Lecture 47+48+DLA

Question 1

physician assisted dying - passive

Answer 1

the patient is refusing treatment and the physician sanctions the refusal

ex: chemo

Question 2

physician assisted dying- active

Answer 2

the intent was to relieve suffering, not kill

ex: high dose of opioids (double effect)

Question 3

physician assisted suicide

Answer 3

this is when the physician provides the means for death, usually a prescription

the patient will administer the lethal dose

Question 4

Euthanasia

Answer 4

the painless killing of a patient suffering from a painful and or uncurbable disease

physician will prescribe and administer the method of death

Question 5

expressed interest standard

Answer 5

Refers all health care decisions to explicit instructions that the patient provided prior to losing his/her decision-making capacity.

patient must be competent
must have an advanced directive
closest thing to patient making own choices

Question 6

substituted judgement

Answer 6

The surrogate refers to the patient’s values, beliefs, character traits, and past decisions in order to make an educated guess with regard to what the patient would have decided in this particular instance

do not have an advanced directive
surrogate must know patient well

Question 7

Best interest standard

Answer 7

This standard is used when you have no indication of what the patient’s values are or what he/she would have wanted

usually used for children

least preferred because it places a huge burden on the surrogate

should involve multiple opinions

Question 8

classification of hypersensitivity

ab vs cell

Answer 8

I,II, III, are antibody mediated

IV is cell mediated

Question 9

type I sensitivity

Answer 9

this is an immediate sensitivity
mediated by IgE (usually against metazoan parasites)

but sometimes IgE gets activated by pollen and dander, etc

IgE binds to high-affinity Fc-e receptors on mast cells and basophils

Upon subsequent exposures, cross-linking of membranebound IgE induces release of mast cell granules

Question 10

role of Th2 and IgE

Answer 10

Th2 releases IL-4 and and IL-13 which stimulates the B cells to produce IgE

Question 11

primary mediators and secondary mediators of mast cells

Answer 11

primary: made before and stored
histamine, heparin, proteases, eosinophil chemotactic factor

secondary: 2-4 hours after
bradykinins, leukotrienes, etc

Question 12

type II hypersensitivity

Answer 12

involves IgG and IgM induced damage to cell surface or matrix antigen

cytotoxic process:
classical complement pathway
phagocytosis via FcR
ADCC via NK cells

non-cytotoxic
interference of receptors

many autoimmune diseases result from type II

Question 13

transfusion reaction via type II hypersens

Answer 13

antibody will attach to the RBC and lead to lysis

after lysis hemoglobin will be seen in the urine
have high levels of bilirubin

fever, chills, blood clots

Question 14

Erythroblastosis fetalis

Answer 14

type II hypersensitivity
hemolytic disease of a newborn (B cell response)

the fetus is Rh + and mother is Rh -
IgG ab cross the placenta

the mother will need a RhoGAM shot

Question 15

hypersensitivity type II (non-cytotoxic)

Answer 15

antibody directed against cell surface receptors, which can stimulate or block the receptor

Graves disease: over-reactive thyroid
antibodies against the TSH receptor

myasthenia gravis:
blocking ab’s against the ach receptor

Question 16

type III hypersensitivity

Answer 16

immune complex mediated

the complex is usually phagocytosed
if not it can be deposited into different tissues

localized: deposited in tissue near antigen entry (bug bite)

generalized: this occurs if the complex forms in the blood; can be deposited in blood vessels, kidneys, and joints
(serum sickness, drug reactions, RA)

Question 17

serum sickness

Answer 17

type III hypersensitivity (general)

Response to foreign protein in serum

Deposition of immune complexes systemically

Fever, vasculitis, arthritis, nephritis

Question 18

type IV hypersensitivity

Answer 18

Upon first contact with antigen, a subset of CD4+ Thelper (Th) cells is activated and clonally expanded

Upon encounter with the antigen, sensitized Th cells secrete cytokines. This attract and activate macrophages

Question 19

importance of type IV hypersens?

Answer 19

important for the clearance of intracellular pathogens

EX: M. tuberculosis and leishmania
contact such as nickel and poison ivy

Question 20

prolonged DTH can lead to…

Answer 20

granuloma formation

Question 21

duty to treat

Answer 21

if there is no treatment relationship, no physician consent, there is no duty to treat

Question 22

common reasons for refusal to treat

Answer 22

practice is full
lack of expertise
patient cant pay
patient is disruptive

Question 23

what are the three limitations to the refusal to treat?

Answer 23

1. discrimination of any extend
2. have already agreed to treat
3. another type of prior agreement ( on call; ED)

Question 24

morally expendable treatment?

Answer 24

1. treatment is useless
2. grave burden
3. when the harm outweighs benefits

Question 25

parts of a relationship?

Answer 25

1. standard of care
2. informed consent
3. confidentiality
4. non- abandonment

SICN

Question 26

standard of care

Answer 26

a diagnostic and treatment process that a clinician should follow for a patient, illness

standards of quality - minimal level of performance
medical review of criteria- which choices are appropriate
performance measures- monitor compliance
guidelines

Question 27

exemptions to duty of informed consent

Answer 27

1. info is already known by patient or commonly known
2. emergency situation
   urgent need, lacks capacity, no ability to get consent from surrogate, no known objection
3. therapeutic privilege- big mental issue if patient were to know
4. wavier- patient does not want to know
5. public health - protect community
6. conscious based objection - moral / religious reasons

Question 28

terminating relationship

Answer 28

mutual consent
patient dismisses physician
treatment is not needed
firing a patient

Question 29

why fire a patient

Answer 29

noncompliance
failure to pay 
verbal abuse
drug seeking 
violating policy / no show

Question 30

torturous abandonment

Answer 30

cannot abandon a patient, especially without significant notice