Ethics Flashcards
T or F: Withdrawal of care must always be proven brain death.
False
- i.e. 7 y.o. CP with MVA presents GCS 4. ICU x 1 week with no change. if parents certain to withdraw they can.
Jehovah’s witness need emergent blood. What do you do?
Transfuse now without parental consent.
What are exceptions to general duty to provide life-sustaining tx?
- No Tx.
- Tx harmful.
- Going to die fast.
- Withdrawal better palliation.
Details:
- distress or suffering cannot be prevented or alleviated
- tx clearly ineffective or harmful
- irreversible progression to imminent death
- life to be severely shortened regardless of tx; withdrawal or limited care provide better palliation
T or F: withhold or withdraw life-sustaining tx ethically appropriate if tx will not benefit child or adolescent.
True
Tips with withdrawal or withholding care:
- interdisciplinary team involved +/- ethics committee or consultant
- recognize cultural, religious, spiritual, moral bkgrd of families
- document + review well decision well
Management decisions should ALWAYS be based on:
best interest of child
NOT:
- cost to society
- burden to fam
T or F: Autonomy may be superseded with CAS if child apprehended.
True.
- CAS authority can supersede wishes of parent + child if apprehended.
T or F: tx decision from proxy decision makers cannot change once made.
False.
What is a substitute decision maker?
- guardian respect child’s previously expressed wishes
What is a proxy decision maker?
= decision makers if pt incapable
- two types:
> substitute= know well and already discussed what they want done
>surrogate= don’t know but decide in best interest
List 3 Hallmarks of Informed Choice
“VIC”
- VOLUNTARIness (no manipulation or coercion)
- Appropriate INFO
- CAPACITY
What is assent?
Info they can understand and appropriate choice of tx.
- i.e. which arm to poke for BW
- best for kids w/ partial skills to make decision
What’s the difference between emancipated versus mature minors?
Emancipated: no longer dependent on parent.
Mature= irregardless of age can understand health condition and tx
If you think parental decision not in best interest of child- what do you do?
- explore decision w/ multi-D
- 2nd opinion.
- ethics committee or consultant
- or if all consultants agree contrary then legal opinion
T or F: there is minimum age for decision making?
False.
Brain death =
irreversible cessation of entire brain (inclding brainstem)
AKA determination of death using neuro criteria
Brain death is most commonly after:
- TBI
2. Asphyxia injury
What are the 3 clinical components of brain death:
- Irreversible coma with known cause
- not metabolic, toxin, drugs, T, lytes etc. - Absence of brainstem reflexes
- pupillary light, oculocephalic, corneal, oculovestibular, gag + cough - Apnea
- no resp effort after adequate stimulus
+ observation period x 2 examinations (12-24h)
T or F: spinal reflexes may occur in brain death
True.
- subtle, semi-rhythmic movement of facial nerve, finger flexion, tonic neck etc.
What is the apnea test in brain death?
Goal: assess function of medulla in driving vent
1- ensure no other reason for apnea (i.e. sedative drugs, metabolic)
2- pre-O2 100%
3- vent adjusted to get PCO2 40
4- baseline gas
5- repeated blood gas till target PCO2 suppressed (60) or unstable
Are EEG and Cerebral blood flow required for brain death dx?
No.
Ancillary test.
- may do if can’t do apnea test well
+ help shorten observation period
Most kids on peds organ donation waiting for:
liver
kidney
small bowel
T or F: anyone can approach families about organ donation
False.
- AAP: approach in systematic person trained in psych, social, medial part of dx
Who can be considered for organ donation?
- declared brain death
- cardiocirculatory death
T or F: consent is all or nothin (no organ specific)
False.
Organ specific
Contraindicatons to Organ Donation:
“PIMM”
Prematurity
Infection (septicemia, TB, Creutzfeldt-Jakob dx, HIV, west nile, Hep B, Hep C)
Malignancy
Mets (disseminated)
Child with severe head injury. Father suspected of abuse. What do you do about withdrawal of care?
Court, Parents both decide, Police need to be aware?
Parents both decide
AAP: decision re: life-sustaining tx for kids injured by suspected abuse should be determined by same send as other kids.
T or F: patient does not need to be brain dead to consent to be obtained for organ donation?
True.
- pt suffered devastating or irreversible brain injury
- near death but does not meet formal criteria
- fam may withdraw and when heart stops organs recovered in OR
- can recover up to 1hr after withdrawal of support
T or F: parent’s wishes are more imp than MD fiduciary obligation to act in best interest?
False.
What is reasonableness when someone makes SDM decision?
Best option= one most rational people would choose after all factors considered?
Define autonomy
Right of individual to make decision and act freely without interference.
Define beneficence
Responsibility of physician to act in patient’s best interest
Old theory of parental authority=
right of parent to make decision for child because considered property of parent= BAD
Define non-maleficence
Do not harm
Clinical tip: what guideline can you refer to if ensure if parental decision oppose best interest for child?
Does it fit….
“All children are entitled to medical tx that is likely to
- prevent serious harm
- prevent suffering
- prevent death”
What are high risk sexual assaults traits for transmission of STI?
- pt has STI signs
- suspected perpetrator has known STI
- genital, oral, anal penetration or ejaculation
- someone living in household has STI
- pt or parent requesting test
What do you disclose to police re: a pt?
- refrain from patient info unless patient consent or warrant/ court order/ subpoena
Is it appropriate to donate organs from anencephalic baby?
No.
- do not usually satisfy brain death b/c adequate brainstem f’n
- once death occur usually organ have irreparable ischemic damage (which occurs due to gradual brainstem deterioration even on life support)
What special consideration may you keep in mind for teenager who hung herself?
- high cervical spine injury= confounding factor to clinical assessment for neurologic brain death
- R/O cervical spine injury before full assessment for brain death
- if can’t do clinical test due to injury= ancillary tests!
Which withdrawal consideration must you make for child submersed in cold water?
- rewarm to min. 34C before resus stopped
- if survive + CVS stable serial neuro exam x 48-72h (as can see significant gains)
- consider withdrawal if no neurologic recovery after this.
Which is true for kids in foster care:
a. in older kids occasional visit warranted if pvx strong attachment
b. disruption in continuity of care potentially harmful
c. if loving in foster home in 1st year of life- will do well.
d. child should be placed with grandparents for best long term oucome
B. Disruption of continuity of care may be potentially detrimental to all kids.
List common medical issues that arise with foster care admission?
- poor hygiene
- under immunization
- dental neglect
- contraception
T or F: mental health problems + behavioural found in 1/2 of foster care kids
True
