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Medical Decisions > Exam 2 Notes > Flashcards

Exam 2 Notes Flashcards

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USMLE® Step 1 flashcards
1
Q

What is largest scarce resource in rural PA?

A

Lack of healthcare professionals

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2
Q

Factors involved in determining the allocation of resources of healthcare (8)

A
  • individual needs
  • contributions of that individual
  • quantity of available resources
  • societies needs
  • insurance companies
  • government
  • providers needs/goals for public health
  • advocacy groups
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3
Q

Indemnity vs managed care

A
  • Indemnity involves insurance company paying for healthcare service (minus deductables and copays) gives freedom to choose doctors, where to receive treatment, but more expensive (paying for service then being denied coverage)
  • managed care involves insurance companies going to the provider and giving a set dollar amount for each patient per year to then spend resources accordingly, has lower costs but limited services and freedom of choice on where and who (being denied coverage upfront)
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4
Q

___ is largest payer of healthcare at 60%

A

government

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5
Q

The problem of advocacy groups

A

The money spent towards organizations focused on specific diseases, if put towards prevention for the general population for common diseases such as cardiovascular disease, would see a better outcome and save more lives for where the largest burden is, but individuals are very focused and passionate about these specific issues (maybe they wouldn’t donate if not specific)

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6
Q

Health definitoin

A

Deficit of physical form, physiologic, or social function of an individual in terms of what society wants or expects or what the individual wants or expects, on an individual level involves limiting pain to allow for functionality, and on a societal level involves limiting disease to allow contribution to society

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7
Q

Assumption of privilege in humans

A

Because of our heightened level of existence, the human condition is of the utmost priority in medicine with everything being seen as less or below, to varying levels of degrees

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8
Q

Health care providers 2 roles

A
  • agent of the patient (responsible for preserving the dignity and autonomy of patient)
  • agent of society (responsible for allocating societies resources)
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9
Q

Decisions based on social dimensions are not considered an attack on personal dignities along as…

A

…there are societal social significant reasons for doing so

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10
Q

Healthcare goals (5)

A
  • instrument of good and not good in and of itself
  • prolong life
  • improve quality of life
  • allocate available resources
  • alleviate suffering

-somewhat indeterminate

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11
Q

__% of all healthcare expenses are spent in the last year of life

A

25%

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12
Q

Healthcare is a combo of these 3 things

A
  • science
  • experience
  • compassion
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13
Q

What factors should be considered to determine need of medical care? (2)

A
  • acuity of illness (triage)

- likelihood of improvement (how many times are we gonna fix a drug abusers heart valve?)

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14
Q

Kant’s Person Principle of Universality

A

The idea that to not treat people equally is to treat them as things rather than persons, as means rather than to ends

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15
Q

Many organizations are still against In Vitro fertilization, including…

A

….the catholic church

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16
Q

How long should a couple who is not conceiving go before undergoing a workup for complication?

A

12 months of unprotected sex under the age of 35, 6 months of unprotected sex over age 35

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17
Q

Assistive reproductive technologies

A

Specialized infertility treatment designed to increase number of eggs or sperm or bring them closer together resulting in improved probability of conception not otherwise possible

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18
Q

Artificial insemination

A

Often best choice for treatment for couples that are infertile due to sperm disorders, involves injecting sperm into the wife’s reproductive tract

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19
Q

Ovarian hyperstimulation

A

Use of fertility meds such as clomiphene or FSH injection to stimulate development of multiple follicles of the ovaries in one cycle

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20
Q

In vitro fertilization

A

Process of retrieving eggs (often thru ovarian hyperstimulation and then ultrasound needle aspiration of the eggs) and sperm from bodies of male and female partners and placing into lab dish to enhance fertilization before placing one or more embryos back into the uterus (in hopes at least one will be viable)

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21
Q

Intracytoplasmic sperm injection

A

Sperm micromanipulation procedure involving insertion of single sperm directly intoo cytoplasm of mature egg using micropipette

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22
Q

Disadvantages and risks of IVF (4)

A
  • ovarian cancer risk increase slightly
  • ovarian hyperstimulation syndrome (abdominal pain)
  • increased rate of multiple gestation
  • expensive
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23
Q

IVF and age

A

Age is a major determinant of success of IVF, age dependent decline in fertility with older women can drop odds of success into single digits, mothers over 40 typically need an egg donor

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24
Q

Fetal reduction

A

Selective type of abortion procedure to limit number of pregnancies in case that more than one viable embryos implant during ART, raises ethical concern as there is no upper limit to number of embryos that can be inserted or carried to term vs aborted

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25
Q

Cryptopreservation

A

Cryopreservation of embryos for future use, despite 10-20% not surviving thawing studies have shown embryos that do do as well as other hcildren

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26
Q

Gestational carrier

A

Woman agrees to carry to term fetus for another person, that fetus may be from the egg and sperm of a couple who want to raise a child or it may be donor eggs and sperm, this is preferred because there is less conflict of interest but there is a concern about exploitation in 3rd world countries for monetary gain

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27
Q

Surrogacy

A

A woman carrier has genetic connection to the embryo, this is controversial because sometimes the mother wants to retain the infant

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28
Q

Gestational carriers/surrogacy can result in child having up to __ different parents

A

7

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29
Q

What to do with left over frozen embryos? (4)

A
  • pay to keep frozen
  • donation to another couple
  • donation to science
  • destroying the embryo
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30
Q

Reprogenetics

A

Reproductive and genetic technologies with potential to reshape the future, including technologies such as IVF, preimplantation genetic diagnosis (choosing which embryo you implant based on their traits), somatic cell nuclear transfer, genetic engineering, and artificial uterus

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31
Q

Preimplantation genetic diagnosis (embryo screening)

A

Form of prenatal diagnosis requiring IVF, identifies embryos with genetic condition that may lead to a certain disease (cystic fibrosis, huntingtons, etc), can also be used for selecting for traits or disabilities or HLA matching

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32
Q

HLA matching

A

Use of preimplantation genetic diagnosis in conception to choose a specific sibling who will have proper type matching to assist a sibling or other who needs a donation from the newborn

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33
Q

Some countries other than the US follow these 5 regulations regarding in vitro fertilization

A

1) Using IVF can only create 3 embryos
2) all embryos must be implanted
3) embryos cannot be altered
4) cannot clone
5) Preimplantation genetic diagnosis is illegal except in certain health conditions

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34
Q

Reproductive cloning

A

Harvesting of a nucleus from a somatic cell that is then fused with an empty egg and implanted in order to create a genetic clone of the original, can be logistical (give child some kind of genetic relation to parent when this would not be possible), or duplicative (attempt to produce a child with exact same genes as selected genotype), all clones are not truly identical, only nuclear DNA is (some comes from mitochondria from the enucleated egg)

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35
Q

Therapeutic cloning

A

Production of human embryos for use in research, harvesting of stem cells to treat illness

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36
Q

Artificial uterus

A

Allow for extracorporeal pregnancy, replacement organ to assist women with damaged or diseased uterus

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37
Q

Genetic engineering

A

Direct manipulation of an organisms genome, either negative (eliminate disorder) or positive (enahnce human being), if somatic cells are altered new DNA will not pass to new generation, if germ cells then it will

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38
Q

Risks of genetic alteration (3)

A
  • altering genes may result in changes we do not expect
  • if passed down future generations may have catostrophic mass results
  • may create pressure for people to use these techniques
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39
Q

Eugenics

A

Practices aimed at improving the genetic composition of a population targeting poor, deaf, blind, homosexuals, etc. done thru segregation, selective breeding, sterilization, euthenasia, mass extinction

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40
Q

Liberal eugenics (new eugenics)

A

Advocates that use of reproductive and genetic technologies where the choice of enhancing human characteristics is left to the individual preference of the parents acting as consumers rather than the public health policies of the state

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41
Q

Organ transplant

A

Surgical operation where a failing or damaged organ is replaced with a new one

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42
Q

Allograft/allotransplant

A

Transplant of organ or tissue between two genetically non-identical members of the same species, risk of rejection due to difference genetics

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43
Q

Xenograft/xenotransplant

A

Transplant of organ or tissue from one species to another, increases risk of noncompatibility, rejection, and disease

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44
Q

US informed/expressed consent process for organ donation

A

Ideal in US that all individuals have to opt in for organ donation and are not obligated to commit to donation upon death (must express consent prior to death on advanced directive or drivers license or if no indication then will ask legal surrogates)

45
Q

Uniform anatomical gift act

A

Made it legal to donate if 18 and older and authorized for recipient to possess an organ

46
Q

Inter-vivos vs cadaver donations

A

Living donor vs after death, no obligation exists on any level to donate inter-vivos in any country

47
Q

The least harm to a dead donor for greatest benefit to living recipients (often times multiple) is the principle of ____ regarding cadaveric organ donation

A

proportionality

48
Q

5 components of informed consent

A
  • full disclosure (risks benefits and alternatives)
  • voluntary
  • competence
  • understanding
  • signed formed consent
49
Q

Presumed consent

A

Policy of some nations regarding organ donation where they are harvested upon death unless a person specifically requests not to donate while living (opt-out)

50
Q

3 types of living donation

A

1) directed to family/friend
2) non directed (general pool)
3) paired donation (swapping between individuals)

51
Q

Organs from living donors are typically…. (2)

A

healthier and fresher (tend to have better outcomes for the recipient)

52
Q

Benefits of proportionality are decreased in __ donors

A

living

53
Q

Recipient of an organ requires reliance on….

A

….immunosuppression

54
Q

Criteria for death prior to 1970 and after 1970

A

Irreversible heart stoppage vs irreversible loss of brain function

55
Q

Dead donor rule

A

Requirement that an individual person be dead before vital organs are removed

56
Q

Uniform determination of death act (1981)

A

Identifies an individual as being dead as either having irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain including the stem

57
Q

Official definition of brain death in the US

A

Brain death, debate still occurs over whole brain vs higher brain death qualifying but currently follow whole brain set up

58
Q

Current approach to discontinuance of treatment of a persistent vegetative state donor (4)

A
  • advance directives
  • surrogates (living will)
  • next of kin/family
  • legal intervention
59
Q

Valid donor card supersedes survivor wishes - therefore where a donor card exists…

A

….family should not be asked for permission but informed of intent.

60
Q

National organ transplant act (NOTA 1984)

A

Forbids sale of organs in interstate commerce as it targets the poor by limiting resources

61
Q

United network for organ sharing (UNOS)

A

Enforcing governing body that prevents selling and instead promotes allocation and procurement of organs based on need and medical condition, began organ procurement and transplantation network (OPTN) has separate policies to govern allocation of each type of organ

62
Q

MELD score

A

Current system that uses a measure of who will receive the best benefit from transplant based on medical need and likelihood from improvement as well as organ specific criteria as being factors that determine who receives transplants as opposed to simply being who is on the list the longest

63
Q

Distribution problems in transplants (3)

A
  • Geographic limitations
  • closeness of a match
  • ethical considerations such as comorbidities
64
Q

AMA suggested guidelines for organ distribution 1996 (5)

A
  • likelihood of benefit
  • urgency of need
  • change in quality of life
  • duration of benefit
  • resources needed for successful treatment

(doesn’t include lifestyle choices!)

65
Q

Organ procurement transplant network criteria (7)

A
  • organ type
  • blood type
  • organ size
  • distance from donor organ to patient
  • level of medical urgency
  • time waiting on list
  • is patient able and willing to transplant immediately and are they healthy enough?
66
Q

Today payment for organ transplants comes from the recipient, either…

A

….private insurance or medicare/medicaid

67
Q

5 strategies to increase cadaveric organ donations

A

1) education
2) mandated choice (enforce that everyone must specify)
3) presumed consent (procurement of organs unless otherwise noted)
4) incentives (assist with funeral/burial costs or charities)
5) prisoners (default presumed consent?)

68
Q

Karen Ann Quinlan case

A

After slipping into a PVS, parents wished to withdraw life sustaining measures but doctors initially denied on the basis of precedent

69
Q

Terri Schiavo case

A

Case where woman found collapsed on kitchen floor satisfied all clinical criteria and status and exam findings for PVS (brain atrophied, lost ton of brain matter) that led to controversial debate as media did not call it PVS

70
Q

Livor mortis and algor mortis

A
  • Pooling of blood that occurs post mortum causing discoloration of skin setting at the base of how an individual is lying
  • the chill and cold temp indicating death
71
Q

Le coma depasse definition

A

Brain death, no responsiveness but an individual has a pulse, has fixed dilated pupils and inability to breath independently

72
Q

Jahi McMath case

A

Girl deemed braindead after surgery that led to debate as the family rejected that idea, went to court to overturn the death cert and she ultimately died of liver failure (died twice), she did eventually begin menstruating and none of her organs died after her first declaration of death

73
Q

Neocortical arguments about death

A

The idea that cortical function = personal identity and that an individual is dead when they have no function (no self awareness, unconsciousness, etc) problem is that there are no reliable clinical tests for higher brain function (awareness)

74
Q

Coma definition

A

State of eyes closed, depressed consciousness from which a patient cannot be aroused by stimulus, distinguished from brain death by presence of brainstem responses, spontaneous breathing sometimes, or non-purposeful motor responses, either ends in progression to brain death, recovery of consciousness, or evolution to vegetative or minimally conscious state

75
Q

Vegetative state definition

A

Severely impaired consciousness, although eyes may open spontaneously, but no awareness of environment, many patients do not acknowledge the examiner, they do not attend or track objects presented to them, movements are nonpurposeful, do not speak

76
Q

Minimally conscious state definition

A

Severe alteration to consciousness, with intermittent but inconsistent, behaviors suggesting awareness, in contrary to patient in coma or vegetative state, may occasionally have purposeful movements and may track motions with eyes or speak slightly

77
Q

Persistent vegetative state

A

Distinct from total brain death (le coma depasse), disorder where have severe brain damage and are in state of partial arousal rather than true awareness, has irregular but cyclic state of circadian sleeping and waking and may show primitive postural and reflex limb movements but no recognition of external stimuli or evidence of awareness, grasp or DTR’s may be intact, classified after 4 weeks of being in it defining it as persistent

78
Q

Locked in state definition

A

When there is injury to brain where there is paralysis, may be able to track objects with eyes but can’t move but can’t speak but fully conscious

79
Q

Other tests and findings other than exam when assessing presence of vegetative state or coma or etc. (3)

A
  • EEG may see almost normal wake sleep patterns
  • PET scan shows absent cortical metabolism
  • CT and MRI - massive brain destruction and enlargement of ventricles, majority of brain replaced with CSF
80
Q

Prognosis of PVS

A

Up to 2 weeks may see good chance of recovery, after sees poor prognosis, but some rare long term incomplete recoveries reported

81
Q

Incompetent

A

Legal term implying an absolute and UNCHANGING condition

82
Q

Decision making capacity

A

The ability to choose, having considered pros and cons, and understanding possible consequences of actions

83
Q

Substituted judgement

A

If a patient has expressed wishes prior to losing capacity to make decisions, proxy decision should follow rather than allowing them to decide on their own what to do

84
Q

Palliative care

A

Care to keep a person comfortable in a setting, not just for the dying, typically done alongside treatment separately but doesn’t have to be

85
Q

Durable power of attorney for health care

A

An advanced directive that names someone to make medical decisions for a person in the future if they cannot make own medical decisions

86
Q

Schloendorff v society of new york hospitals

A

Lady named Mary with irregular vaginal bleeding, wanted biopsy of possible tumor but didn’t want tumor taken out, surgeon did anyways and was charged huge bill for it and court ruled in her favor of her right to determine what she wants done to her body

87
Q

Elizabeth Bouvia case

A

28 yo qualdriplegic due to severe cerebral palsy, wanted to be admitted to hospital in safe clean environment and starve herself to death slowly and die on her own terms, doctors inserted NG tube against her will, went to court and stated she didn’t want life sustaining treatment, which then allowed her to do so

88
Q

Evientiary standard

A

Way to be sure a patient would refuse life sustaining treatment in their own case, rule of clear and convincing evidence, solemn pronouncements on serious occasions consistently repeated, consistent with life values, and made shortly before need for treatment, living will and advanced directives are forms of evidence for this, if family disagrees doesn’t have leg to stand on if they disagree but if they don’t believe based on substituted judggement or misinterpretation may have to go to hospital ethics committee

89
Q

Limitations of advanced directive/living will (2)

A
  • Cannot cover all conceivable end of life decisions

- Patients preferences change over time or circumstance

90
Q

Healthcare surrogate

A

Any competent adult expressly designated by a principal to make healthcare deecisions upon principal’s incapacity, designation signed before 2 separate witnesses, effective until stated time of termination or until revoked, has authority to make all healthcare decisions unless expressly limited

91
Q

Revocation of advanced directives/living wills (4 ways to do it)

A
  • Signed and dated statement of invalidation
  • physical destruction of it
  • subsequent advanced directive that differs materially
  • oral expression of intent to revoke
92
Q

Medical decision making by proxy

A

Competent adult NOT expressly designated to make healthcare decisions for principal but authorized to do so by statute (such as a legally appointed guardian, spouse, adult child, parent, adult sibling, etc)

93
Q

Most popular 2 drugs of abuse in americans 12 and over

A
  • Marijuana

- Prescription or black market opioid pain relievers

94
Q

Abuse in healthcare workers

A

Prescription drug abuse/misuse is present in up to 10-15% of healthcare providers and continues to grow significantly, most often painkiller agents such as opioids or benzos

95
Q

Substance use vs substance abuse

A

Occasional use of chemical substance without developing tolerance or withdrawal when not in use, vs the use of illegal drug or inappropriate use of legal drug, repeated use to produce pleasure, alleviate stress, or alter or avoid reality

96
Q

Substance addiction

A

Drug addiction is a complex brain disease characterized by drug craving, seeking, and use that can persist even in face of extremely negative consequences,

97
Q

Personality traits that may make one more prone to substance abuse (3)

A
  • OCD
  • family history of substance abuse or mental illness
  • sensation seeking behavior
98
Q

Signs of drug abuse in a healthcare provider co-worker or friend (9)

A
  • frequent tardiness and absences
  • unexplained disappearances during work hours
  • inappropriate behavior
  • affective liability or irritability
  • frequent trips to restroom
  • weight loss or weight gain
  • poor physical coordination
  • cold sweaty tremoring palms or puffy face
  • extreme hyperactivity
99
Q

Depressants/pain meds abuse signs and symptoms

A

Barbituates and tranquilizers, seem drunk as though from alcohol but without associated odor of alcohol, difficulty concentrating, clumsy, poor judgement, contracted pupils**

100
Q

Alcohol abuse signs and symptoms

A

Clumsiness, difficulty walking, slurred speech, sleepiness, poor judgement, dilated pupils***

101
Q

Marijuana abuse signs and symptoms

A

Red, glassy eyes, inappropriate laughter, sleepiness, burnt scent, loss of motivation

102
Q

Stimulants abuse signs and sympotms

A

Hyperactivity, euphoria, irritability, excess talking, followed by depression and crash excessive sleeping, sees dilated pupils***, weight loss

103
Q

Inhalants abuse signs and symptoms

A

Includes glues, aerosols, vapors, sees watery eyes, impaired vision, memory and thought, secretions from the nose or rashes around the nose and mouth, drowsineess, poor muscle control, anxiety

104
Q

Hallucinogens abuse signs and symptoms

A

Dilated pupils, bizarre and irrational behavior, hallucinations, mood swings, detachment

105
Q

Heroin abuse signs and symptoms

A

Needle marks, sweating, sleeping at unusual times, twitching, contracted pupils that do not respond to light**

106
Q

Physician specific factors associated with substance use (7)

A
  • high stress long work hours
  • cigarrette use
  • history of multiple affiars or marriages
  • history of multiple jobs in multiple communities
  • practice in EM, anesthesiology, psych
  • self medication or self prescribing behavior
  • practicing in academic medicine
107
Q

6 I’s of suspected abuse

A
  • irritability
  • inability
  • inaccessibility (MIA)
  • irresponsibility
  • isolation
  • incidentals (appearance and findings)
108
Q

Medical futility and its 2 subclasses

A

An intervention is labelled this if they have no realistic chance of achieving intended goals - physicians are generally under no obligation to provide futile treatment, either qualitative types (not improving quality of life - terry schiavo) or quantitative (statistically will not benefit patient - CPR in rigor mortis patient)

109
Q

What should be done if suspect healthcare worker to be using illicit substance (4)

A
  • immediately intervene to protect safety of any patient in danger
  • do not permit visibly impaired coworker to care of patients
  • immediately report to appropriate supervisor
  • document

Medical Decisions (3 decks)

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