Ethics

Question 1

True or false: Adult patients of sound mind are allowed to refuse life-saving treatments.

Answer 1

True.

You should not force blood products, antibiotics, or any other treatments on a patient who does not want them.

Question 2

What should you do if a child has a life-threatening condition and the parents refuse a simple, curative treatment (e.g., antibiotics for meningitis)?

Answer 2

First try to persuade the parents to change their mind; if this fails, attempt get a court order to give the treatment.

Do not treat until you have talked to the courts unless it is an emergency. Even with Jehovah’s witnesses who do not want their children to receive a blood transfusion, you should seek the court’s assistance in getting the transfusion if it is the only treatment option available.

Question 3

True or false: People with terminal illnesses can choose to die.

Answer 3

TRUE

This is the rationale behind hospice care. Let competent people die if they want to do so. Do not commit active euthanasia, but respect a patient’s wishes for passive euthanasia.

Question 4

What is the difference between active and passive euthanasia?

Answer 4

Active euthanasia is the intentional hastening of death

Passive euthanasia is withholding treatments and “letting nature take its course.”

Question 5

With whom can you discuss your patient’s condition?

Answer 5

Only with people who need to know because they are directly involved in the patient’s care and with people authorized by the patient (e.g., authorized family members). Do not tell a medical colleague who is uninvolved with the patient’s care how that patient is doing, even if the colleague is a friend of yours or the patient.

Question 6

In what situations are you allowed to breach patient confidentiality?

Answer 6

The patient

• asks you to do so.
• has a reportable disease
• is a danger to others
• is abused

The courts mandate you to do so.

You must fulfill the duty to warn or protect (if a patient says that he is going to kill someone or himself, you have to tell someone, the authorities, or both).

Question 7

What are the components of informed consent?

Answer 7

• Diagnosis (his or her condition and what it means).
• Prognosis (the natural course of the condition without treatment).
• Proposed treatment (description of the procedure and what the patient will experience).
• Risks and benefits of the treatment.
• Alternative treatments.

Question 8

What should you do if a patient is incompetent to make decisions?

Answer 8

Get the family and/or courts to appoint a guardian (surrogate decision maker or health care power of attorney).

Question 9

True or false: A living will should not be respected if the next of kin asks you not to follow it.

Answer 9

False.

living wills or patient-mandated “do-not-resuscitate” orders should be respected and followed if properly documented. The classic question involves a patient who says in a living will that if he or she is unable to breathe indepen- dently, a ventilator should not be used. Do not put the patient on a ventilator, even if the husband, wife, son, or daughter tells you to do so.

Question 10

What should you do if a patient is in critical condition or in a coma and has made no advance directive or living will?

Answer 10

The wishes of the family, next of kin, or health care power of attorney should be followed. In cases of disagreement among family members, suspicion of ulterior motives, or uncertainty, involve the hospital’s ethics committee. As a last resort, go to the courts for help.

Question 11

What about depression in the context of end-of-life decisions?

Answer 11

Depression always should be evaluated as a reason for “incompetence.” Patients who are suicidal may refuse all treatment, but their refusal should not be respected until the depression is treated.

Question 12

True or false: In some circumstances, patients can be hospitalized against their will.

Answer 12

True.

Psychiatric patients frequently are hospitalized against their will if they are deemed to be a danger to themselves or others. Patients can be held only for a limited time (1 to 3 days) before they must have a hearing before a court official to determine whether they must remain in custody. These decisions are based on the principle of beneficence (the principle of doing good for the patient and avoiding harm).

Question 13

True or false: Restraints can be used on patients against their will.

Answer 13

True.

Restraints can be used on an incompetent or violent (e.g., delirious, psychotic) patient if needed, but their use should be brief and reevaluated often (at least once every 24 hours). Be aware that the use of restraints in delirious or demented patients rarely helps and may cause injury.

Question 14

When do patients younger than 18 years of age not require parental consent for a medical decision?

Answer 14

• if they are emancipated (married, living on their own and financially independent, raising children, or serving in the armed forces)
• have a sexually transmitted disease
• want contraception
• are pregnant
• want illicit drug treatment or counseling
• have psychiatric illness.

Some states have exceptions to these rules, but for Step 2 purposes in such situations, let minors make their own decisions.

Question 15

What should you do if a child has a medical emergency and the parents are unavailable for decision making?

Answer 15

Treat the child as you see fit; that is, act in the child’s best interest.

Question 16

True or false: It is acceptable to hide a diagnosis from a patient if the family asks you to do so.

Answer 16

False.

Do not hide a diagnosis from a patient (including a child) if the patient wants to know (even if the family asks you to do so).

Do not lie to any patient because the family asks you to do so.

Conversely, you should not force patients to receive information against their will; if they do not want to know the diagnosis, do not tell them.

Question 17

What should you do if a patient requires emergency care but the patient cannot communicate and no family members are available?

Answer 17

Treat the patient as you see fit unless you know that the patient wishes otherwise.

Question 18

True or false: Withdrawing care and withholding care are the same in the eyes of the law.

Answer 18

True. It is important to communicate this principle to family members who feel guilty. The simple fact that a patient is on a respirator does not mean that you cannot turn the respirator off.

Question 19

True or false: In terminally ill, noncurable patients, one of the primary goals is to relieve pain.

Answer 19

True.

Opioids are commonly used, even though they may cause respiratory depression. It is more important to make patients comfortable and pain-free than to worry about respiratory depression in this setting.