Ethics and Legal Issues Flashcards
1.
A 65-year-old man presents to the physician’s
office with his daughter, who is a resident in
internal medicine. She encouraged her father
to come in because he has experienced a 4.5-
kg (10-lb) weight loss in 2 months, as well as
decreased appetite and occasional night sweats.
She thinks his eyes appear somewhat icteric.
After the physician conducts the interview, the
physician and the patient’s daughter leave so
the patient can undress for the examination.
Once in the hallway, the daughter says to the
physician in a low voice, “I am really afraid
that he might have pancreatic cancer, and he
would be devastated to find out. Can you
please discuss his test results with me first so that we
can decide what to tell him together?”
Which of the following is the physician’s most
appropriate response?
(A) “Don’t worry, I doubt that he has pancreatic cancer”
(B) “I am ashamed of you, an internal medi-
cine resident should know better than to
ask me that”
(C) “I appreciate your concern, but your father
has a right to full disclosure, and it would
be inappropriate for me to withhold infor-
mation from him”
(D) “I would be happy to do that, but first we
have to have a full family meeting and dis-
cuss together what would be best for your
father”
(E) “If this is really important to you, I can tell
you the results before I tell your father”
- The correct answer is C.
Patients have a right
to full disclosure of their medical status, and
family members cannot request that the physi-
cian withhold information from a patient. Fur-
thermore, without the patient’s explicit permis-
sion, the physician cannot discuss the patient’s
health status with anyone else.
2.
A 74-year-old woman with dementia has been
in the intensive care unit (ICU) for 14 days fol-
lowing acute respiratory decompensation and
renal failure. She is receiving continuous he-
modialysis, and her electrolytes have been sta-
ble. Her oxygen saturation has been main-
tained on mandatory mechanical ventilation.
She remains in critical condition, but the ICU
team believes that she has a reasonable chance
of recovering. A living will shows that she has
agreed to intubation and resuscitation if neces-
sary. However, her daughter, who is her desig-
nated health care proxy and who until now has
been in contact with the medical team only by
phone, arrives stating that she has power of at-
torney and asking that her mother be taken off
the ventilator. Which of the following is the
best course of action?
(A) Discuss with the daughter her reasons for
withdrawing care
(B) Maintain current management based on
the patient’s prognosis
(C) Obtain a court order mandating continua-
tion of ventilatory support
(D) Obtain an ethics consultation
(E) Withdraw ventilatory support based on the
daughter’s power of attorney
- The correct answer is A.
Before any decision
regarding this patient’s care is undertaken, the
daughter’s reasoning must be elucidated. Al-
though she has durable power of attorney, the
daughter’s decision clearly disagrees with the
patient’s living will. Patients reserve the right to
change their decision within a given set of cir-
cumstances. However, when a proxy does so, it
must be determined whether the patient might
have made the same decision. This determina-
tion is difficult but must be done to rule out
any conflict of interest or ulterior motives by
the daughter.
3.
A 45-year-old woman is scheduled to undergo
elective bilateral tubal ligation. The gynecol-
ogy resident, covering for a colleague, greets
the patient in the preoperative area with the
consent paper, which outlines the nature and
indications of intervention, risks and benefits,
and potential alternatives. The physician, how-
ever, finds the patient to be a Laotian-speaking
woman with limited English skills, and she
does not seem to understand the resident’s ex-
planations. The patient’s husband, who speaks
some English, offers to translate the physician’s
explanation and appears to be eager for his
wife to undergo the procedure. How should
the resident proceed to obtain consent?
(A) Allow the patient’s husband to translate
(B) Ask the husband to be a surrogate decision
maker and sign the consent
(C) Ask the husband to step out and again ex-
plain, slowly and clearly, the informed
consent with the patient
(D) Draw an “X” next to the signature line and
ask the patient to sign the form
(E) Obtain a translator or translation services
for the patient and conduct proper discus-
sion for informed consent
- The correct answer is E.
The patient must be
informed of all components of an informed
consent in a language that she understands.
The only appropriate way to discuss the in-
formed consent is through a translator.
4.
An 87-year-old man with prostate cancer, Glea-
son grade 9, is now receiving palliative care fol-
lowing failure of hormonal therapy and che-
motherapy. He has severe bone pain from
multiple metastases, despite receiving both bis-
phosphonate and radiation therapy. His oxy-
genation is borderline on room air, and he has
required supplemental oxygen by face mask.
The patient and his family are distraught that
he is in so much pain, and they ask the physi-
cian to “make the pain stop.” The physician ex-
plains that raising the dose of opiates will sup-
press the patient’s breathing, but the family
repeats their request. Which of the following is
the best course of action?
(A) Give strong nonsteroidal anti-infl
ammatory drugs to avoid respiratory depression,
even if the pain is not well controlled
(B) Increase the dose of bisphosphonate
(C) Intubate the patient
(D) Medicate the patient with sufficient opioids to control his pain, regardless of respiratory response
(E) Obtain an ethics consultation
- The correct answer is D.
Treating a patient’s
pain with the risk of hastening death has been
addressed and supported by both the U.S. Su-
preme Court and the Catholic Church. In
Vacco v. Quill (1997), Justice O’Connor stated
that a patient has no legal barrier to receiving
relief from pain “even to the point of causing
unconsciousness and hastening death.” The
Catholic Church has adopted the principle of
double effect, whereby the hastening of death
as an adverse effect of pain relief is morally ac-
ceptable if there was no intention of doing so
by the treating physician.
5.
A patient in the clinic has a positive HIV test,
first by enzyme-linked immunosorbent assay
antibody assay and then confirmed by Western
blot. She is married, has three children, and is
sexually active with her husband. After explain-
ing what the results mean, she is advised that it
is important for the husband to be informed of
these test results. She appears stunned and
frightened by this suggestion. What is the most
appropriate course of action?
(A) Call up the husband and suggest he stop
in for an appointment so that he can be in-
formed of the results of the test
(B) Contact the public health department and
ask that they inform the husband
(C) Continue persuading the patient of the im-
portance and necessity of informing her
husband and offer support and resources
to enable her to have this discussion
(D) Send an anonymous letter informing the
husband of the exposure
(E) Tell her that it is illegal for her not to in-
form her husband and other sexual con-
tacts who have been potentially exposed
- The correct answer is C.
The patient should
be convinced to disclose this information per-
sonally to her husband and the practitioner
should not directly contact the husband; this is
the best way to maintain a trusting and open
doctor-patient relationship. Support should be
made available to the patient so that she can
inform the husband. Disease intervention spe-
cialists or HIV partner counseling and referral
services, operating out of the department of
health, may serve as valuable resources to help
patients contact their partners. These services
vary from state to state, but they can be offered
to patients to facilitate this process.
6.
An 85-year-old mentally competent patient is
brought to the emergency department in respi-
ratory distress. No living will is brought with the
patient, and before contact is made with the
family, the patient requires intubation and pres-
sors and is transferred to the ICU. Broad-spec-
trum antibiotics are started for a presumed
pneumonia. The family, including the patient’s
wife and children, arrive the next day. A discus-
sion is initiated with the family regarding the pa-
tient’s wishes as they relate to Do Not Resusci-
tate (DNR) and Do Not Intubate (DNI) orders.
During this time the patient’s wife is declared
the surrogate, and she states that she would like
the antibiotics continued, but her husband
should be DNR. The patient begins to recover
and is able to be extubated on day 3 of his hos-
pital care. On CT scan of the chest to evaluate
the extent of his pneumonia, he is found to have
a pulmonary embolism. A recommendation is
made by the hospital staff that he receive an in-
ferior vena cava filter. In this situation, under
whose authority can the filter be placed?
(A) A court of law
(B) The patient
(C) The patient’s children
(D) The patient’s doctor
(E) The patient’s spouse
- The correct answer is B.
Whenever possible,
consent for any treatment or procedure should
be obtained from the patient. In this situation,
although the patient’s wife was the surrogate,
her decision-making capacity ended when the
patient was extubated and was able to speak for
himself.
7.
An 89-year-old woman is diagnosed with meta-
static breast cancer to the lungs, bone, and
brain. Four months after diagnosis, the patient
is admitted to the hospital with excruciating
bone pain and changes in her mental status.
What term refers to the administration of mor-
phine to relieve this pain with the incidental
consequence of causing respiratory depression
and death?
(A) Indirect euthanasia
(B) Involuntary active euthanasia
(C) Nonvoluntary active euthanasia
(D) Passive euthanasia
(E) Voluntary active euthanasia
- The correct answer is A.
The administration of
morphine or other medications to relieve pain
with the incidental consequence of causing re-
spiratory depression leading to death is known
as indirect euthanasia and is legal everywhere
in the United States.
8.
A 14-year-old boy arrives for an athletic check-
up. Physical examination reveals needle tracks
on his arms. On questioning, the patient ad-
mits to recent heroin use. When asked if he
would consider treatment, he says yes, but only
if he can tell his parents that he is going to an
academic camp. What is the most appropriate
course of action?
(A) Detain the boy and admit him to treat-
ment under minor law
(B) Inform the boy’s parents and leave the de-
cision about treatment up to them
(C) Inform the boy’s parents and refer him to a
treatment center
(D) Refer him to a treatment center only
(E) Refer the patient to another pediatrician
- The correct answer is D.
Just as minors are ex-
empt from parental consent or involvement
when they are treated for sexually transmitted
diseases and pregnancy counseling, they may
also undergo drug rehabilitation without pa-
rental knowledge.
9.
A 93-year-old man is transferred to the emer-
gency department after staff at the long-term
care facility note confusion and agitation. He
takes many medications, including insulin and
a glipizide for diabetes and a β-blocker for hy-
pertension. On examination the patient mum-
bles incoherently when not spoken to and yells
at the speaker when directly addressed. His
temperature is 38.2°C (100.8°F), respiratory
rate is 28/min, blood pressure is 135/88 mm
Hg, pulse is 58/min, and oxygen saturation is
72% on room air. A hospital staff member re-
minds the physician that the patient’s chart
contains a signed DNR order. Which of the
following is the most appropriate next step in
management?
(A) Culture of blood, urine, and sputum
(B) Haloperidol administration
(C) No intervention out of respect for the DNR order
(D) Oxygen by nasal cannula
(E) Serum glucose measurement
- The correct answer is D.
Attention in the
emergency department must first be directed to “the
ABCs” (Airway, Breathing, Circula-
tion). Because he is conversant, the patient’s
airway is intact. His respiratory rate indicates
some distress, and his oxygen saturation is low.
Oxygen supplementation via mask or nasal
cannula is in order, and it is possible that this
may be suffi cient to begin to improve the pa-
tient’s mental status while other problems are
sought and addressed. DNR does not mean
“do not treat.” Taken literally, a DNR order
only applies after cardiac arrest has occurred,
although in practice some actions that may be
undertaken prior to cardiac arrest (e.g., endo-
tracheal intubation) may be considered resus-
citative. DNR orders may sometimes be writ-
ten as DNR/DNI, if that is the patient’s wish,
to help ease confusion.
10.
A 10-year-old boy is brought into the emer-
gency department after an injury and is bleed-
ing profusely. His parents arrive soon afterward,
and state that they are Jehovah’s Witnesses and
do not consent to giving blood to their child,
even though to fail to do so threatens the
child’s life. The child, awake and receiving
pain medications, agrees with his parents and
requests that he receive no blood. Which of
the following is the next step in treatment?
(A) Attempt to save the child, but honor the
child’s wishes and give no blood
(B) Attempt to save the child, but honor the
parent’s wishes and give no blood
(C) Get a court order, then give the child blood
(D) Give the child blood immediately, as needed
(E) Refuse to treat the child with those restrictions placed
- The correct answer is D.
Treatment can be
initiated on the basis of legal precedent. This
patient is 10 years old and is not emancipated.
Legally, he does not have the ability to refuse
treatment. His parents cannot refuse treatment
for him if that refusal will pose a serious health risk.
11.
A 32-year-old woman presents to her primary
care physician’s office complaining of dysuria,
urgency, and frequency. The physician quickly
scribbles a prescription for antibiotics, and the
patient takes it to the pharmacist, saying, “Darn
urinary tract infection again.” A few hours later,
the pharmacist contacts the physician’s office
because she notices that the amount of antibiot-
ics the physician prescribed is 10 times the usual
dose given for urinary tract infection. The physi-
cian admits that she was distracted by having so
many patients waiting to be seen and must have
accidentally added an extra zero. What is the
most appropriate next step for the physician?
(A) Ask the pharmacist to explain the error to
the patient
(B) Call the patient, explain what happened,
and apologize for the error
(C) Make a note to be more careful about
double-checking prescriptions in the future
(D) Thank the pharmacist and return to seeing
patients; she can tell the patient about the
error next time she sees her because no
harm was done
(E) Thank the pharmacist and return to seeing
patients; the pharmacist will tell the pa-
tient about the error
- The correct answer is B.
The physician has an
obligation to fully disclose any errors made in
patient care. The most effective and responsi-
ble way to do this is to call the patient immedi-
ately, explain what happened, and apologize.
This is particularly easy in this case because no
harm was done. Furthermore, acknowledg-
ment of an error and an apology can help the
physician avoid litigation.
12.
A 75-year-old man is in a persistent vegetative
state following a large intracranial bleed sec-
ondary to an arteriovenous malformation. Two
advance directives are in the chart. One is a
living will stating that the patient requests with-
drawal of life-sustaining treatment if he were to
ever be in a vegetative state. The other is a du-
rable power of attorney form stating that his
brother is the legally designated surrogate
health care decision maker. After reading these
forms, the brother approaches the physician
and requests that the medical team continue to
treat, feed, and hydrate the patient. How
should the medical team proceed?
(A) Medical team should consult the hospital
ethics committee
(B) Medical team should continue to feed and
hydrate the patient but not provide addi-
tional care (e.g., antibiotics if the patient
develops an infection)
(C) Medical team should continue to treat,
feed, and hydrate the patient
(D) Medical team should let a court decide
how to proceed
(E) Medical team should seek out the opinion
of the next closest family member to re-
solve the issue
(F) Medical team should withdraw all treatment
- The correct answer is F.
A living will is a legal
document written by the patient dictating the
patient’s wishes about withholding or withdraw-
ing life-sustaining treatment in the event of a
terminal disease or a persistent vegetative state.
In this case, the patient meets criteria for per-
sistent vegetative state and therefore the medi-
cal team should follow the patient’s written re-
quest and withdraw life-sustaining treatment. If
the living will were not present, the surrogate
health care decision maker would have had au-
thority to dictate how to proceed with treat-
ment. Although surrogates should typically
make decisions consistent with the stated
wishes of the patient, this case highlights the
importance of patients making their wishes
known in a format such as the living will.
13.
A primary care physician is caring for a patient
with stage IV ovarian cancer. The woman, who
has chosen to participate in hospice care, asks
the physician to give her “something to end it
all.” Which of the following is the most appro-
priate next step for the physician?
(A) Call the patient’s daughter and explain her
mother’s request
(B) Discuss with the patient her feelings and
identify why she is asking for life-ending
medication
(C) Provide the patient with a prescription for narcotics
(D) Refer the patient to a psychiatrist
(E) Tell the patient that her request is shock-
ing and such medication will not be provided
- The correct answer is B.
Taking time to un-
derstand a patient’s emotions and reasons for
asking for life-ending measures is the correct
answer. Understanding why the patient has
made such a request will help address the un-
derlying problem.
14.
An academic internal medicine physician does
nephrology research while maintaining a small
outpatient private practice. In the course of his
reading he learns of a promising new drug with
a novel mechanism of action to regulate blood
glucose levels in diabetes. He decides to invest
in the company that makes this drug (and oth-
ers) by purchasing approximately $2,000 worth
of stock in it. His total stock portfolio is worth
approximately $75,000. He is not on the pay-
roll of this company, nor has he received any
consulting fees or speaker fees for seminars
sponsored by this company. What level of dis-
closure is most appropriate for this potential
conflict of interest?
(A) No disclosure is necessary
(B) Telling all his patients that he owns this stock
(C) Telling only diabetic patients for whom he
decides to prescribe the drug that he owns
this stock
(D) Telling only his diabetic patients that he
owns this stock
- The correct answer is B.
A central principle of
bioethics is that the physician has a fiduciary
relationship with patients, meaning that physi-
cians have a responsibility to act in a patient’s
best interest. This responsibility extends to dis-
closures of conflicts of interest, in which pro-
fessional obligations are influenced by personal
interest. In this example the physician owns
stock in a pharmaceutical company that makes
a number of drugs. Disclosures should be
made to any and all affected parties, including
his patients. Because conflicts of interest may
affect the quality of research reported, disclo-
sures must be made to institutions and groups
involved with research such as journals review-
ing investigators’ manuscripts and scientific
meetings at which one might present.
15.
A 46-year-old man with advanced pancreatic
cancer is hospitalized following a pancreatic
duct stent placement. He has recently been
told that he is not a candidate for a Whipple
procedure. His previously marked jaundice has
improved, but he is experiencing ongoing 8 of
10 abdominal pain. The patient was divorced 6
years ago, and his parents are his only family.
Since his procedure, the patient has asked sev-
eral members of the medical team to help him
end his life. Which of the following is the most
appropriate next step?
(A) Admit this patient to hospice care
(B) Call patient’s family and inform them of
patient’s request
(C) Consult the psychiatry service about pa-
tient’s ability to make medical decisions
(D) Evaluate pain management
(E) Increase opioid dosage with the intent of
causing respiratory depression
- The correct answer is D.
Inadequate pain con-
trol and comorbid depression are the two most
common causes of such a request by a patient,
and both should be evaluated in this situation.
