Lecture 47+48+DLA Flashcards
physician assisted dying - passive
the patient is refusing treatment and the physician sanctions the refusal
ex: chemo
physician assisted dying- active
the intent was to relieve suffering, not kill
ex: high dose of opioids (double effect)
physician assisted suicide
this is when the physician provides the means for death, usually a prescription
the patient will administer the lethal dose
Euthanasia
the painless killing of a patient suffering from a painful and or uncurbable disease
physician will prescribe and administer the method of death
expressed interest standard
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
substituted judgement
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
Best interest standard
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
classification of hypersensitivity
ab vs cell
I,II, III, are antibody mediated
IV is cell mediated
type I sensitivity
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
role of Th2 and IgE
Th2 releases IL-4 and and IL-13 which stimulates the B cells to produce IgE
primary mediators and secondary mediators of mast cells
primary: made before and stored
histamine, heparin, proteases, eosinophil chemotactic factor
secondary: 2-4 hours after
bradykinins, leukotrienes, etc
type II hypersensitivity
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
transfusion reaction via type II hypersens
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
Erythroblastosis fetalis
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
hypersensitivity type II (non-cytotoxic)
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
type III hypersensitivity
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)
serum sickness
type III hypersensitivity (general)
Response to foreign protein in serum
Deposition of immune complexes systemically
Fever, vasculitis, arthritis, nephritis
type IV hypersensitivity
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
importance of type IV hypersens?
important for the clearance of intracellular pathogens
EX: M. tuberculosis and leishmania
contact such as nickel and poison ivy
prolonged DTH can lead to…
granuloma formation
duty to treat
if there is no treatment relationship, no physician consent, there is no duty to treat
common reasons for refusal to treat
practice is full
lack of expertise
patient cant pay
patient is disruptive
what are the three limitations to the refusal to treat?
- discrimination of any extend
- have already agreed to treat
- another type of prior agreement ( on call; ED)
morally expendable treatment?
- treatment is useless
- grave burden
- when the harm outweighs benefits
parts of a relationship?
- standard of care
- informed consent
- confidentiality
- non- abandonment
SICN
standard of care
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
exemptions to duty of informed consent
- info is already known by patient or commonly known
- emergency situation
urgent need, lacks capacity, no ability to get consent from surrogate, no known objection - therapeutic privilege- big mental issue if patient were to know
- wavier- patient does not want to know
- public health - protect community
- conscious based objection - moral / religious reasons
terminating relationship
mutual consent
patient dismisses physician
treatment is not needed
firing a patient
why fire a patient
noncompliance failure to pay verbal abuse drug seeking violating policy / no show
torturous abandonment
cannot abandon a patient, especially without significant notice
