Legal Flashcards
A patient with early-stage Alzheimer disease is brought to your office by his wife to discuss the benefits and risks of possible major surgery.
Which one of the following would be the most appropriate next step in determining this patient’s decision-making capacity for surgical informed consent? (check one)
-Assessing his ability to understand the risks, benefits, and alternatives
- Reviewing his living will
-Determining his health care surrogate
-Obtaining a competence evaluation
-Obtaining a psychiatric evaluation
Assessing his ability to understand the risks, benefits, and alternatives
Medical decision-making capacity is defined as a patient’s ability to understand the benefits, risks, and alternatives to a given treatment, or the option of no treatment. Other elements of medical decision-making capacity include the ability to demonstrate appreciation of said benefits, risks, and alternatives; the ability to demonstrate reasoning in making a decision; and the ability to communicate a choice.§A living will and surrogate decision maker are considerations when a patient has been determined to lack decision-making capacity. They are not used to determine decision-making capacity. A living will is an advance directive that communicates a patient’s values and treatment preferences when and if they are incapacitated.
A surrogate decision maker is an advocate for the patient when it has been determined they do not have decision-making capacity. For example, a surrogate can be someone the patient has appointed in a type of advance directive called a durable power of attorney for health care. If the patient has not appointed someone, then a default person according to state law is specified.
Capacity and competence are not the same. Capacity is a medical term about the ability or inability to make decisions about medical treatments and care, whereas competence is a legal term referring to global decision-making about issues such as finances, property, and wills. Capacity is determined by the treating physician and can vary with the circumstances of the decision such as its complexity. While a psychiatric consultation may be helpful in certain circumstances, it is not required.
A 55-year-old female receives a gynecologic and breast examination from a nurse practitioner, who also orders a routine mammogram. Who is legally responsible for ensuring that the patient is notified of the results of the mammogram?
(check one)
The nurse practitioner
The supervising physician
The facility performing the mammogram
The patient
The facility performing the mammogram
While it is certainly appropriate for the nurse practitioner or physician who ordered the test to notify the patient of mammography results, the facility performing the test is legally responsible. This is specified
by the federal Mammography Quality Standards Act, first passed by Congress in 1992.
You see a 72-year-old male for follow-up after his third hospital admission for heart failure within the past 4 months. He is a widower and lives alone, but he wants to talk about options for in-home nursing care. He is accompanied today by his sister and his neighbor. This is the first time you have seen the patient.
Which one of the following is the best choice regarding your interactions with the three of them?
(check one)
Construct a family genogram to determine how to proceed with the patient’s care
Speak privately with the sister and neighbor to determine possible ulterior motives
Determine the reason each person is present today
Discuss the patient’s health information freely, as he willingly brought the neighbor and sister along
Determine the reason each person is present today
Interactions between the physician and patient involve the patient’s family and friends, as well as others who may be part of the patient’s social support system. These interactions, as well as the physician-patient relationship itself, are also strongly influenced by ethnic, cultural, and spiritual values and by beliefs about illness and approaches to treatment and ongoing care. Involvement of family members in a patient’s care is advantageous to good communication and helpful for both accurate diagnosis and appropriate treatment (SOR C).
Patient confidentiality should be protected, and the mere presence of other people accompanying the patient does not automatically constitute permission to discuss private health information with them. The physician should determine not only who is present with a patient, but also each person’s reason for being present (SOR C). Speaking to relatives or friends without the patient present may be appropriate under certain circumstances but would not be the best option in this scenario. Constructing a genogram can also be helpful, but that would not be the first priority in this case.
An 82-year-old white male has a cardiopulmonary arrest while mowing his lawn and his heart rhythm is restored after 8 minutes of CPR by a neighbor. He is now your patient in the coronary care unit. He is on a ventilator and has severe hypoxic encephalopathy. Echocardiography shows an ejection fraction of 12% as a result of the massive anterior myocardial infarction he sustained. Your neurology consultant confirms that the patient will never again be able to meaningfully communicate, and will be ventilator-dependent.
Prior to this, the patient had been living independently and had no health problems. He has no living relatives, and his attorney confirms that he has no written advance directives. The neighbor, who is a close friend, tells you that on several occasions recently he and the patient had discussed such a scenario, and that the patient had said that if he had little chance of a meaningful recovery he would not want to remain on life support.
In consultation with the hospital ethics committee, which one of the following would be most appropriate in this case?
(check one)
Transfer care of the patient to another physician
Ask a court to appoint a guardian to make medical decisions
Withdraw life support
Defer the decision regarding life support to the hospital attorney
Ask the patient’s attorney to decide whether to terminate life support
Withdraw life support
The most common form of advance directive is a patient’s conversations with relatives and friends, and these carry the same ethical and legal weight as written directives. Neither the hospital attorney nor the patient’s personal attorney, in the absence of a previous discussion with the patient, has the ethical or legal authority to make the decision. Since the patient has previously expressed his wishes, it is unnecessary to have the court appoint a surrogate decision maker. Care should be transferred to another physician only if the original physician has a philosophical or religious objection to carrying out the patient’s wishes.
You are preparing to inform a patient of a diagnosis of terminal metastatic cancer. When sharing bad news with a patient, which one of the following is the most appropriate next step? (check one)
Selecting which information to share with the patient
Asking the family what the patient knows
Obtaining the patient’s permission to discuss the diagnosis
Explaining palliative care
Informing the patient about hospice
Obtaining the patient’s permission to discuss the diagnosis
As health care has moved to a patient-centered, decision-making model, there is a focus on communication skills and patient preferences. These apply when physicians share serious or bad news with patients.
The Setting, Perception, Invitation, Knowledge, Emotions, and Strategy/Summary (SPIKES) protocol can be used for sharing bad news.
It is during the invitation step of SPIKES that a physician determines how much information or detail a patient desires to hear. Patient preferences vary and are influenced by demographics including age, sex, education, and culture (SOR B). While most patients want to know their diagnosis, the amount of detail varies. It is important to recognize this before sharing serious or bad news.
Asking permission to discuss the information enables the patient to control the conversation. The following questions are examples of how to ask for patient permission: Would it be okay if I give you those test results now? Are you someone who likes to know all of the details, or would you prefer that I focus on the most important results? If the patient declines, then offer to review the diagnosis again when they are ready or when a family member is present.
Previously in the paternalistic patient care model, the physician would select the information to share to help steer the patient toward the best decision. While the family is important, SPIKES is directed toward the patient because it is the patient, not the family, who controls the amount of detail that is discussed.
The last S in SPIKES is for Strategy and Summary. While palliative care and hospice could be included in that discussion, it would vary based upon what the patient wants to discuss at the time the bad news is initially shared.
An 84-year-old female presents for follow-up of multiple chronic medical problems. She is usually accompanied by her daughter, who lives nearby, but today is brought in by her son and daughter-in-law, who live out of town. They are supportive, but are insistent that the patient see a specialist for a problem that she has previously decided not to pursue further. The patient wants to avoid conflict but does not want to see any other physicians.
Which one of the following is the most appropriate way to deal with this situation?
(check one)
Speak with the son and daughter-in-law privately
Maintain neutrality and avoid triangulation
Call the daughter to discuss the situation
Try to talk your patient into seeing the specialist
Schedule the appointment to appease the family, then cancel it later
Maintain neutrality and avoid triangulation
When family dynamics lead to conflict during an office visit, it is best for the physician to attempt to remain neutral by avoiding triangulation, which occurs when the two sides in conflict each attempt to align with a third party. Priority should be given to the patient’s right to privacy and confidentiality, and the physician should ask permission from the patient to discuss his or her health issues with other people. Physicians should always remember who they are primarily responsible to.
You provide care for a 65-year-old female who has metastatic breast cancer. She would like to consider simple treatments and/or admissions, but wishes to avoid any further surgeries, heroic procedures, transfers to the ICU, or intubation.
Which one of the following forms should you recommend as most beneficial for directing her end-of-life care? (check one)
Cardiopulmonary resuscitation (CPR) directives
A living will
A medical power of attorney
Physician Orders for Life-Sustaining Treatment (POLST)
Physician Orders for Life-Sustaining Treatment (POLST)
Physician Orders for Life-Sustaining Treatment (POLST) forms are a portable order set signed by the provider and either the patient or the surrogate to direct care across various settings (including EMS, residential retirement facilities, nursing homes, emergency departments, and inpatient settings) at the end of life. The form is typically printed on bright-colored cardboard to make it easier to locate by EMS, with scanned versions available for electronic medical charts. It describes the patient’s wishes for cardiopulmonary resuscitation (CPR) and indicates the levels of care desired including full treatment, limited or selective interventions, and comfort-focused care. It is the best way to direct end-of-life patient care and respect diverse wishes. POLST forms are more useful than CPR directives because they describe broader end-of-life treatment choices. A living will is applicable only under the narrow conditions of a terminal or persistent vegetative state. A medical power of attorney is useful but does not convey values and wishes.
A 90-year-old male with metastatic prostate cancer and osteoarthritis of the knees is brought to the hospital with acute kidney injury due to dehydration, along with generalized weakness and ambulatory dysfunction. Prior to his hospitalization he lived independently with part-time caregiver assistance. Over the next 2 days his renal function improves, although physical and occupational therapy evaluations reveal significant deficits in his activities of daily living. The decision is made to transfer him to a skilled nursing facility.
In planning for his discharge, you discuss completion of a Physician Orders for Life-Sustaining Treatment (POLST) form with the patient and his daughter, who says that her father already has an advance directive. She asks you what distinguishes a POLST form from other advanced care planning documents.
You explain to her that, as opposed to an advance directive, a POLST form (check one)
does not require a signature from a treating physician
is required for patients with a terminal illness in hospice care
provides specific orders for emergency medical services
should be completed for all patients during an annual Medicare wellness visit
supersedes the expressed wishes of a patient who can communicate
provides specific orders for emergency medical services
An organization that is now known as National POLST began as an advisory panel and task force to improve consistency in honoring the wishes of patients with serious illness or frailty regarding end-of-life care. POLST, originally an acronym for Physician Orders for Life-Sustaining Treatment, varies in name at the state level, although at the national level POLST is defined as a portable medical order. POLST forms differ from other legal advanced care planning documents such as advance directives and living wills, although the processes can work together.
The primary purpose of a POLST form is to provide specific medical orders in the event that a patient is unable to communicate. Legal advanced care planning documents, in contrast, express general treatment wishes and identify a health care proxy for surrogate decision-making but do not provide specific orders for care. POLST forms are completed by a treating physician and signed by the patient or surrogate and the physician, unlike advance directive documents, which are completed by the individual and are often notarized. POLST forms are intended only for patients with serious illness and frailty, not for healthy persons, whereas advance directives can be completed by any competent adult. POLST completion is voluntary and is neither a requirement for entering hospice nor a routine part of the Medicare annual wellness visit. Neither document type is intended to supersede the expressed wishes of a patient who can communicate.
A 25-year-old female comes to your office at 30 weeks gestation for a routine obstetric follow-up. Her pregnancy has been uncomplicated except for a lack of insurance. She is an immigrant from Guatemala and does not speak English. You have used a telephone interpreting service for her previous visits, but today her 15-year-old niece is with her and she says that she would be happy to interpret for you.
Which one of the following would be most appropriate? (check one)
Have the niece ask the patient for permission to act as interpreter
Proceed with the visit, since it is unlikely that you will need to discuss complicated medical issues
Confirm the niece’s significant understanding of English, then have her interpret
Recommend the use of the telephone interpreting service as best medical practice
Tell her that it is illegal to use interpreters who are not certified
Recommend the use of the telephone interpreting service as best medical practice
Physicians should use trained interpreters whenever possible to avoid mistakes and pitfalls associated with using family members or untrained interpreters for medical interviews. Simply being bilingual does not mean someone will be an appropriate interpreter. Although it is technically legal to use a nontrained interpreter for this patient, title VI of the Civil Rights Act requires interpreter services for all patients with limited English capabilities who are receiving federal assistance (except Medicare Part B). This patient does not have Medicaid, but ethically it would be appropriate to extend the same courtesy to her.
It is difficult to predict what may occur in any visit, and a physician is open to serious medical mistakes by assuming a visit does not require an interpreter, because the patient may bring up a serious medical issue. Confidentiality is a concern when using family members to interpret, since they may not have an understanding of the need for confidentiality. It is not appropriate to ask the patient through her family member about her preferences for interpreting.
You are concerned about the alcohol use of a 45-year-old family physician colleague in your community. One evening you smell alcohol on their breath when they are on-call making evening rounds at the hospital. When you try to talk with them about it, they deny having a problem and tell you to mind your own business.
Which one of the following should be your next course of action? (check one)
Do nothing further
Report your concern to your state medical board
Report your concern to the American Academy of Family Physicians
Report your concern to the American Board of Family Medicine
Report your concern to the American Medical Association
Report your concern to your state medical board
There is an ethical and, in most states, legal obligation to report this physician for the safety of their patients. The state medical board is the appropriate agency to contact with such a concern. They will investigate the report and have the authority to intervene. The American Academy of Family Physicians and American Board of Family Medicine are not involved with licensing or intervention in the event of physician impairment.
The physician counseling a 4-year-old child about the death of a loved one should keep in mind that children in this age group: (check one)
often feel no sense of loss
often believe they are somehow responsible for the death
should not attend a funeral
should usually be told the loved one is having a long sleep
usually accept the finality of death with little question
often believe they are somehow responsible for the death
Children from the ages of 2 to 6 often believe they are somehow responsible for the death of a loved one. The emotional pain may be so intense that the child may react by denying the death, or may somehow feel that the death is reversible. If children wish to attend a funeral, or if their parents want them to, they should be accompanied by an adult who can provide comfort and support. Telling a child the loved one is asleep or that he or she “went away” usually creates false hopes for return, or it may foster a sleep phobia.
According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), in which situation would a physician be allowed to disclose personal information without the patient’s written authorization? (check one)
The patient makes a verbal request to release information
The patient’s spouse requests information
The adult children of the patient request written information
A lawyer who claims to represent the patient requests information
Another physician involved in the patient’s care requests information
Another physician involved in the patient’s care requests information
HIPAA legislation states that a patient’s personal medical and financial information cannot be released
unless the patient authorizes such a release in writing. The exceptions to this standard are the following:
(1) coordination of care between providers and those involved in the patient’s case (i.e., caretakers, nurses, consulting physicians); (2) arranging payment for medical services rendered; and (3) health-care operations such as evaluating a provider or system’s competency or quality. The privacy rule allows some discretion to a physician in “coordinating care,” even allowing a physician to speak with family members if that physician “in his or her professional judgment” feels it is in the patient’s best interest. In such situations
it is advisable to ask the patient’s permission to do so if possible, and the information should be related on
a need-to-know basis
You admit a 50-year-old female to the hospital with pneumonia secondary to COVID-19. Her medical history is significant for controlled major depressive disorder. Upon admission, she requires respiratory support with oxygen via a high-flow nasal cannula. You ask her wishes regarding emergency measures and she states that she does not wish to be resuscitated or intubated. She reports that she watched her mother die a “horrible death” from COVID-19 about 6 months earlier and does not want to put herself through that. She does not have an advance directive and her only living relative is her father who is cognitively impaired. You are hesitant to write the DNR/DNI order given her good health and high likelihood of survival if she were to clinically decline.
Which one of the following would be most appropriate prior to writing a DNR/DNI order for this patient? (check one)
No further actions prior to writing the order
Administering a Patient Health Questionnaire–9 (PHQ-9) and writing the order if her score is <10
Asking a second attending physician to verify her wishes
Consulting a psychiatrist for a formal assessment of mental capacity
Consulting the hospital ethics board
No further actions prior to writing the order
Individuals are assumed to have the mental capacity to make their own medical decisions unless there are reasons to question a patient’s capacity, such as risk factors for impaired decision-making or abrupt changes in mental status. It is the responsibility of the care team to honor the reasonable wishes of each patient, including decisions regarding end-of-life care. DNR/DNI orders can be fluid and changed throughout a hospital stay as more information becomes available. Patients should be provided with the tools needed to make medical decisions and ensure that they have insight into the consequences of the decisions. A DNR/DNI order should be written at this patient’s request without administering a depression screen or consulting other professionals.
In the U.S. legal system, which one of the following is a required finding to determine that medical malpractice has occurred? (check one)
Conflict of interest
A financial charge rendered to the patient
A causal relationship between breach of duty and injury to the patient
Presentation of the case to a grand jury
Testimony from an expert witness for the plantiff
A causal relationship between breach of duty and injury to the patient
For a physician to be found guilty of medical malpractice in the United States, the plaintiff must show that the physician acted negligently in providing care and that the negligence resulted in injury. Determining this requires proof of the following four legal components: (1) a professional duty owed to the patient; (2) a breach of said duty; (3) an injury caused by the breach; and (4) resulting damages. Although physicians are legally required to disclose conflicts of interest, having a conflict of interest is not an essential element in a malpractice decision. Malpractice may occur even if the patient is not rendered a financial charge, provided that the four essential criteria are met. Medical malpractice cases that are not settled or otherwise dismissed proceed to a jury trial, not to a grand jury. Grand juries are part of the criminal indictment process and are not relevant to medical malpractice cases. While expert witness testimony is often used in a malpractice case, typically to help establish whether there has been a breach of a professional standard of care, such testimony is not a requirement for a medical malpractice decision.
In which one of the following scenarios would additional consent from a child’s parent or guardian be necessary before proceeding with treatment in nearly every U.S. state? (check one)
A 6-year-old female with divorced parents who lives primarily with her mother is brought to the clinic by her father to discuss his concerns of possible abuse
An 8-year-old unconscious male is brought to the emergency department by a neighbor after falling out of a tree and striking his head
A 13-year-old male is brought to the clinic by a babysitter with a note giving permission to treat signed by a parent
A 15-year-old female who is considered emancipated under state law comes to your office to discuss family planning
A 16-year-old female who has driven herself to her clinic appointment reports a 2-day history of ear pain; she says her mother made this appointment for her
A 16-year-old female who has driven herself to her clinic appointment reports a 2-day history of ear pain; she says her mother made this appointment for her
Informed consent to treat is considered an important ethical and legal part of caring for children and adolescents. Some situations can become confusing when trying to balance the need for treatment, a child’s consent, and a parent or guardian’s permission. In most states, 18 is the age when legal decisions can be made; however, in some states 21 years old is the age of legal consent.
Children below the age of majority must have proof of permission to treat from a parent or guardian for non-emergent care. This does not apply to emergency situations in which a delay in care could result in serious harm. Another exception to parental consent is when a child is considered emancipated under state law. This can happen with a court order, or (in some states) if the child is married, is a parent, is in the military, or is living independently. Either biologic parent can consent to treatment unless one of them is explicitly denied guardianship. If a child presents with a non-emergent condition and does not have evidence of permission from a parent or guardian, permission should be sought before the physician interaction takes place.
