Day 3.2 Behavioral Science- Ethics Flashcards
Autonomy
Respect pts as individuals, honor their preferences in care
Beneficence
Act in pt’s best interest. If it conflicts with autonomy, pt decides
Non-maleficence
Do no harm. (But if benefits outweigh risks- surgery- pt can mk decision to proceed)
Justice
Treat pts fairly
Informed consent- legal requirements
- discussion of risks, benefits, alternatives (incl no treatment)
- pt’s agreement to plan of care (signed document)
- freedom from coercion
Exceptions to informed consent (4)
- pt lacks decision-making capacity (use substituted judgement- what pt would have wanted) or is legally incompetent (minor)
- emergency = implied consent
- therapeutic privledge - withholding info if telling would severely harm pt or undermine informed decision-making capacity)
- waiver- pt waives right of informed consent
Consent for minors
parental consent must be obtained unless minor is emancipated (married, self-supporting, has kids, in military)
What counts as “has decision-making capacity” for a pt?
- pt makes and communicates choice
- pt is informed (risks, benefits, alternatives)
- decision remains stable over time
- decision is consistent with values and goals
- decision is not a result of delusions or hallucinations.
Note: pt’s fam cannot require that a doctor withhold info from pt (unless it’s a kid)
Oral advance directive
pt’s prior oral statements used as a guide.
problem with variance in interpretation
more valid if pt was informed, directive is specific, pt md a choice, decision was repeated over time, it was recent, and multiple ppl can validate what was said.
Written advance directive- what are the two types?
living will
durable power of attorney
Living will
What to do if pt is incapacitiated
Usu says to withhold/withdraw life support if pt has terminal dz or is in persistent vegetative state
Durable power of attorney
Pt designates surrogate to make medical decisions if pt loses capacity. Can also specify decisions in clinical situations. Surrogate retains power unless revoked by pt. More flexible than living will.
Exceptions to confidentiality
- potential harm to others
- high likelihood of harm to self
- no other means to warn/protect those at risk
- physicians can take steps to prevent harm
ex of exceptions to confidentiality
Infectious dz- docs have duty to warn public health officials and identifiable ppl at risk
child or elder abuse (even suspicion must be reported)
impaired automobile drivers
suicidal/homicidal pts- can hold them involuntarily
Tarasoff decision
Law requiring docs to directly inform and protect potential victim from harm; can breach confidentiality.
Malpractice
Civil suit under negligence requires 4 D’s:
1. Duty- doc had a duty to the pt
2. Derelection- doc breached the duty
3. Damage- pt suffered harm
4. Direct- the breach of duty is what caused the harm.
Burden of proof in a malpractice suit is “more likely than not”- so only 51%
Most common factor leading to litigation is poor communication.
Non-compliant pt
work to improve doc-pt relationship
educate
Pt has difficulty taking meds
give written instructions, try to simplify treatment regimen
Fam asks for info abt pt pgx
Can’t tell them without pt permission. Pt right to confidentiality.
17yo requests abortion
Needs parental notification/consent.
Consent NOT req’d for emergency abortion, treating STDs, medical care during pregnancy, mgmt of drug addiction
Terminally ill pt req’s end his life
Refuse doc-assisted suicide.
Can prescribe medically-appropriate analgesics that “coincidentally” shorten pt’s life
Pt finds you attractive
Ask direct closed-ended q’s
Use chaperone if necessary
NEVER have relationship w pt.
Don’t say “there can be no relationship while you’re a pt”- implies relationship is possible.
Pt refuses necessary procedure
or Pt wants unnec procedure
Find out why pt wants/doesn’t the procedure.
Address underlying concerns
Avoid unnec procedures
Pt angry abt wait time
Apologize
Don’t explain delay
Pt is upset by how other doc treated him
Suggest pt speak to that doc directly.
If problem is w office staff, tell pt you will speak to that person. (But not to other docs)
Kid wants to know more abt illness
Ask what parents have already told him.
Parents decide how much kid gets to know.
Pt continues to smoke, thinks it’s good for him
Ask how pt feels
Give advice on cessation if pt wants to make an effort to quit
Minor wants condoms
Provide counsel and condoms
Don’t need parental consent
Drug company offers referral fee for pts enrolled in a study
Doc can not receive compensation for enrolling pts.
Also can’t receive compensation for referrals to specialists, MRI providers, etc
Prego 15yo wants to keep baby, her parents want to put it up for adoption
15yo decides. Provide info, discuss options, encourage discussion bt pt and parents.
Even tho she’s a minor she gets to make decisions for her child.
Pt is suicidal
Assess seriousness of threat. If serious, suggest pt remains in hosp voluntarily, if not can keep him involuntarily.
Woman w mastectomy feels ugly
Ask why
Do NOT offer reassuring statements- not your job.
Exceptions to parental consent for minors
Dz req’d by law to treat- STD (gonorrhea), TB
Minor is prego and need care (everything except abortion)
Treatment for drug addiction/dependency
Birth control prescriptions
Emergency where consent can’t be obtained
APGAR score
1-10, evaluated at 1 min and 5 min. Appearance Pulse Grimace Activity Respiration
0/1/2: A: blue/trunk pink/all pink P: none/100 G: none/grimace/grimace+cough A: limp/some/active R: none/irreg/regular
Low birth weight definition and assocations
<2500grams
Greater incidence of physical, emotional problems
Caused by prematurity or IU growth problems
Complications of low birth weight:
Infections
Respi distress syndrome (immature Type II pneumocytes)
necrotizing enterocolitis
intraventricular hemorrhage
persistent fetal circulation (PDA, Patent FO)
What are the main infections in neonates?
E. coli
Listeria
Group B Strep
3months:
Gross Motor: rolls over, hold head up, moro reflex disappears (falling)
Fine Motor: hands together
Verbal: laugh, squeal (social smile)
Self-care: n/a
6mo
Gross Motor: sit alone (FA says 7-9mo)
Fine Motor: pass a block
Verbal: single syllables
Self-care: self-feed with hands
12mo
Gross Motor: stand and walk(FA says 15mo)
Fine Motor: put block in cup (FA says stacks 3)
Verbal: 1-3 words
Self-care: drink from cup
15mo
Gross Motor: walk backward, run Fine Motor: 2-block tower (FA says stacks 3 at 12 mo) Verbal: 6 words Self-care: use fork/spoon Babinski disappears. Separation anx
18mo
Gross Motor: climb stairs, kick ball
Fine Motor: 4-block tower
Verbal: combine words
Self-care: brush teeth with help
2 yr
Gross Motor: jump up
Fine Motor: 6-block tower
Verbal: half-understandable to strangers (FA: 2 word sentences; 200 words; object permanence)
Self-care: wash/dry hands
When does gender identity develop
Between 2-3 years old
3 yr
Gross Motor: jump forward, ride tricycle (3 at 3)
Fine Motor: copy a circle, dash, line (FA9blocks)
Verbal: completely understandable- 900 words, complete sentences
Self-care: brush teeth, make cereal, dress themselves, board games
4 yr
Gross Motor: hop on one foot
Fine Motor: draw cross, stick figure; button clothes
Cooperative pla
Imaginary friends!!
Grooms self, brushes teeth, buttons and zips
5 yr
Gross Motor: tie shoes
Fine Motor: copy square, triangle
Verbal: identify coins, colors, count to 5
When is toilet training?
Between 2-3 years
Pee at 3
9mo
Gross motor: crawling
Has stranger anxiety (7-9mo)
Birth-3mo
Rooting reflex
Orients to voice
Car seats
20lbs back seat, face forward
4yrs and 40+lbs booster seat in back until 4’9’’ (usu 8-12 yrs) so that belt fits correctly.
Belted in back until 13yr
Tanner stages: boys
1: prepubertal
2: enlgmt scrotum and testes
3: enlgmt of penis (length first)
4: enlgmt of penis (breadth), testes, and scrotum, scrotum darkens
5: adult
Tanner stages: pubic hair
1: prepubertal
2: sparse longs, slightly pigmented
3: darker, coarser, curlier
4: adult hair but in sml area
5: adult hair in lg area
Tanner stages: girls
1: prepubertal
2: breast bud w elevation of breast and papilla, areola enlarges
3: further enlgmt
4: areola and papilla form secondary mound about lvl of breast
5: papilla only projects, areola recesses
M/F ages of development
Female: breast-11, growth spurt-12, menarche-13
Male: stage 2- 12yo; growth spurt- 14-15yo
Chgs in elderly (8)
- Sexual (M-slower erection/ejaculation, longer refractory period; F-vag shortens, thins, dries- atropic vaginits)
- Sleep patterns: decreased REM, decrsd slow wave (3&4), increased latency and awakenings. Mostly stay in stg 1&2
- Common medical conditions-arthritis, HTN, heart dz, osteoporosis
- Decrsd incidence of psychiatric disorders
- Increased suicide rate (esp males 65-74yo retired)
- Decrsd vision, hearing, immune resp, bladder control
- Decrsd renal, pulm, GI fn
- Decrsd muscle mass, incrsd fat
What are the changes in sleep patterns in depressed pts?
Increased REM and decreased latency (so get to REM quicker)
Decreased slow wave (3&4)- this is also seen in elderly.
Latency in sleep
How fast you get to REM sleep.
Increased latency means it takes longer to get there (seen in elderly)
Decreased latency means you get to REM quickly (seen in depressed pts)
Grief- normal
Shock, denial, guilt, somatic symptoms
Up to 2 months depressed.
Usually lasts 6mo-1year.
May experience illusions (see normal stimulus and misinterpret- eg see someone and think it’s deceased person)
Grief- pathological
Excessively intense or prolonged grief
Grief that is delayed, inhibited, or denied
May experience depressive sympt, delusions, hallucinations (seeing things that aren’t there)
Become pathological when:
Depression criteria are met after the first 2 months, for a period of 2 wks or more
Generalized feelings of hopelessness, worthlessness, helplessness, guilt (this is deprsn)
Suicidal ideation
Feelings do not diminish in intensity by 6mo
Inability to engage, move on, trust others by 6mo
Kubler-Ross grief stages
Death Arrives Bringing Grave Adjustments:
Denial
Anger
Bargaining
Grieving (depression)
Acceptance
Stages don’t occur in order, can have >1 at one time.
Also occur in mjr life chgs- marriage, baby
Effects of stress
Incrsd production of FFA and 17-OH corticosteroids (immunosuppression), lipids, cholesterol, catecholamines
Decreased water absorption, muscular tonicity.
Gastrocolic reflex- defecate more
Mucosal secretion
DDX for sexual dysfn
- Drugs- esp anti-HTN (B-blockers), neuroleptics, SSRIs, ethanol
- Diseases (deprsn, diabetes, hyperprolactinemia, low testosterone)
- Psychological (performance anx, fear of heart attack)
BMI
weight in kg / (height in m)^2 18.5-24.9 normal 25-29.0 overweight >30 obese >40 morbidly obese
Restless leg syndrome
Unpleasant parathesias compels pt to have voluntary, spontaneous, continuous leg mvmts- crawling on legs, worms in mucles
Usu primary idiopathic disorder
Secondary RLS can be from iron deficiency, end-stg renal dz, diabetic neuropathy, parkinson’s, prego, rheumatic dzs (RA), varicose veins, caffeine
Rx for RLS
Pramipexole or Ropinirole (or levidopa, carbodopa) (these are used to treat parkinson's too) iron replacement avoid caffeine clonazepam gabapentin (anti seizure) opoids (last line)
How much time (percentage) is spent in each sleep stage?
1: 5%
2: 45%
3-4: 25% (slow wave sleep)
REM: 25%
What are the stages of sleep?
Awake (eyes open), alert, active mental concentration
Awake, eyes closed
Stg1: light sleep
Stg2: deeper sleep, bruxism
Stg3-4: deepest non-REM sleep. sleepwaking, night terrors, bed-wetting/enuresis. slow wave sleep
REM: dreaming, loss of motor tone, memory processing, penile tumescence (erection), increased O2 use by brain
EEG waveforms
1: theta
2: sleep spindles and K complexes
3-4: delta (slow wave- lowest frequency, highest amplitude)
REM: beta
Awake/alert - beta
Awake w eyes closed- alpha
(if you count beta and alpha beforehand): BATS Drink Blood at night
Key to initiating sleep
Sertonergic predominance of the raphe nucleus of the brainstem
Which stage is reduced by NE?
REM
NE is a stimulant
Extraocular mvmt during sleep
Happen during REM
Due to activity of PPRF/conjugate gaze center
(PPRF does horizontal eye mvmt- REM, saccades, nystagmus)
Other terms for REM
paradoxical sleep
desynchronized sleep
terms used bc REM has same EEG pattern as awake/alert (Beta)
How do benzodiazapines affect sleep?
Shorten stg 4
Good for night terrors and sleepwalking
How does imipramine affect sleep?
Shortens stg 4
Used to treat enuresis
How do alcohol, benzos, barbituates affect sleep
Assoc’d w decreased REM and decreased delta waves (Stg3-4) so reduce high-quality sleep.
Stg 3-4 + REM is 50% of the total sleep time
REM sleep
Increased and variable pulse during REM Also increased and variable BP Penile/clitoral tumescence Occurs every 90min, increasing duration throughout night. ACh is the main NT REM decreases w age
REM is like sex: increased pulse, tumescence, decreases with age
Narcolepsy
Disordered regulation of sleep-wake cycles
May include hypnaGOgic (GOing to bed) or hypnopoMic (Morning, just before awakening) hallucinations
Sleep episodes (both nocturnal and narcoleptic) start with REM.
Cataplexy in some pts
Strong genetic component
Cataplexy
Feature of narcolepsy
Loss of all muscle tone following strong emotional stimulus (often laughter)
Rx for narcolepsy
avoid drugs that cause drowsiness
scheduled naps
stimulants- modafinil is 1st line; amphetamines
support group
if cataplexy: venlafaxine, fluoxetine, atomoxetine- used for ADHD
Sodium oxybate (GHB) can help reduce cataplexy
Circadian rhythm
SCN of hypothalamus controls ACTH, prolactin, melatonin, nocturnal NE rls.
SCN –> NE rls –> pineal gland –>melatonin.
SCN is regulated by light.
Retina (not having light) stim’s SCN
Sleep Terror Disorder
Periods of terror with screaming in middle of night.
Occurs during slow-wave sleep (stg 3-4), usu in kids
Not nightmares- no memory of event
Difficult to arouse pt during episode
When is bedwetting (enuresis) treated?
Can’t be dx’d until 5yo (developmental, not just chronological)
Usu wait until 7yo to treat
How is enuresis treated?
First line- behavioral:
toilet training
motivational therapy (star chart)
restrict fluid before bed
night time chaperone, night light, scheduled waking
enuresis alarm pad- classic conditioning. mist effective long-term therapy
2nd line: drugs (but high likelihood of recurrence when you stop)
Imipramine for short term- decreases stg 4
Desmopressen (DDAVP)- anti-diuretic. used to be intranasal but that caused seizures (retain water, so decreased Na+, so seizure)
Indomethicin suppository- decrsd renal bld flow, so decrsd GFR, so decrsd urine
