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Medical Ethics Exam 1 > End of Life Care > Flashcards

End of Life Care Flashcards

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USMLE® Step 1 flashcards
1
Q

Curing

A

The alleviation of symptoms or the termination or suppression of a disease process through surgical, chemical, or mechanical intervention

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2
Q

Healing

A

May be spontaneous, but more of it is a gradual awakening to a deeper sense of self (and of the self in relationship to others) in a way that effects profound change. Healing comes from within and is consistent with a person’s OWN readiness to grow and to change

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3
Q

What percentage of Americans die in in a hospital or nursing home?

A

70% (39% in hospital; 31% in nursing home)

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4
Q

Half of conscious patients had moderate to severe pain at least ___ before death

A

1/2 the time

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5
Q

__% of patients did not wish to have CPR… BUT physicians of more than half were NOT aware of DNR order preference

A

31

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6
Q

Nearly ___ of DNR orders were written within 2 days of patient death

A

half

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7
Q

__% of the patients spent at least 10 days in the ICU

A

40%

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8
Q

TENO Study: 1/4 of people who died did not receive enough pain medication and sometimes received none at all. Inadequate pain management was 1.6 times more likely to be a concern where vs where?

A

In a nursing home vs a home with hospice care

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9
Q

TENO Study: 1/2 of patients did not receive enough emotional support. This was 1.3 times more likely to be the case where?

A

In an institution

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10
Q

What is the biggest concern when considering yesterday’s solutions as today’s problems?

A
  • Cost*

e. g. Mechanical ventilation, Renal dialysis, Pacemakers/defibrillators, Organ transplantation

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11
Q

What are the major medical issues at the end of life?

A
  1. Withholding and Withdrawing Care (e.g. Invasive Nutrition, Resuscitation (DNR), Antibiotics)
  2. Medical Futility
  3. Assistance in Dying
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12
Q

What is the first question that should be answered when dealing with end of life care?

A

What is/are the PATIENT’S goal(s)?

***Ask this before “what else can we do here?” or “What else can we offer this patient?”

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13
Q

What is the object of all clinical decision-making?

A

First, to secure the health, well-being, or good dying of the patient and to do this in a manner that respects the integrity of all participants in the decision-making process.

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14
Q

What is the moral valance of technology?

A

Technology is NEUTRAL. How it is used gives it its moral valance.

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15
Q

In what context is there a huge difference between withholding and withdrawing treatment?

A

Emotionally

There is no difference morally, ethically, medically, legally, or religiously

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16
Q

What is the goal of withholding and withdrawing artificial nutrition and hydration?

A

Restoration/cure, stabilization, preparation for death

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17
Q

What is the process for withholding and withdrawing artificial nutrition and hydration?

A

After listening carefully to patient/surrogate decision-maker, MAKE A MEDICAL RECOMMENDATION (NOT a question) consistent with patient’s goals of care

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18
Q

Recommendations: Feeding Tubes in Advanced [End Stage] Dementia

A

Percutaneous feeding tubes are not recommended in patients with advanced dementia; rather, oral-assisted feeding is recommended

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19
Q

What are the 3 signals that indicate desire to refuse food?

A

Pursing lips, blocking with hand, and saying “No”

20
Q

What is 6-6-6-6?

A

What was your mother like 6 months ago, 6 weeks ago, 6 days ago, 6 hours ago?

Helps family members see that patient has been changing

What does this mean to you?

21
Q

What is involved in a “Goals of Care” conversation?

A
  1. Review the clinical situation
  2. Assess the decision maker’s understanding (6-6-6-6; what does this mean to you?)
  3. Establish patient’s Goals of Care
  4. Present options to manage clinical issues
  5. Weigh risks and benefits with values and preferences
  6. Measure effects the decision has on family and loved ones
  7. Offer additional sources of decisional support
  8. Provide ongoing support and recognize the need to revisit the decision
22
Q

Euthanasia

A

Clinician performs lethal intervention
Note: includes the intention that death is the result
Not legal anywhere in the US

23
Q

Physician Assisted Suicide

A

Clinician provides the means; patient acts

Legal in Oregon, Washington, and Montana; Vermont and New Jersey with restrictions

24
Q

Voluntary Euthanasia

A

Requested; Killed

25
Q

Involuntary Euthanasia

A

Expressed with wish to the contrary; Killed

26
Q

Nonvoluntary Euthanasia

A

Made no request/Gave no consent; Killed

27
Q

“Passive” Euthanasia

A

Erroneous term; Intent is lacking

28
Q

What are some Established Practices for Terminally Ill Patients?

A
  1. Voluntary/Informed refusal of treatment by patient
  2. Withholding and withdrawing treatment on behalf of incapacitated patients on the basis of substituted judgment or best interests
  3. Palliative and Hospice Care
29
Q

What are some Controversial Issues for Terminally Ill Patients?

A
  1. Voluntarily stopping eating and drinking
  2. Palliative sedation (aka “Terminal Sedation”)
  3. Physician Assistance in Dying
  4. Patient/surrogate demands for futile therapies –> Troubled Concept of Medical Futility
30
Q

What is the OVERUSED (and inappropriate) Clinical Argument for using analgesics that may hasten death?

A

“Better to give enough medication to control the patient’s symptoms than to have the patient suffer EVEN if this means the patient will die sooner”

31
Q

Principle of Double Effect: “Foreseen but not intended consequence”: Four Elements

A
  1. Nature of the act (good, at least morally neutral)
  2. Agent’s intentions (agent must intend only good; bad effects can be foreseen, tolerated, permitted, but not intended)
  3. Distinction between means and effect (bad effect must not be a means to the good effect)
  4. Proportionality between the good effect and the bad effect (good must outweigh the bad)
32
Q

Medical Futility

A

Unacceptable likelihood of achieving a therapeutic benefit for the patient

33
Q

Quantitative vs Qualitative Components of Medical Futility

A

Quantitative: how many times and to what degree do we have to fail before we agree to call a Rx futile?

Qualitative: PATIENT must have capacity to appreciate benefit of the Rx and the Rx should release pt from preoccupation with illness/render him or her capable of achieving other life goals

34
Q

Medical Futility: Effectiveness

A

Assessment of the capacity of the tx to alter the natural hx of the disease… objective determination by the CLINICIAN

35
Q

Medical Futility: Benefit Assessment of value, desirability of effect

A

Determination by the PATIENT

36
Q

Burden

A

Assessment of costs, discomfort, pain, inconvenience, both subjective and objective

Determined by PATIENT and CLINICIAN

37
Q

Considered medical futility when the proposed intervention… (4 things)

A
  1. Won’t achieve the patient’s goal
  2. Serves no legitimate goal of medical practice
  3. Is ineffective more than 99% of the time
  4. Does not conform to accepted community standards
38
Q

What is more common than unequivocal cases of medical futility?

A

Miscommunication, value differences

39
Q

Medical Futility: Due Process

A
  1. Earnest Attempts
  2. Joint decision making
  3. Negotiation of disagreements
  4. Involvement of an institutional (ethics) committee
  5. Transfer care to another physician
  6. Transfer to another institution
40
Q

Quinlan, 1975

A

First major “right to die” case

Process (Hospital Ethics Committee)

41
Q

Cruzan, 1990

A

First US Supreme Court ruling on “right to die”

Process (Patient Self-Determination Act (1991) Advance directive)

42
Q

Schiavo, 2005

A

Ruled Terri’s Law unconstitutional

Increased/Enhanced patient-physician communication

43
Q

What is the order of the Circle of Decision Makers?

A

Self –> Directions from Individual (Living Will/Durable Power of Attorney for Health Care) –> Best Interests –> Court

44
Q

What is the focus of Level I, II, and III of End of Life Care Discussions?

A

Level I: Individual

Level II: HCP

Level III: Institution

45
Q

Hospice

A

Is a PHILOSOPHY of care, not a location

Medical Ethics Exam 1 (5 decks)

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