core ethical principles - NONMALEFICENCE

Answer 5

do not harm

Question 6

Nonmalleficence must be balanced agaist….

explain

Answer 6

beneficence
if the benefits outweigh the risks, a patient may make an informed decision to proceed (most surgeons and medications fall into this category)

Question 7

core ethical principles - Justice

Answer 7

to treat persons fairly and equitably. This does not always imply equally (triage)

Question 8

informed consent is not just a

Answer 8

document/signature

Question 9

informed is a process (not just a document/signature) that requires:

Answer 9

• disclosure: discussion of pertinent information
• understanding: ability to comprehend
• capacity: ability to reason and make one’s own decision (distinct from competence, a legal determination)
  voluntariness: freedom from coercion and manipulation

Question 10

informed consent - patients must

Answer 10

• have an intelligent understanding of their diagnosis and the risk/benefits of proposed treatment and alternative options, including no treatment.
• be informed that he or she can revoke written consent at any time even orally

Question 11

informed consent - exceptions (and explain)

Answer 11

1. patients lacks decision capacity or is legally incompetent 2. implied consent in an emergency
2. therapeutic privilege: withholding information when disclosure would severely harm the patient or undermine informed decision - making capacity 4. Waiver-patient explicitly waives the right of informed consent

Question 12

a minor is generally –>

Answer 12

any person under 18

Question 13

parental consent-health-state

Answer 13

Parental consent laws in relation to health care vary by state in general, it should be obtained unless emergent treatment is required (eg. blood transfusion) even if it opposes parental religious/cultural beliefs, or if a minor is legally emancipated (eg. married, self supporting, military)

Question 14

parental consent - in general, it should be obtained unless

Answer 14

1. emergent treatment is required (eg. blood transfusion) even if it opposes parental religious/cultural beliefs
2. if a minor is legally emancipated (eg. married, self supporting, military)
3. sex (contraception, STIs, pregnancy)
4. Drugs (addiction)

Question 15

situations in which parental consent is usually not required:

Answer 15

1. sex (contraception, STIs, pregnancy)
2. Drugs (addiction)
3. emergency/trauma

Question 16

parental consent - physician should always encourage

Answer 16

healthy minor-guardian communication

Question 17

emancipated minor

Answer 17

at least one: 1. self-supporting 2. military 3. married

4. have a child for whom he or she cares

Question 18

decision making capacity - Physician must determine whether

Answer 18

the patient is psychological and legally capable of making a particular health care decision

Question 19

decision making capacity - components

Answer 19

1. patients>=18 years old or otherwise legally emancipated
2. patients makes and communicates a choice
3. patient is informed (known and understands)
4. decision remain stable over time
5. decision is consistent with patient’s values and goals not clouded by mood disorder
6. decision is not a result of altered mental status (delusions, delirium, hallucinations)

Question 20

Advance directives?

Answer 20

instructions given by a patient in anticipation of the need for medical decision –> Deatils vary per state law

Question 21

Advance directives - types

Answer 21

1. oral advance directive
2. living will (written advance directive)
3. Medical power of attorney

Question 22

oral advance directive?

Answer 22

Incapacitated patient’s prior oral statements commonly used as guide

Question 23

oral advance directive - disadvantages

Answer 23

variance in interpretation

Question 24

oral advance directive - when is more valid

Answer 24

1. if patient was informed
2. directive was specific
3. patient made a choice
4. decision was repeated over time to multiple people

Question 25

living will (written advance directive)?

Answer 25

describes treatments the patient wishes to receive or not receive if he/she loses decision-making capacity

Question 26

living will (written advance directive) - usually

Answer 26

patients directs physician to withhold or withdraw life-sustaining treatment if he/she develops a terminal disease or enters a persistent vegetative state

Question 27

Medical power of attorney?

Answer 27

Patient designates an agent to make decision in the event that he/she loses decision-making capacity. Patient may also specify decision in clinical situations. Can be revoked by patient if decision-making capacity is intact –More flexible than living will

Question 28

Medical power of attorney vs living will (written advance directive) according to flexibility

Answer 28

Medical power of attorney is more flexible

Question 29

Surrogate decision maker?

Answer 29

If a patient loses decision-making capacity and has not prepared an advance directive, individuals (surrogates) who know the patient must determine what the patient would have

Question 30

Surrogate decision maker: priority of surrogates (in order)

Answer 30

first: spouse –> adult children –> parents –> adult siblings –> other relatives

Question 31

confidentiality?

Answer 31

respect patients PRIVACY and AUTONOMY

Question 32

confidentiality if patient is not present or is incapacitated

Answer 32

disclosing information to family and friends should be guided by professional judgement of patient’s interest

Question 33

confidentiality - special characteristic

Answer 33

the patient may voluntarily waive the right to confidentiality (eg. insurance company request)

Question 34

General principles for exceptions to confidentiality

Answer 34

1. potential physical harm to other is serious and imminent
2. Likelihood of harm to self is great
3. No alternative means exists to warm to protect those at risk
4. Physician can take steps to prevent harm

Question 35

Examples of exceptions to patient confidentiality

Answer 35

1. Reportable disease (STI, TB, hepatitis, food poisoning) - physician may have a duty to warn public officials, who will then notify people at risk
2. Child and/or elder abuse
3. Imapired automobile drivers (eg. epileptics)
4. Suicidal/homocidal
5. The Tarasoff decision

Question 36

The Tarasoff decision?

Answer 36

California Supreme Court decision requiring physician to directly inform and protect potential victim from harm

Question 37

core ethical principles - AUTONOMY is the obligation

Answer 37

1. to respect patients as individuals (truth-telling, confidentiality). 2. to create condtitions necessary for autonomous choice (informed consent). 3. to honor their preference in accepting or not accepting medical care

Question 38

a competent patient patient request cessation of artificial life support?

Answer 38

both legal and ethical for the physician to do it

Question 39

causes of impaired physicians - types and management

Answer 39

1. substance abuse
2. physical or mental illness
3. old age
   Reporting is an ethical requirement because patients must protected and the impaired physician must be helped

Question 40

Most and least likely specialist that sued for malpractice

Answer 40

Most –> surgeons and anaesthesiologists

Least –> psychiatrists and family doctors

Question 41

recently there has been an increase in number of malpractice claims due to

Answer 41

breakdown of the traditional physician patient relationship

Question 42

For malpractice claim, the patient must prove that the physician demonstrated

Answer 42

1. dereliction (or negligence)

2. a duty that caused damags directly to the patient

Question 43

malpractice - crime

Answer 43

malpractice is a tort, or civil wrong, NOT A CRIME. A doctor may be required to pay money to compensate the patient for suffering as well as for medical bills and lost income

Question 44

if you are not sure about patients competence –>

Answer 44

assume that he is competent