Ethics and Critical Appraisal

Question 1

A 7-year-old with CP is involved in an MVA and presents with a GCS of 4. He has been in the ICU for 1 week with no improvement despite aggressive management. Parents approach you regarding the withdrawal of treatment because of his underlying disability. Which of the
following is true:
a. if two EEGs done 24 hours apart show isoelectric background, then withdraw
b. do cerebral angiography to document no blood flow to confirm brain death
c. obtain a neurology consult to substantiate brain death
d. discuss the options again with the parents, and if they remain certain about the decision then proceed with withdrawal

Answer 1

d. discuss the options again with the parents, and if they remain certain about the decision then proceed with withdrawal

Question 2

A 7-year-old child has been in a MVA. He is unstable with a HR 160. Hb 50. The parents are Jehovah’s witnesses. How should you proceed:

a) transfuse blood now without parental consent
b) await for a court order before transfusing blood
c) respect the parents decision to refuse transfusion
d) transfuse with albumin instead of blood
e) spend time with the parents in hopes of changing their decision about transfusion

Answer 2

a) transfuse blood now without parental consent

Question 3

Management decisions in the treatment of a critically-ill newborn should be based on:

a) cost to society
b) burden to parents
c) best interests of the child
d) ventilate at all costs regardless of neurologic outcome

Answer 3

c) best interests of the child

Question 4

Which of the following statements regarding autonomy is true in pediatrics:
a. the wishes of the parents supersede the wishes of the child
b. if there is a psychiatric problem, the wishes of the parent and child are not valid
c. CAS authority can supersede the wishes of the parent and the child
d. the right to autonomy can be used to force the MD to take medical action that they feel is inappropriate
e. if conflict exists, the physicians opinion takes precedence over that of the parent of
child

Answer 4

c. CAS authority can supersede the wishes of the parent and the child

Question 5

An 8 year old male with Down syndrome is admitted to the PICU with his 5 th episode of pericarditis. Which is true:

a. it is time to discuss a DNR
b. when parents and physicians disagree on management, the ethics committee must be consulted
c. the choice is up to the patient
d. once parents have decided to treat the child, they may change their minds at a later stage

Answer 5

d. once parents have decided to treat the child, they may change their minds at a later stage

Question 6

Which of these patients can give a valid consent:

1. A teenager who is currently drunk who was sexually assaulted 36 hours ago
2. Down’s syndrome with femur fracture
3. 14 y/o who wants an abortion
4. A patient who is hallucinating
5. Person who is unconscious who needs surgery

Answer 6

3. 14 y/o who wants an abortion

Question 7

Parents of a 15y boy suspect he is using drugs. They ask you to obtain a urine sample and “add this test on” after the sample is collected. What to do you do?

a. Refer the boy to psychology
b. Ask social work consult
c. Do as the parents ask
d. Ask to speak with the boy

Answer 7

d. Ask to speak with the boy

Question 8

Regarding consent for organ donation, which is true:

a) It is possible to consent only to donation of specific organs
b) can consent to donation of organs despite the absence of full brain death criteria
c) there are no absolute contraindications to organ donation
d) some tissue donations do not require consent

Answer 8

a) It is possible to consent only to donation of specific organs

note - b is technically true as well - can opt to remove life sustaining treatment and organs are then procured after cardiac death

Question 9

What are some contraindications to an patient being an organ donor?

Answer 9

prematurity (<32 weeks)
infection (TB, CJD, West Nile, Hep B, Hep C
malignancy (malignant neplasms, leukemia, melanoma)

Question 10

14 year old with ALL, his 3 rd relapse. Parents want to try experimental therapy, but the kid does not. Which of the following statements is true?

a. He has a right to not be treated if he understands the consequences of this
b. Must continue with treatment as the parents consented at the outset of therapy
c. Consult an ethics committee
d. The parents get to decide for him

Answer 10

a. He has a right to not be treated if he understands the consequences of this

Question 11

Child with a severe head injury. The father is suspected of abuse. What do you do about the decision to withdraw care?

a) Court decides
b) The decision still must involve both parents, including the father
c) Police need to be informed before care is withdrawn

Answer 11

b) The decision still must involve both parents, including the father

Question 12

7 month infant with severe head injury. Social worker suspects abuse and mentions it to you.

a) Decision to withdraw should still involve complete communication with family
b) Decision to withdraw made by judge
c) Decision made by health care team

Answer 12

a) Decision to withdraw should still involve complete communication with family

Question 13

Young child is in PICU with a brain tumor; terminal. Which is true?

a) Organ donation does not need consent for all the organs
b) Patient need not be brain dead for consent to be obtained for organ donation
c) There are no absolute contraindications for organ donation
d) Do not need consent for tissue donation

Answer 13

b) Patient need not be brain dead for consent to be obtained for organ donation

Question 14

You are speaking with a 16 year old girl and her mother in your office. You have recommended that she have some bloodwork done as a part of the work up you are performing. Her mother wants her to have the bloodwork done, but the girl refuses. You respect the girl’s decision not to have the bloodwork performed.

a. What ethical principal is demonstrated by this clinical scenario?
b. Name 3 necessary parts of informed consent.

Answer 14

a. autonomy - - the principle of respect for autonomy is key to medicine and implies the patient’s right to refuse and the physician’s obligation to respect that refusal

b. 1. appropriate information: provide the information required to make a decision
2. decision-making capacity: ability to receive, understand and communicate information; appreciation of the personal effects of interventions, alternatives or nontreatment
3. voluntariness: free from manipulation or coercion, and decision maker can change their mind at any time

Question 15

9 year old girl diagnosed with ALL. Parents do not to tell child of this diagnosis. Name and describe the ethical principles as they apply to the following:

a) You agree with the parents and do not tell the child?
b) You disagree with the parents and opt to tell the child.

Answer 15

a) parental authority: right of a parent to make decisions for their child; assumes and expects that parents are acting in the best interest of the child

b) non maleficence (do no harm) if you as the physician
believe that withholding this information would cause the patient harm in the long run

Question 16

“Parents have a legal and moral obligation to be surrogate decision makers for their child”. Discuss why this principle is generally true.

Answer 16

• there is a fundamental understanding that parents have a right to speak for their child and determine what is done to their child
• parents are responsible for bringing up their children and that responsibility necessarily requires them to have rights for decision making
• apart from the children, the parents will be the ones most likely to live with the consequences of the decision that is made
• parents know the child best
• affection and close family ties make parents most likely to reach decisions based on the child’s best interest

Question 17

Mrs. X has just given birth to a baby boy at 27 weeks gestation. He is currently in oxygen, having mild respiratory distress. The physician looking after him wants to intubate him and send him to a tertiary care centre. Mrs. X has serious concerns about this baby’s viability, and in fact wants nothing done for this child. She is adamantly refusing treatment.
Outline 2 reasons why parental rights as a decision maker may be overridden in this case.

Answer 17

1. when a parent’s decision about an important medical question (e.g. continuation of life sustaining treatment) seems to be clearly opposed to the child’s best interest, the physician should seek to override that decision
2. all children are entitled to medical treatment that is likely to prevent serious harm, suffering or death

withdrawal of care in this situation would be well against the established standard of care for a 27 week prem in Canada with mild respiratory distress for whom the prognosis would be relatively good

Question 18

15 y/o girl sexually assaulted 5 days ago by a 32 year old man for whom she babysits. All of the following are true except.

1. Forensics are not indicated
2. CAS must be informed
3. Give post coital contraceptive now
4. Low risk for STD
5. She is competent to refuse further treatment and investigations

Answer 18

4. Low risk for STD - would be high risk if:
   - genital/oral/anal penetration
   - symptoms of STI
   - perpetrator has known STI or risk factors

Re: forensics - some sources say no forensics after 72 hours, some say can do up to 120 hours (5 days)

Question 19

Alcohol-related MVC. Police want a blood EtOH level. You:

a) give it
b) ask for warrant
c) call CMPA
d) wait for patient to wake up for consent

Answer 19

b) ask for warrant
generally physicians should refrain from disclosing patient information to the police or any other third party unless
there is patient consent or the disclosure is required by law

“Unless required by law (including a legislative provision, search warrant, or other court order) or given consent by the patient, a physician cannot be required to perform an
invasive service on a patient (such as taking blood from a suspected impaired driver for the purpose of confirming his or her blood alcohol content) or to provide any other
information or evidence about a patient” - from CMPA

Question 20

You attend the birth of a known term anencephalic baby. The mother asks you about the possibility of organ donation. Is this a possibility? Give the reason for your yes or no answer (1 line).

Answer 20

No - they will not usually satisfy the criteria of brain death because of adequate brainstem function
- by the time the inevitable brain or somatic death has occurred, the organs will have suffered irreparable ischemic damage, making them unsuitable for
transplant

Question 21

This child could be classified as brain dead with the present physical examination. What would be some concerns regarding organ donation in this patient?
Teen who had hung herself.

Answer 21

High cervical spine injury is considered a confounding factor to the clinical assessment for neurologic determination of brain death

• cervical spine injury must be ruled out before full clinical assessment for brain death can be done (especially brainstem reflexes - dolls eyes)
• if cannot do clinical testing due to c-spine injury, ancillary testing is required

Question 22

This child could be classified as brain dead with the present physical examination. What would be some concerns regarding organ donation in this patient?
Baby with pneumoccocal meningitis treated for 3 hours

Answer 22

If baby has only been treated for 3 hours there cannot have been an adequate observation period for two examinations separated in time (24h for neonate, 12h for everyone else)
- as well this may not be sufficient treatment time for a potentially reversible cause (meningitis)

Question 23

This child could be classified as brain dead with the present physical examination. What would be some concerns regarding organ donation in this patient?
Child submersion. Now at 35.9 degrees:

Answer 23

• observation and serial neurologic exam for 48-72 hours as significant gains/changes in neuro status can be made in this time
• after 48-72 hours of observation, consideration to withdrawal of support should be given inpatients without neurologic recovery
  Note: has been sufficiently rewarmed (34 degrees)

Question 24

4 “medical reasons” why brain dead patient may not be able to be an organ donor

Answer 24

• active Hep B, C or CMV infection
• active/uncontrolled extracranial malignancy
• severe untreated systemic sepsis
• active disseminated TB
• risk of rare viral or prion protein illness (e.g. Creutzfeld-Jakob)
• active West Nile virus or rabies
• AIDS

Question 25

All are needed to declare brain death except:

1. EEG
2. 2 physicians are required to declare brain death
3. No spontaneous respiration despite hypercarbia
4. Absent corneal reflex
5. Absence of hypothermia

Answer 25

1. EEG

Question 26

What are the 3 components of neurologic determination of death?

Answer 26

1. Irreversible coma w/ known cause (coma = unresponsive, no purposeful movement, no posturing)
2. Absence of brainstem reflexes (pupillary light, oculocephalic, corneal, gag/cough, oculovestibular)
3. Apnea (absence of resp effort in response to adequate stimulus - i.e. CO2 >60)
   ● To establish dx findings must remain consistent x 2 examinations separated by observation period

Question 27

Which is true regarding children in foster care:
a) In older kids, occasional visits with parents is warranted if child previously had developed a strong attachment to parents
b) Disruption of continuity of care may be potentially
detrimental to all children
c) If they are in a loving foster home for their first year of life, they will do well long term
d) Child should be placed with grandparents for best long-term outcome

Answer 27

b) Disruption of continuity of care may be potentially

detrimental to all children

Question 28

A 15-month-old child presents with diarrhea and FTT. The mother has a history of IV drug use. She doesn’t know who the father of the child is. You suspect HIV as a cause of the child’s presentation. You would do all of the following EXCEPT:

a) discuss the benefits and harms of knowing about one’s HIV status
b) discuss the issues and services available for those with HIV
c) discuss the confidentiality of the test
d) explore the risk factors
e) explain that you will follow-up by telephone as soon as the test results are available

Answer 28

e) explain that you will follow-up by telephone as soon as the test results are available

Need to give these results in person