Ethics Flashcards
True or False: There is no ethical difference between withholding or later withdrawing treatment
True
True or False: The opinion and guidelines of the family prevail over your opinion as the physician
True
What should be done in cases where there is conflict between you and family (interests of the child in your opinion differ from the parent/guardian’s opinion)?
Get ethics committee involved
True or False: It can be appropriate for a “mature minor” (>14) to have a say in their treatment
True
What happens in terms of parents wishes in cases where they are perpetrators of child abuse?
Alternate guardian is assigned and hospital ethics committee must be involved to determine who makes decisions
What determines when and how to implement DNR orders?
Family values and decisions
What are beneficial interventions or required reconsiderations in terms of DNR?
Temporary revisions to standing DNR orders (for instance, what is allowed in the OR if a child with a DNR is having a surgical procedure)… these need to be planned in advance and very specific
What do beneficial interventions or required reconsiderations allow parents to do?
Distinguish between interventions they feel comfortable with and the resuscitative efforts they wish to avoid (guidelines should try to encompass any possible occurance).
Whose responsibility is it to meet with and educate everyone (parents, school providers, ect) about what is and is not considered resuscitation and what interventions are allowed within the DNR context for a child?
The PCP
Any question dealing with cost containment (AKA conflict of interest between insurance companies and needs of patients) should be answered with what?
Advocating for the patient
What is cost sharing?
Insurance companies provide financial incentive for limiting the use of consultants and resources
What is the most common and most challenging conflict of interest in terms of health care costs?
Cost sharing
What are loyalty conflicts?
When you need to refer outside your ongoing network of specialists and affiliated institutions
What is paperwork burden?
Time consumed getting prior authorization and appeals for rejected services (this time isn’t reimbursed and represents a financial disincentive)
Loyalty conflicts and paperwork burden are examples of what in pediatrics?
Conflicts of interest (pediatricians financial interests are in conflict with child’s needs)
In the NICU, all decisions are based on what?
Newborn’s best interest, factoring in parental wishes (in the end, newborn’s best interest overrides parental wishes)
What happens in the NICU if parents wishes aren’t in the best interest of the newborn?
Get ethics involved
What should you do in the NICU if treatment is clearly futile and parents want to continue?
Override parents with ethics committee help
What should you do in the NICU if the best interests aren’t clear, but parents wish to withdraw care?
Defer to parent’s authority
Withdrawal must be based on what?
Best long term interests of the infant
True or False: In terms of extreme prematurity, the gold standard is the % survival with maximal care rather than gestational age alone
True
True or False: Taking cost into consideration is unethical
False- on a global level, this is very ethical
Which unit typically has costs that are disproportionately high?
NICU
True or False: If there is no chance of survival, don’t code
True
What rules if there is a good prognosis for a child?
Parental preference
What must be implemented if a good outcome is likely?
Resuscitation and treatment
True or False: Withdrawing and witholding support are inappropriate terms to be used around a family
True
True or False: Good outcome is a subjective term
True
What is the dead donor rule?
Removal of both paired/vital organs and a non-paired organ cannot precede or cause death
What is considered to be a controversial definition of death?
Cardiorespiratory death
What cannot factor into the donor status of a patient?
DNR order
True or False: Children can be stem cell donors for siblings
True
True or False: Parents who decide to conceive another child so the new child can become a savior sibling is unethical
False- this is not considered to be unethical in and of itself
Name 5 conditions that have to be met when siblings are considered as stem cell donors
- No adult or other donor options are available
- A strong positive relationship between siblings
- Both the donor and recipient are to benefit
- Risk to donor is minimal
- In addition to parental permission, the child, if old enough must also agree (assent)
What involves wakefulness and awareness of self and environment?
Consciousness
Patients with what state lake wakefulness and also lack awareness of self and environment?
Coma
Patients in what state lack awareness, but do have wakefulness?
Vegetative
In order to declare brain death what must be done?
Conditions that can mimic brain death must be treated or excluded (metabolic derangements, intoxication, hypothermia)
What 6 factors must be considered for a child who could be a solid organ donor?
- No adult or other donor options are available
- A strong positive relationship between siblings
- Both the donor and recipient are to benefit (benefit to donor is largely psychological)
- Risk to donor is minimal (surgical risk)
- In addition to parental permission, the child, if old enough must also agree (assent)
- The absence of coercion must be verified by a 3rd party
Why would a sibling with severe cognitive disabilities not serve as a solid organ donor for a sibling?
Sibling with disabilities wouldn’t likely benefit psychologically from this (needs to have mutual benefit)
Why do children <11 get priority on kidney donor waiting lists?
Due to the impact of renal disease on growth and development
True or False: Autonomy and bodily integrity of the mother is critical and must be honored
True
True or False: Pregnant women have the same rights to make medical decisions as those who are not pregnant
True
For anything questions regarding conflict of maternal-fetal interest, what is the key thing to do?
Discussion of all aspects of the conflict and respect Mom’s decision
What is assent?
Willingness to accept treatment
True or False: Assent is mandatory before treatment begins
False- it is preferred, but not mandatory (consent is mandatory)
True or False: Immunizations aren’t considered to be life saving
True
True or False: In situations where the treatment is likely to prevent substantial harm, the child’s right to treatment outweighs parental religious freedom
True
True or False: In situations where treatment will happen regardless of the child agreeing to it (assent), the child should be told this
True
True or False: Newborn screening is mandatory
False
*Parents give passive permission by doing nothing…they must sign a waiver to opt out of newborn screening
What 3 things should be considered when deciding if a disease should be included in newborn screening?
- Does it have significant deleterious effect on the child
- Does it have effective treatment available if diagnosed early
- Is there a screen that is acceptable to the population
True or False: Newborn screens are diagnostic
False
*False positives are common…this triggers need for more definitive testing
True or False: Some cases of disease get missed by newborn screening
True- If presentation is classic, workup the child for the disorder in question
True or False: If the newborn screen comes back positive, you should refer for genetic counseling
False
What do you need to do in cases of testing for carrier status of a disease or fetal testing of certain diseases?
Make sure parents have all the information needed to make a decision and you have not pressured them in any way
Name 1 example of a condition for which ethics committees will refuse genetic testing in siblings until they are 18
X-linked adrenoleukodystrophy
Who should be involved in determining which gender to raise a child with a disorder of sex development?
Multidisciplinary approach
What are two important factors to consider in the management of a child with a disorder of sex development?
- Any genital surgery as a child should be potentially reversible if the patient would want to change gender in adulthood
- Fertility should be preserved if possible
How should you tell a child about a disorder of sex development?
Gradually and based on developmental level (don’t surprise them with this when they are older)
What type of medicine is intended to be based on knowledge of safety and efficacy obtained from randomized, controlled trials?
Conventional
*This excludes all treatments that aren’t supported by such studies/evidence
What are treatments that are outside of conventional treatments and include chiropractic treatments, herbs, bioelectronics remedies, and nutritional therapy?
Alternative medicine
What type of medicine uses both alternative treatments and conventional treatments?
Complementary medicine
What form of medicine blends conventional medicine and alternative therapies (has some evidence of safety and effectiveness)?
Integrative medicine
What is the difference between complementary and integrative medicine?
Integrative includes things that were initially alternative, but now are evidence based (probiotics, omega 3’s, ect)
True or False: Some herbs and vitamins can interfere with metabolism and elimination of medications
True (think about this if there is a medication that isn’t as effective as it was in the past)
What basic rule applies whether you are discussing conventional or non-conventional treatment?
Risk-Benefit
True or False: Courts won’t interfere with the use of alternative treatment unless it’s life-threatening or coupled with refusal to use conventional treatment
True
True or False: Meds that are less effective than proven conventional treatments shouldn’t be used instead of these proven conventional treatments
True
If a doctor isn’t comfortable with an alternative therapy, is transfer to another physician who is comfortable appropriate?
No
What should you counsel parents on in situations regarding enhancement therapies?
- Importance of individualism
- Happiness is independent of extrinsic factors
What are 4 conditions for which growth hormone is FDA approved?
- Turner
- Chronic renal insufficiency
- Prader-Willi
- Non-growth hormone deficient idiopathic short stature
True or False: It is okay to accept small gifts from pharmaceutical reps
False
True or False: A gift textbook is appropriate
True- but only if it helps to improve treatment
When is a sponsored CME lecture beneficial?
If the speaker has complete and unbiased control of what is presented
True or False: Are samples to a patient appropriate
Yes, it helps the patient
When are patient samples not appropriate?
If this leads to the prescription of a costly medication when a less expensive alternative is available
What is an important thing to remember for patients in terms of cost of healthcare?
Anything leading to increased cost when less expensive and equally effective treatments are available means the patients needs aren’t being met
What are 3 things to remember regarding ethics committees?
- Members should be from different backgrounds and perspectives
- Subcommittees should answer to main ethics board
- CME on ethics topics are needed to keep members qualified
How should you tell a child that they are HIV positive?
Slowly over time and consistent with the developmental stage of the child
What is really important for HIV positive teens and helps to ensure treatment compliance?
Support
What activity modifications should you recommend for HIV + patients?
Against close contact sports where bloody/bodily fluid transmission is likely (boxing, wrestling, ect.)
True or False: Parents are required to disclose a child’s positive HIV status to school
FALSE
*Schools need to handle every situation with universal precautions
What measure should teens with HIV do in terms of decisions regarding health care?
Identify a health proxy to make decisions for them if they become incapacitated
Children who are exposed to what are at risk for physical injury, likely to be aggressive with their peers, prone to separation anxiety as toddlers, at risk for school failure as adolescents, and at risk for risky sexual behavior?
Intimate partner violence
True or False: Children exposed to intimate partner violence are more likely to be shy and withdrawn
FALSE
*More likely to be agressive
What behavior might you see from an infant exposed to intimate partner violence?
A lot of crying, resistant to comforting
What behavior might you see from a toddler exposed to intimate partner violence?
Extreme separation anxiety
What needs to be done within 72 hours of placement in foster care?
Health care screen
What should be done within 30 days of entry into foster care?
A comprehensive health assessment
Who represents children at court hearings for child abuse?
A law guardian (may be a trained volunteer- Court Appointed Special Advocate/CASA or and actual attorney
True or False: Screening for intimate partner violence is recommended as part of routine encounters
True
When is screening for intimate partner violence particularly crucial?
Cases of children with frequent non-specific symptoms (stomach aches and headaches)
True or False: You only need to screen Mom’s for intimate partner violence of they are depressed or anxious
False
True or False: Only mothers are victims of intimate partner violence
False
In screening for intimate partner violence, should the questions be specific or general?
Specific
True or False: You have to report suspicion of intimate parter violence even if there is no evidence or suspicion of child abuse?
True- As mandated reporter because children are likely being exposed to violence too
At what age should you ask guardians about intimate partner violence with children not present?
If the child is over 3 and verbal
True or False: In any cases of suspected abuse it isn’t a good idea for you to interview the child
True- Authorities should do this
What is the preferred place for foster placement?
With relatives (versus a non-relative home)
What is always the primary goal of Child Protective services?
Reunification of the family (as long as the child is in a safe environment)
True or False: Healthy children cannot participate in studies that involve more than minimal risk
True
When can children with a condition or disorder participate in a study that poses more than minimal risk?
If there is potential benefit to them from the study
Ex: Experimental treatments when no other proven-effective treatments exist
When is a study that poses more than minimal risk for patients if there is no direct benefit?
Only is there is a “minor” increase over the minimal risk
What is a deviation from standard practice?
Malpractice
What action results in a breach of the physician’s duty to act reasonably, and results in injury to the patient?
Malpractice
Who helps to prove breaches in a physician’s duty in court?
Expert witnesses
What 4 things do pediatricians serving as expert witnesses have to be?
- Thorough
- Fair
- Objective
- Impartial
True or False: An expert witness’s compensation cannot be contingent on the outcome of the case
True
True or False: Situation in practice that might lead to litigation should be reported to the malpractice carrier as early as possible
True
True or False: Disclosing errors to families is legally and ethically mandated
True
