Social Science and Ethics Flashcards
Consent for medical emergencies
x
management
x
in what medical circumstances can a minor provide their own consent?
- Emergency care (all states)
- Sexually transmitted infection (all states)
- Mental health and substance abuse treatment
- Pregnancy care
- Contraception
in what legal circumstances can a minor provide their own consent?
- Financially independent
- Parent
- Married
- Active military service
- High school graduate
Falls in Elderly
x
prevention
x
what are interventions that have been proven to be useful in the prevention of falls in elderly patients?
muscle strength and balance training, withdrawal of psychotropic medications, and home hazard evaluation and modification by a trained professional (i.e. nurse)
RCA (Root Cause Analysis)
x
what are the steps in RCA?
1) Collect data
2) Create causal factor flow chart
3) Identify root causes
4) Generate recommendations & implement changes
5) Measure success of changes
define
x
what is considered a sentinel event in RCA?
an unexpected occurrence involving actual or risk of death or serious injury
example: suicide
Impaired Colleagues
x
what is required of physicians who note impaired physician behavior?
Physicians are ethically and legally obligated to report impaired colleagues to physician health programs or state licensing boards in keeping with applicable state laws.
goal is maintaining patient safety
Accepting Gifts
x
what is appropriate response by physicians in regards to gifts from patients?
physician’s response should support the best interest of the patient and preserve the physician-patient relationship
what should you consider when accepting a gift?
gift’s cost, the meaning of the gift to the patient, and the patient’s probable motivations and expectations for giving the gift
when should a gift be declined?
gifts accompanied by expectation of preferential treatment, or that are extravagant, excessively valuable, or intimate, should be declined.
Herbal Supplements
x
when a patient chooses to use herbal supplements against medical advice, what do you do?
- Patient’s decision should be documented in the chart.
- The physician should follow the patient’s health status and not abandon the patient despite this decision.
Child Abuse/Non-accidental trauma
x
history
x
what is the history of a child abuse case?
- vague or changing details
- injury inconsistent with child’s developmental stage
- sibling described as responsible
Physical Exam
x
what is the PE of a child abuse case?
- injury inconsistent with history
- multiple fractures or bruises in different healing stages
- likely inflicted injuries (eg cigarette burn)
- poorly kempt child
- bruises on neck, abdomen, or unusual sites
- injury to genitalia, hands, back, or buttocks
caregiver behavior
x
what is the history of a caregiver behavior case?
- argumetative or violent
- lack of emotional interaction with child
- inappropriate response to child’s injury
- inappropriate delay in seeking medical care
- partial confession in causing injury
Vaccine Hesitancy
x
define
x
what is the definition?
delay or refusal of immunization
misconceptions
x
what area common misconceptions?
Vaccines cause autism: Following the retraction of the fraudulent Wakefield study, studies have consistently shown no association between immunizations and autism spectrum disorders.
what area common misconceptions?
Vaccines overload the immune system”: Immunizations have no impact on subsequent immune responses to other antigens.
what area common misconceptions?
Natural infection is better”: Natural infection invariably is associated with higher risk of complications compared to immunization. For example, wild-type rotavirus causes more intussusception than live-attenuated rotavirus vaccine.
management
x
what is the best management?
Vaccine-hesitant parents are often open-minded and can be convinced over time with education and nonjudgmental, honest discussion
Treatment of Friends
x
management
x
what is the ethically sound management approach for treating friends?
recommend that treatment of friends should be restricted to limited care in emergency situations when no other physician is available.
Transfusions and Jehova’s Witness
x
management
x
what is the management of jehova’s witnesses in emergent situations?
principle of patient autonomy, no blood transfusions, but supportive measures like vasopressing and fluids is ok
when is blood trasnfusions ok in jehova’s witnesses?
had the patient been unconscious (and his desire to avoid blood products unknown)
when can a child who is a jehova’s witness get a blood transfusion?
in an emergency situation, the parent cannot refuse life-sustaining treatment for a child who has not reached the age of consent
Guardianship
x
management
x
what is important to do when assessing a mentally disabled regarding medical decision making?
Guardianship should be clarified early in the medical relationship to facilitate decision making
Assessment of decision-making capacity
x
Criterion
x
what are the criterion for decision making capacity?
“CUCR”
- Communicates a choice
- Understands information provided
- Appreciates Consequences
- Rationale given for decision
Communicates a choice
Patient able to clearly indicate preferred treatment option
Understands information provided
Patient understands condition & treatment options
Appreciates consequences
Patient acknowledges having condition & likely consequences of treatment options, including no treatment
Rationale given for decision
Patient able to weigh risks & benefits & offer reasons for decision
goal of assessing decision making capacity
x
what is the goal?
determine if the patient demonstrates both consistent, logical reasoning and a clear understanding of the condition and the risks of refusing treatment
Medical Errors
x
management
x
how should medical errors be disclosed?
prompt disclosure actually decreases malpractice risk, accompanied by an empathic apology and explanation
factors
x
what factors contribute to medical errors?
patient, staff, equipment, work environment, education and training, and task
patient factors include?
clinical condition, language, cultural or religious beliefs, social support
staff factors include?
fatigue, langauge, stress, mental impairment
equipment factors include?
unavailability, disrepair
work environment factors include?
staffing workloads, error reporting policy and practice, physical design of patient care area
education and training factors include?
presence of senior staff, unfamiliar task, inexperience
task factors include?
guidelines and policies, algorithms and protocols, test result availability
Sexual Abuse
x
risk factors
x
what are risk factors?
Preadolescent girls
Unstable family relationships
Perpetrator is often a trusted adult
features
x
what are sexual abuse features?
Nonspecific behavior changes
Developmentally inappropriate sexual play
Genitourinary concerns
Genital trauma
Laboratory evidence of STI
management
x
how do you manage?
Notify child protective services
STI treatment
Emergency contraception
Mental health referral
Trichomonas vaginalis
x
syx
x
what are the syx?
malodorous vaginal discharge and pruritus
dx
x
what are dx findings?
visualizing trichomonads,
pear-shaped motile organisms on wet mount;
vaginal pH >4.5
Home Health Services
x
define
x
how do they qualify for homecare with skilled care?
individuals must have a serious illness or injury that makes leaving the home exceedingly difficult or taxing
dx
x
what is the dx criteria patients must meet?
meet the criteria for being “homebound,” which includes >1 of the following:
Use of a supportive device (eg, crutch, cane, wheelchair, walker) for mobility
Ability to leave home only with the assistance of another individual
Medical contraindication to leaving home
services
x
what are common skilled home health services?
physical and occupational therapy, medication compliance monitoring, and wound care
Parenting
x
management
x
extensive research shows a child’s wellbeing is determined by?
the quality and security of the child-parent relationship and the competence of the parents, rather than the parents’ gender or sexual orientation
Children raised by gay and lesbian parents do not show greater incidence of gay/lesbian orientation or gender dysphoria. T or F
TRUE
Patient invitations to a significant life
x
management
x
Accepting a longtime patient’s invitation to a significant life event does not violate ethical professional boundaries. T or F
TRUE
when deciding to attend a patients wedding or garduation, what does the ethics dictate?
Physicians must use professional judgment and cultural sensitivity in responding to social situations outside the professional relationship.
informed consent
x
management
x
for routine non urgent consent , what must be obtained?
written consent by proxy should be signed by the parent or legal guardian specifying who may consent to the child’s medical care.
if legal guardian were to refuse medically necessary non emergent treatment , what do you do?
A court order can be obtained to overrule the parental decision
if emergent consent required, what must be done?
Verbal consent
define
x
what is informed consent?
process whereby a patient makes a health care decision based on the physician’s explanation of the diagnosis and a discussion of the risks and benefits
unique situations
x
in the event that cultural obligations prevent a women or man from signing a document of consent, what should you do?
document the informed consent discussion, including the patient’s understanding of the information presented
the standardized form is just a surrogate for the key factor: informed consent discussion has taken place
End-of-life care
x
purpose
x
what is the purpose of end of life care?
focused on minimizing discomfort, anxiety, and distress for the patient and family once efforts to cure or modify disease become futile
management
x
if there is disagreement about whether future care is futile , patients should seek agreement through what approach?
stepwise approach that includes involvement of consultants and the hospital ethics committee
Excessively needy patients
x
management
x
how do you manage excessively needy patients who demand attention for nonurgent concerns?
by setting limits in a firm but empathic manner
what is the best approach for setting limits with excessively needy patients?
Educating patients about specific guidelines for contacting the physician outside of office hours
Also providing alternate resources for routine questions
Physicians Personal Issues
x
boundaries
x
what boundaries regarding physician personal issues should be established?
physician’s personal issues should never enter the interaction between doctor and patient during a clinical visit unless specifically solicited by the patient
A physician should never solicit for funds or other support, even for medically-related issues, during clinical visits because such efforts may alienate patients or make them feel that their care will be affected if they do or do not participate. T or F?
TRUE
Initial encounters with demanding patients
x
management
x
what is the best management with initial encounters?
nonjudgmental, empathic approach that validates their concerns
the next best approach is?
further history, performing a basic laboratory workup, and building a doctor-patient relationship should take priority
principle of autonomy
x
define
x
what is it?
patient’s right to refuse treatment, and the physician must respect the patient’s decision
primary myelofibrosis
x
poor prognostic factors
x
what are poor prognostic factors?
significant weight loss; hemoglobin level <10 g/dL, leukopenia (white blood cells <4,000 /mm3) and platelet count <150,000/mm3
only patients age <60 with primary myelofibrosis can be considered as candidates for what?
hematopoietic cell transplantation (the only effective medical trx for primary myelofibrosis)
Forced Sterilization
x
management
x
if a woman with intellectual disabilities (ie down syndrome) is requesting contraceptive and mother wants tubal ligation as she is concerned her daughter struggles to take basic care of herself and could never care for a baby, what do you do?
validate mother’s concerns but discuss alternate birth control options besides tubal ligation
what does involuntary sterilization violate?
Involuntary sterilization violates a woman’s right to privacy, her reproductive rights, and her bodily integrity
Decision-making capacity
x
define
x
what is it?
patient is alert and able to make decisions
association
x
what principle is involved?
autonomy
Advanced Directives
x
define
x
what is it?
competent adult patient may, via an advance directive, formulate and provide valid consent to withhold or withdraw life-supporting treatment in the event that any injury or illness renders that individual incapable of making such a decision
Next of Kin
x
management
x
who is next of kin in situations where medical decisions must be made without advanced directives?
the patient’s spouse , then children
Medical Errors
x
management
x
how do you manage a medical error?
prompt disclosure accompanied by an apology and discussion of preventive measures. Do it in a timely manner!
what else should you do?
reassure patients of efforts to prevent further errors from occurring.
Sexual or Romantic Relations between Physicians and Key Third Parties
x
define
x
what does the AMA code of ethics state?
Physicians should refrain from sexual or romantic interactions with key third parties (parents, guardians, spouses or partners) when it is based on the use or exploitation of trust, knowledge, influence, or emotions derived from a professional relationship.
what does that mean?
Physicians are ethically obligated to act in the best interest of the patient
Romantic and Sexual Relationships between physicians and current patients
x
Due to the highly personal and emotional nature of the psychiatrist-patient relationship, romantic and sexual relationships between psychiatrists and former psychiatric patients are considered unethical as well. T or F
TRUE
in what circumstances is the romantic relationship between physician and patient considered debatable?
the relationships between non-psychiatric physicians and former patients have been debated, and if the physician-patient relationship was brief or relatively impersonal it may be acceptable
Elder Abuse
x
screening
x
who should be screened for elder abuse?
> 65 for elder abuse
what are risk factors for elder abuse?
Advanced age (>80)
Depression
Female
History of hip fracture or stroke
Social isolation
Difficulty caring for self
Dementia
Poor socioeconomic status
Suspicious caretaker behavior
Indication of financial exploitation
what are physical signs of elder abuse?
Skin tears, abrasions & bruises lacking adequate explanation, especially on the trunk or other unusual locations
Fractures in sites not typical of osteoporotic fractures (eg, long bones of the arms & legs)
Dehydration & malnutrition
Pressure ulcers
Signs of sexual abuse (eg, bruised breasts, anogenital trauma)
Surrogate Decision Makers
x
define
x
when a decision must be made regarding withdrawal of life support measures, it is important for a physician to act in the patient’s best interest by identifying what ?
identifying a surrogate, with whom he must effectively communicate and discuss all issues and concerns
what is the order of default surrogates in most states? list in descending priority
descending priority: Spouse, adult children, parent, adult sibling, nearest living relative, and close friend.
management
x
in the event that patient’s without advanced directives have multiple family members who are next of kin and disagree, what is the next best ?
hospital’s ethics committee should be involved-mediate between the different family members
In extreme cases, the case may need to be taken to court, where a guardian is appointed to assist in the medical decision-making
in the event that there is a durable power of attorney for health care (DPOA-HC) who is acting as a surrogate for decision making, who do you follow in cases where family disagrees about direction of care?
DPOA
x
x
Physician Lecturers
x
according to AMA code of ethics, physician lecturers are able to accept what?
physician lecturers to accept reasonable honoraria and/or reimbursement for reasonable travel expenses, but must provide full disclsure and the nature of the financial ties to the company
Physicians lecturing at industry-sponsored programs should do what?
retain full control over the presentation’s content, so they cannot accept pre-made slides
Emergency Situation and Decision Making Capacity
x
management
x
in emergency situation , patients who lack decision making capacity may be treated to what extent?
treated without formal consent under the doctrine of implied consent
Implied consent means what?
allows physicians to provide such treatments to an incapacitated patient that a “reasonable person” would be expected to accept under similar circumstances.
If this were a nonemergency situation and the patient lacked decision-making capacity, what would the physician have to do?
pursue a surrogate decision maker (eg, next of kin, guardian)
Life threatening Care
x
management
x
in life threatening emergencies, inability to obtain consent or parental refusal of consent , should not delay what?
should not delay care (i.e. Parental refusal to consent to an intervention that may prevent severe injury or death may be considered an act that is not in the best interest of the child, and medical providers should proceed with treatment)
would you need to obtain a court order in this situation?
court order should also be sought to legally overrule a parental decision; however, treatment should not be withheld while awaiting a decision, due to risk of severe disabilty and death
in non life threatening situations, inability to obtain consent or parental refusal of consent requires what?
organizing a family conference and consulting the hospital’s ethics committee are appropriate measures
Religious Beliefs and Medical Care
x
who is allowed to lawfully refuse their own care based on religious beliefs?
Adults and emancipated minors (eg, financially independent, married)
if religious beliefs interfere with potentially life-saving treatment in a minor, treatment should proceed without delay. T or F
TRUE
Discharge against medical advice (AMA)
x
what are the components of discharging a patients AMA?
Discuss specific benefits/risks of proposed treatment & alternatives
Discuss specific risks of refusing treatment
Assess decision-making capacity
Understands proposed treatment
Understands risks of refusing treatment
Demonstrates a reasoned basis for leaving against medical advice
Discuss follow-up care & option to return to emergency department
Notify primary physician, family
Document in medical record
Prescription opioid abuse
x
management
x
what should be done regarding opioid medication requests?
1) confirm the patient’s medical history and prescription use by contacting the patient’s previous physician.
2) State-based, online prescription drug monitoring programs should also be checked
risk factors
x
what are risk factors for opioid misuse?
personal or family history of substance abuse and psychiatric disorders
features
x
what are features of drugs seeking behavior?
- requesting high doses or a specific medication by name
- running out of medication
- reporting lost or stolen medication
- pain out of proportion to the physical examination.
Patient-physician email communication
x
define
x
what is the purpose?
simple, nonurgent health care issues is useful in clarifying instructions, improving rapport, and increasing patient satisfaction
management
x
what is the management approach for patients abusing email privelage?
Physicians should set clear parameters early on with patients regarding appropriate use of email.
what should the email privilages entail?
most useful when managing simple health care issues
(eg, medication refills, basic questions about pre- or post-operative care, appointment scheduling, advice clarification)
Potential Transplant Recipients
x
management
x
what is the management of potential transplant recipients to ensure they meet criteria?
no active substance or alcohol abuse and adequate social support
so detailed psychosocial evaluation
what is an aboslute vs relative contraindication to cardiac transplantation?
absolute contraindication: active substance or alcohol abuse.
relative contraindication: lack of adequate psychosocial supports
