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Ethics (COLLECTIVE) > Medical Indications > Flashcards

Medical Indications Flashcards

1
Q

What are the 4 ethical principles related to clinical medicine?

A
  1. beneficence
  2. nonmaleficence
  3. autonomy
  4. justice
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2
Q

What are 4 unspoken ethical priniciples regardign clinical medicine?

(not the main 4)

A

empathy

compassion

fidelity

integrity

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3
Q

What is the common pattern for organizing details pertaing to a patient?

What does this data lead to?

A
  • Chief complaint (CC)
  • History of Present Illness (HPI)
  • Past Medical History (PMH)
  • Physical Examination
  • Laboratory and Investigational Results

these things lead to decisions regarding diagnosis and treatment

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4
Q

As seen in the case of Libby Zion, giving a patient a combination of pethidine (demerol-to control jerking motions) and phenelzine caused what negative reaction?

A

serotonin syndrome

  • symptoms that can range from mild (shivering and diarrhea)*
  • to severe (muscle rigidity, fever and seizures); can be fatal.*
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5
Q

What does a doctor’s professional identity include?

A
  • obligations to provide competent care to the patient
  • preservation of confidentiality
  • communication– honestly and compassionately
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6
Q

What is a surrogate decision-maker (in a medical setting)?

A

appropriate surrogate decision-makers:

  • the patient’s family
  • domestic partner
  • close friend
  • Make medically-relevent decisions regarding a patient who is deemed incompetent.*
  • If a patient has expressed specific wishes regarding treatment, these should be respected.*
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7
Q

What is an advanced directive?

A

allows patients to determine their goals regarding health and medical treatment based on personal values, attitudes, and beliefs surrounding health care, illness, and death.

(life-sustaining treatments for a terminal condition, persistent vegetative state AND end­stage condition)

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8
Q

What is a living will?

A

A living will is a written, legal document that spells out medical treatments you would and would not want to be used to keep you alive, as well as other decisions such as pain management or organ donation.

(life-sustaining treatment for permanent unconsciousness or when death is imminent)

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9
Q

What is meant by the principle of autonomy?

A

“I have the right to do what I choose with my own body as long as I understand the consequences to my decisions.”

“You have the Right to make Wrong choice about your health care”

= FREE WILL

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10
Q

What are the “four boxes” that constiture the essential ‘structure’ of a clinical case?

*(pattern for collecting, sorting and ordering of clinical ethical problem facts) *

A

1. Medical Indications:

diagnostic and therapeutic interventions used to evaluate and treat medical problems

2. Patient Preferences:

express choices of patient (or those authorized) about their treatment

3. Quality of Life:

features of patient’s life prior to, subsequent to treatment

4. Contextual Features:

identify familial, social, institutional, legal settings within which a particular case takes place

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11
Q

What are medical indications?

A

“facts about patient’s physiological/psychological condition that indicate which forms of diagnostic, therapeutic, or educational interventions are appropriate”

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12
Q

What is meant by the principle of beneficence?

A

“duty to try bring about physical/psychological improvements in health via medicine”

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13
Q

What is meant by the principle of nonmaleficence?

A

“achieving beneficence without injury or reducing injury risk”

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14
Q

What are the main goals of medicine?

A

“PREVENTION, CURE, CARE OF INJURY”

“Cure sometimes, relieve often, comfort always”

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15
Q

What are the 6 main characteristics of prefessional conduct?

A

Altruism:

essence of professionalism (best interest of patients, not self-interest)

Accountability:

required at many levels (individual patients, society and the profession)

Excellence:

conscientious effort to exceed normal expectations and make a commitment to life-long learning

Duty:

free acceptance of a commitment to service.

Honor and Integrity:

consistent regard for highest standards of behavior and refusal to violate one’s personal/professional codes.

Respect for others:

patients and their families, other physicians and professional colleagues (nurses, medical students, residents, subspecialty fellows)

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16
Q

What are the 5 questions that define the scope of medical indications?

A

**Question 1: **

What Is the patient’s medical problem? Is the problem Acute? Chronic? Critical? Reversible? Emergent? Terminal?

**Question 2: **

What are the goals of treatment?

**Question 3: **

In what circumstances are medical treatments not indicated?

Question 4:

What are probabilities of success of various treatment options?

**Question 5: **

How can this patient be benefited by medical/nursing care?

          How can harm be avoided?
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17
Q

What are the 2 medical principles that medical indications are based on?

A

**beneficence **and nonmaleficence

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18
Q

Always start a patient consultation/interaction/admittance with…..?

A

A review of medical indications

  • determine goals (physician’s, patient’s)
  • formulate recommendations
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19
Q

medical “helping” is defined as:

A

“trying to heal and doing so as safetly and painlessly as possible.”

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20
Q

Reviewing medical indications creates a clear picture of a patient’s medical condition.

Where do these indications come from?

What do they lead to?

A
  1. patient history
  2. physical examination
  3. data from labratory

interpreted by clinical experience (physician’s)

Indications lead to:

  • differntial diagnosis
  • management plan
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21
Q

What is a differential diagnosis?

A

distinguishing a disease of illness from others with similar signs and symptoms

22
Q

What are important distinctions that are made regarding the disease?

A

is it….

- acute? rapid onset, short course

- chronic? persistant and progressive

- emergent? causing immediate disability if not treated

- non-emergent? slowly progressive

*- *curable? primary cause known; treatable by definitive therapy

- incurable?…duh.

23
Q

What are important distinctions that are made regarding the treatment?

A

Is it…

- burdensome? known to cause serious adverse affects

- nonburdensome? **unlikely to have serious side effects

- curative?* offer definite cprrection of a condition*

- supportive? offer relief of symptoms;

slow disease progression if it is currently uncurable

(* ‘burdens’ - decided upon by physician and patient*)

24
Q

Analysis of the patient should answer what questions?

A

“What is the diagnosis?“

“What are the medical indications for treatment?”

“What are the probabilities of success?”

“What are the consequences of failure to treat?”

“Are there any reasonable alternatives for treating this clinical problem?

25
Q

What are 8 *general goals *of medicine?

A
  1. Cure disease
  2. Maintain/improve of quality of life (relief of symptoms, pain, suffering)
  3. Promote of health and prevention of disease
  4. Prevent untimely death
  5. Improve functional status or maintain compromised status
  6. Education and counseling of patients regarding their condition and prognosis
  7. Avoid harm to patient in course of care
  8. Provide relief and support near time of death

**sometimes goals conflict**

26
Q

In every case the patient and clinician should…

A
  • clarify goals of intevention
  • set & reset goals realistically
27
Q

In what 4 instances would medical intervention NOT be indicated?

A

interventions non-indicated when…

  1. intervention has no scientifically shown effects on disease

(but is desired or requested by physician/patient)

  1. intervention may not be successful in a particular patient
  2. intervention migh become** **non-indicated as patient’s condition changes
  3. intervention not applicable to dying/terminal/progressive lethal disease patient
28
Q

When is a medical intervention indicated?

A

when the application of intervention = improvement in condition

(case specific)

29
Q

“medically indicated”

A

“what a sound clinical judgment determines to be physiologically and medically appropriate in the circumstances of a particular case.”

30
Q

“dying” patient

A

A situation when clinical conditions indicate definitvely that patient’s organ systems are deteriorating repidly and irriversibly.

  • death is expected within hours
  • “actively dying” or “imminently dying”
31
Q

“terminal” patient

A

no standard clinical definition.

  • Medicare/Medicaid: “prediction of having 6 months or less to live”
  • clinical definition *SHOULD *be:

” A patient whom experienced clinicians expect will die from a lethal, progressive disease, despite appropriate treatment, in a relatively short period of time”

(i.e. days, weeks, a few months)

32
Q

BENEFIT-TO-RISK ratio

A

assess how much risk is justified by intended benefit

(don’t forget to consider: patient’s preferences/quality of life, context)

33
Q

“Physiological Futility”

A

A condition in which physiological systems have deteriorated so drastically that no medical interventions can reverse the decline.

34
Q

“Potentially Terminal”

A

“a condition that’s not terminal, but an acute episode may threaten to kill the patient”

35
Q

Medical Intervention that is futile…

A

…offers no therapeutic benefit to patient.

(ethical justification for the physician to recommend withdrawing all interventions)

36
Q

There are different approachs to gathering info. on patients entering the ICU.

What it the APACHE approach?

A

Acute

Physiology

And

Chronic

Health

Evaluation

37
Q

There are different approachs to gathering info. on patients entering the ICU.

What it the MODS approach?

A

Modified

Organ

Dysfunction

Score

38
Q

“futility problem”

A

justifying withdrawing or withholding treatment

39
Q

“Clinical Judgment”

A

A process where clinicians attempt to make consistantly good decisions in the face of uncertainty

40
Q

How is clinical uncertainty reduced?

A
  • evidence-based medicine
  • clinical data
  • medical science
  • logical reasoning
  • development of practice guidelines
  • “[Medicine] A science of uncertainty and an art of probability” - Dr. William Osler*
41
Q

You are dealing with a ‘terminally ill’ patient who is unresponsive. Their** **personal preferences are not indicated.

What should you use to formulate your recommended treatment (or lack of)?

A
  • Objective data about survival
  • Sound clinical discretion about probabilities of improvement
  • (quality of life and appropriate use of resources becoe appropriate ethical resources)*
42
Q

The observation that none of the goals of medicine can be achieved in a particular case provides ____________________?

A

…the first ethical ground that **further life-sustaining treatment can be omitted. **

43
Q

“probabilistic futility”

A

the treatment is very unlikely to achieve its goal

(statistically; based on clinical data)

44
Q

“Medical Futility”

A

not physiologically futile, but there is a vanishingly low probability of restoring patient’s health (if it is maintained, quality of life will be decreased)

45
Q

What are 3 main questions about futility?

A
  1. What level of statistical or experimental evidence is required to support judgment of futility?
  2. Who decides whether an intervention is futile, physicians or patients?
  3. What process should be used to resolve disagreements between patients (or surrogates) and the medical team about whether a articular treatment if futile?
46
Q
  1. What level of statistical or experimental evidence is required to support judgment of futility?
A
  • judgment that intervention is highly unlikely to produce desired results
  • studies demonstrate low level of success
  • there is no definitive “how low?” level; suggested that

<1% chance of success in a clinical study = futile

47
Q
  1. Who decides whether an intervention is futile, physicians or patients?
A

generally thought that physicians should make decisions about treatment futility** in light of subjective views, values, goals of patients and their surrogates**.

(in theory physician has the final say; can withdraw from case)

48
Q
  1. What process should be used to resolve disagreements between patients (or surrogates) and the medical team about whether a articular treatment if futile?
A
  • institutions should design a policy
  • should be nonunilateral decisions (unless physiologically futile)
  • should allow physician to withdraw from a case
  • stress the need for valid empirical evidence
  • negotiations should occur between medical personel, family, and/or surrogates
49
Q

Futility is useful in medical ethics because…

A

… it highlights the necessity to make decisions about treatments that are of questionable benefit

50
Q

What is the one situation where physicians can invoke futility to justify unilateral decision making pertaining to treatments?

A

physiological futility

Ethics (COLLECTIVE) (2 decks)

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