ETHICS part 1

Right to Refuse Treatment:- case

MVA 6yo girl and mother, Needs blood. But JEHOVAHs Witness. Husband
said hes on his waybut cant contact him afterwards. Next Step:
A: Administer Blood Products to BOTH Patients
[If incapacitated, many Jehovahs witnesses carry a card that identifies their
desire to refuse blood products] This case: Mom is unresponsive and not
carrying a blood refuse card, and next of kin decision maker husband is not
available to communicate. PHYSICIAN is allowed to treated incapacitated
patient without consent in Emergency setting.]
[ALWAYS provide life-saving therapy to a Minor]
Support & Empathy:
Dr. questions her sexual history. She bursts into tears. She said she was
sexually abused as a child. Most appropriate response?
A: That sounds like an awful experience; are you comfortable
talking about it?
[Not: I understand how upsetting this is; we can return to the sexual history
another time = Acknowledges Pts distress but AVOIDS the issue]
Goal: Respond with Empathy and Concern. Acknowledge the trauma and
communicate willingness to discuss it when patient is ready.
Advance Directive:
79yo COPD. Other med problems CAD, DM2, Obese. He Smoked cigarettes
daily for 50 years Which is most essential to address during rest of
admission process?
A: Inquire about presence of ADVANCE DIRECTIVES and patients
wishes for end-of-life care
[NOT: Educate about smoking cessation to reduce risk of dying from heart or
lung disease TRAP!!! Hes gonna die.]
[Advance care planning: ideally done in outpatient visits with primary care
doctor. But Dr should Readdress these decisions during Hospital
admission.
Advance Directives: Living Will & Health Care Proxy.
Living Will
specifies pts end-of-life wishes and often includes specific directives
regarding intubation, CPR, Feeding Tube, other life-Prolonging interventions.]
[Health Care Proxy: allows pt to designate specific individual to make

health care decisions should patient become incapacitated.]

Informed Consent by Unqualified:

55yo F. Metastatic Breast Cancer develops dyspnea and tachycardia.
Attending informs the patient that a Pericardiocentesis is needed.
Attending is called to assist with urgent case. Asks the INTERN to Obtain
Informed consent for the procedure. Intern obtains consent forms describing
procedure. She has Never performed or observed a pericardiocentesis
but remembers reading about it in a book last year. Which is Appropriate
action by intern?
A: Ask the supervising RESIDENT to assist in obtaining informed
consent for the pericardiocentesis
[Ask the NEXT higher up. ]
[NOT: Obtain pts signature after confirming that the pt has read the informed
consent.. bc Pt answers questions based on limited knowledge are not
appropriate]
INFORMED CONSENT: Description of the procedure and Alternative
Treatments and discuss Risk & Benefits, the follow with assess Pts
Understanding and Preference. IDEALLY: informed consent should be
obtained by person doing the procedure.

Hospice Care model:

78yo Esophageal Cancer. Pt does not wish to receive treatment for cancer
doesnt want heroic measures to keep him alive. Physician considers referral
to HOSPICE CARE. Which is requirement for referring a patient for Hospice
care?
A: Patient has a prognosis of <6months
[Hospice care gives terminally ill Pts with advance metastatic cancers or
other terminal illnesses and life expectancy of <6months should be evaluated
for Hospice Care]

Basics of Medical Insurance:

25yo F has DM1. She requests advice in choosing a health insurance plan. Pt
has no Disability and says her main priority is LOW monthly payments.
Which insurance option appropriate?
A: Health Maintenance Organization

Monthly payments PPO $$$, POS $$, HMO $

[HMO: low monthly payments, Low Copayments and deductibles, Low total
cost for Patient]
Absence of Advance Directive:
68yo M brought to Emergency by Friend who saw pt pass out while having
drinks and dinner. COPD Hx, CAD, Alcohol abuse. Friend says Pt has a sister
who lives in area but is unware when they last spoke. Friend has known Pt for
5 years and says there are good buddies. They have discussed dying and
believes pt would prefer to Go naturally and refuse and heroic measures.
Action by Physician?
A: Attempt to contact the patients sister for consent to intubate!!
[If patient is incapacitated, patients FAMILY can act as Surrogate decision
maker.] 1st
[If patient has NO FAMILY, then a person who cares about and knows the
patients wishes can act as a substitute. - do no intubate based on friends
report of pts wishes]

Child Abuse: - Contact child protection services immediately

Withhold-info:
75yo M Chinese manbrought into ER by family. He only speaks Mandarin.
Pathology biopsy report: Bronchiogenic carcinoma. Family ask Physician not
to disclose any bad news to their father as it would distress him to know.
When pt is asked about this through the interpreter, he defers to his sons
judgement saying I am not interested in knowing. Family and son
state they dont want the pt to receive any further info Response to
patients son?
A: I will not inform him of the results if that is his preference
[Pts have RIGHT to REFUSE to RECEIVE medical info.].. Some Cultures view
withholding med info is appropriate.to avoid harm, disrespect, mental
distress caused by disclosure to pt.

 How to Address Patient: Address the pt 70yo by her surname and ask her
preferred form of address.
Disagreements between staff:
Attending asks the intern to start pt on propranolol for his heart condition.
After rounds, intern recalls that during medschool, she learned beta
adrenergic antagonists can interact poorly with cocaineWhich actions
should intern do?
A: Do Not order the medication until DISCUSSING concerns with
Attending physician and asking how to proceed

Communication Religious beliefs:

78yo M, afraid of dying during procedure asks you to pray for him. Youre
religious beliefs are different from his. Reply?
A: I understand you are afraid and that your beliefs are important. I will
keep you in my thoughts during your procedure
Requests to Withold info:
Dr. please dont tell me what they find, because if its cancer I dont want to
know. Your response?
A: Tell me more about your concerns so I can better understand why
you feel this way
Mistakes: - Disclose the error with an explanation and apology
Boundary Violations:
Physician is approached by a friend who asks the physician to do her a favor
and write a prescription for antidepressant med. Response:
A: I would like to help, but I am uncomfortable prescribing for
someone I am not treating
Procedure Contrary to Physician belief Abortion: ***
Pt requests gynecologist terminate the pregnancy as soon as possible. Dr.
prefers not to perform abortions on moral grounds but does have training in
the procedure. Appropriate course of care?
A: Provide the patient with resources for providers who will perform
abortions
Domestic violence :
23yo Woman broken nose.When asked if she feels unsafe with her

boyfriends, she says No Everything is Fine. Response?

A: Do you have a safe place to go in an emergency

Errors:
19yo Hispanic Female shakes head no when asked if she could be
pregnant or is sexually active.. Diagnosis of Ruptured ectopic pregnancy
made. Which interventions would LIKELY Prevented the delay in diagnosis?
A: Determining whether Patient needs language assistance.
Medication Review:
93yo F. Risk of all. Medication list. Which is most effective strategy in
managing pts fall risk?
A: MEDICATION review
[TRAP: Not WALKER]
Case of Medication related falls are common in Elderly nursing home
patients..
Interdisciplinary Collaboration:*****
72yo Neurocognitive disorder. Pt thinks he took his meds daily since
discharged, but pill count shows he did not take the majority. Which
interventions would likely prevent this outcome?
A: Involvement of a social worker in discharge Planning
[TRAP: Not Discharge Checklist, NOT Patient Education, NOT Simplification
of med dosing schedule]
[Collaboration of multiple disciplines Physician, Nurse, Social
Worker]
Discontinue Unnecessary drug:
70yo. Intermittent headaches and poor sleep. Meds include Amitriptyline for
migraines, Simvastatin, diclofenac, over the counter Diphenhydramine for
insomnia. Which is appropriate next step?
A: Discontinue Diphenhydramine
[Stop use of Unnecessary drug.]
Medication Errors:***
Numbers: 2.0mg aripiprazole. Patient mistakenly receives 20mg instead of
2mg. Whis is most effective intervention to reduce this type of error?
A: Educate physicians to avoid use of trailing zeros

 Communication:
Physician instructs nurse to administer 25mg of Diphenhydramine IV push.
Nurse response to ensure lower risk of communication errors?
A: Giving 25mg of Diphenhydramine IV push now

Discharge Checklist
Effective to improving pt adherence to treatment: Give Patient with a
hospital discharge checklist

Medicare:
38yo Homeless woman and 35yo BF. Brings 19yo son with cerebral palsy.
Medicare coverage covers who?
A: The womans disable son
[Medicare is Federal insurance: covers 65yo older with work history or
Younger with Disabilities]
[Pregnant woman, her boyfriend, and child when born = can be covered by
MEDICAID only not medicare]
Handoffs - Medical errors:
Need to use standardized patient handoffs = prevents medical
error.like delated antibiotic trement.
Patient education Dose schedule: Educate patient of the risks of irregular
dosing

Sleep Deprivation: physician fatigue Medical Errors.