Ethical Situations, infectious diseases, euthanasia communication with patients, adherence, sick role

Question 1

Patient is not adherent

Answer 1

Attempt to identify the reason for nonadhetence and determine his willingness to change
Do not coerce the patient into adhering or refer him/her to another physician

Question 2

Patient desires an unnecessary procedures

Answer 2

Attempt to understand why
Address UNDERLINE concerns
Do not refuse to see the patient or refer to another physician
Avoiding performing unnecessary procedures

Question 3

Patient has difficulty taking medications

Answer 3

Provide written instructions
Attempt to simplify treatment regimen
Use teach-back method (ask patient to repeat medication refimen back to physician) to ensure patient comprehension

Question 4

Family members ask for informations about patient’s prognosis

Answer 4

Avoid discussing issues with relatives without the patient’s permission

Question 5

A patient’s family member asks you not to disclose the results of a test if the prognosis is poor because the patient will be “unable to handle it”

Answer 5

Attempt to identify why the family member believes such information would be detrimental to the patient’s condition
Explain that as long as the patient has decision making capacity and does not indicate otherwise, communication of information concerning his/her care will not be withheld

Question 6

A child wishes to know more about his/her illness

Answer 6

Ask what the parents have told the child about his/her illness. Parents of a child decide what information can be relayed about the illness

Question 7

a 17 years old is pregnant and request an abortion

Answer 7

Many states requires parental notification or consent for minors for an abortion.
Unless there are specific medical risk associated with pregnancy, a physician should not attempt to sway the decision of the patient to have an elective abortion (regardless of maternal age or fetal condition)

Question 8

Patient is suicidal

Answer 8

Assess the seriousness of the treat
If it is serious, suggest that the patient remain in the hospital voluntarily
Patient can be hospitalized involuntarily if he/she refuses

Question 9

15 year old girl pregnant and wants to keep the child. Her parents wants you to tell her to give her chid for adoption

Answer 9

The patient retains the right to make decision regarding the child, even if her parents disagre

Provide information to the teenager about the practical issues of caring a baby

Discuss the options, if requested.
Encourage discussion between teenager - parents

Question 10

A terminally ill patient request physician assistance in ending his/her own life

Answer 10

In the overwhelming majority of states, refuse involvement in any form of physician assisted suicide
Physician may however prescribe medically appropriate analgesic that coincidentally shorten the patient’s life

Question 11

A woman who had mastectomy says she now feels ugly

Answer 11

Find out why the patient feels this way

Do not offer falsely reassuring statement (“you still look good”)

Question 12

Patient states that he/she finds you attractive

Answer 12

Ask direct, close ended questions and use chaperon if necessary.
Romantic relationships with patients are never appropriate.
Never say “there can be no relationship while you are a patient” because this implies that a relationship may be possible if the individual is no longer a patient

Question 13

Patient is angry about the amount of time he/she spent in the waiting room

Answer 13

Acknowledge the patients anger, but do not take a patient’s anger personally.
Apologize for any inconvenience
Stay away from efforts to explain the delay

Question 14

Patient is upset with the way he/she was treated by another doctor

Answer 14

Suggest that the patient speak directly to that physician regarding his/her concerns.
If the problem is with a member of the office staff, tell the patient you will speak to that person

Question 15

An invasive test is perform on the wrong patient

Answer 15

Regardless of the outcome, a physician is ethically obligated to inform a patient that a mistake has been made

Question 16

A patient requires a treatment not covered by his/her insurance

Answer 16

Never limit or deny care because of the expense in time or money.
Discuss all treatment options with patients, even if some are not covered by their insurance companies

Question 17

A 7-years boy loses a sister to cancer and now fells responsible

Answer 17

At ages 5-7, children begin to understand that death is permanent, that all life functions end completely at death, and that everything that is alive eventually dies –> Provide a dierce, concrete description of his sister’s death. Avoid clishes and euphemisms. REASSURE THAT THE BOY IS NOT RESPONSIBLE. Identify and normalize fears and feelings. Encourage to play and healthy coping behaviours (eg. remembering her in his own way)

Question 18

legal standard of death in US (when a person’s death is beating)?

Answer 18

irreversible cessation of all functions of the entire brain, including the brainstem –> the doctor is autorized to remove life support

Question 19

a patients organs after death

Answer 19

cannot be harvest, unless the patient (or parent of a minor) has signed a document (eg. organ donor card) or informed surrogates wish to donate

Question 20

euthanasia in usa - legal?

Answer 20

in ALL states (and according to medical codes of ethics) –> it is a CRIMINAL ACT

Question 21

physician assisted aid in dying in USA- legal

Answer 21

it is legal in a very few states in CAREFUL selected patients

Question 22

USA - analgesia that coincidentally shorten life

Answer 22

it is legal and ethical to provide MEDICALLY NEEDED ANALGESIA to termiante ill patient, even if it coincidentally will shorten the patient’s life

Question 23

infections - usa - most states require physicians to report

Answer 23

varicella (chicken box), hepatitis, MMR
salmonela, shigella, TB, syphilis, gonorrhea, chlamydia
AIDS (or HIV without AIDS)

Question 24

HIV + physician

Answer 24

Physicians are not required to inform either patients or the medical establishment about another physician’s HIV + status. an HIV + physicians who follows procedures for infection control does not pose a risk on patients

Question 25

can a physician refuse to treat a patient because of fear of infection (eg. TB)

Answer 25

it is legally to refuce but it is UNETHICAL

Question 26

physician has the right to inform somebody for the HIV+ status of another patient

Answer 26

HIV + patients must protect their sexually partners. If they fail or refuse and the physician has knowlegde of this, the physician can inform the threatened partner

Question 27

Referral a patient to another physician - when

Answer 27

should be reserved for MEDICAL REASONS outside the range of the physician

Question 28

Interviewing techniques - direct questions?

Answer 28

are used to elicit informations quickly in an emergency situation, or when the patient is seductive or overly talkative

Question 29

Interviewing techniques - open ended question?

Answer 29

are used to obtain as much information as possible and encourage the patient to speak freely

Question 30

Interviewing techniques - children with difficulty to respond - techniques

Answer 30

1. question in third person (eg. what do you think a child who is scared would want the doctor to say)
2. non-verbal means of expression (eg. lets draw a picture together of someone going to the doctor’s office

Question 31

42 years old complains about how disorganized the doctor office is

Answer 31

i am sorry. pls tell me what you experieenced and let me know if you have any suggestion about how we can make it better (try to see the problem from the patient;s view. Patients, esp with OCD are often fearful about becoming dependent as well as being ill)

Question 32

50 years old dirty, dishevelled patient has had at least one complaint about the office or staff on every visit. today complains that one of the vest nurses was fresh to her

Answer 32

i apologize, i will speak ti the nurse about that (do not blame the patient, no matter how provocative he or she is, for problems with office staff)

Question 33

45 years old patient whose both parents died of CRC before 50 refuses to had colonoscopy because heard that the procedure is uncomfortable

Answer 33

“tell me more about your concerns related to the procedure”

identify the real reason for the refusal (fear that cancer will be found). DO NOT ATTEMPT TO FRIGHTEN THE PATIENT INTO ADHERING (eg. with photographs with untreated patients)

Question 34

68 years old female insists on stopping a needed treatment (chemotherapy) because it is making her uncomfortable

Answer 34

“lets discuss ways that we can make the treatment more tolerate to you”

do not stop treatment before alternatives have been explored

Question 35

a nurse tells the doctor that she saw a diabetes patient to put sugar in her coffee

Answer 35

“lets discuss your diet again”

do not become angry at noncompliant patient. This patient may need to be reminded of how to follow her diet

Question 36

a patient believes (falsely) that his poor health behavior is actually beneficial to him

Answer 36

“tell me more about how you fell about your cigarette smoking” (Do not recommend methods of smoking cessation until the patient express willingness to try to stop

Question 37

Without telling you what he is felling, a 54 hypertension patient asks the doctor to tell hime more about his illnes and side effect of the drugs

Answer 37

“tell me about the side effects you have been experiencing”

This patient may be reluctant to bring up embarrassing issues associated with the illness or treatment

Question 38

A 5 years old girl needs to have a procedure that involves minor pain

Answer 38

“this will feel like a bug bite and it will stop hurting after count to five together”. The doctor should tell the child about how much pain she is likely to feel in a way that she will understand

Question 39

The parents of a healthy 17 years old want the doctor to perform an abortion. the girs want to keep the baby whom tests have shown Down syndrome

Answer 39

Do not recommend a course of action, but do facilitate discussion about the options between the parents and the patient. The fact that baby has Down syndrome is irrelevant

Question 40

25 years old request a 1st trimester abortion from a physician who has religious and morel prohibitions against abortions

Answer 40

“I do not perform abortions, but i will refer to a doctor who does”. Doctors are not required to perform any procedure a patient request. Do not be judgemental, do not impose your own beliefs on the patient and do not try to change her mind

Question 41

An 82 years old has had 2 fall at home. She tells the doctor that her adult children are concerned and want her to go into a nursing home. She does not want to go

Answer 41

“let’s try to find out why you are falling”.
Then treat her medical problems and recommend environmental changes that allow her to stay safety at home as long as possible

Question 42

A 76 male who is of different religion than you are, tells the doctor that he had a religious vision while praying and asks the doctor to pray with him

Answer 42

“that mast have been a very important moment for you”

Although the doctor does not have to pray with the patient, he should show support and understanding

Question 43

A 60 dying patient asks thet doctor how long he has to live (3 months)

Answer 43

“While there have been exceptions, most people at this stage of the illness live about 3 months”

Be truthful and direct. Reassure the patient that you will not abandon him, but do not ofter philosophical or religious statements

Question 44

Interviewing techniques - aim and technique per aim

Answer 44

1. to establish support: a. support and empathy (interst and concern) b. validation (to give value and credits)
2. to maximize information gathering a. facilitation (encourage to speak) b. reflection (encourage to elaborate an answer) c. silence
3. to clarify information: a. confrontation (to call attention to inconsistencies in the patient response) b. recapitulation (to sum up informations)

Question 45

psychiatric vs physical illness according to morbidity and mortality

Answer 45

much higer in psychiatric illness

Question 46

the sick role - explain

Answer 46

a sick person asssumes a specific role in society and follows predictable behavioral patterns. These patterns include exemption from usual responsibilities, expectation of care by others, efforts toward getting better, and cooperation with health care personnel

Question 47

Adherence - is NOT related to

Answer 47

patient’s gender, religion, socioeconomic or marital status, race, intelligence, education

Question 48

factors that increase adherence

Answer 48

1. good physician-patient relationship
2. acute illness
3. simple treatment schedule
4. writen instruction
5. short time in waiting room
6. feeling ill and limitations of usual activities
7. Recommending one behavioural change at a time
8. beliefs that the benefits of care>time and money
9. peer support

Question 49

factors that decrease adherence

Answer 49

1. cold and unapproachable physician
2. few symptoms with little activity disruption
3. verbal instriction (not written)
4. chronic illness
5. Complex treatment schedule
6. long time at waiting room
7. Recommend multiple behavioral changes per time
8. Little peer support
9. Beliefs that money, time >care benefits

Question 50

Type A personality is characterized by

Answer 50

1. time pressure
2. competitiveness
3. Coronary artery disease

Question 51

Which patients are at greater risk for psychological reactions to illness, hospitalization, or surgery

Answer 51

1. history of psychiatric illness
2. if their relationship (family or medical staff) worsen
   - -> fear can result in anger expression
3. ICU patiens
4. Renal dialysis
5. Surgical patients with unrealistic exptections for a procedure