ARCHER NOTES

1. Ethics in Medicine
Archer Online USMLE Reviews
www.ccsworkshop.com
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2. Confidentiality
•
•
Physicians cannot tell anything about their patient without
the patients permission.
Getting a consultation is permitted only if the consultant is
bound by confidentiality.

The physician must BREAK CONFIDENTIALITY in the following
cases..
• If the patient is threat to self or others
• Duty to warn and duty to protect
• Suicide ,homicide or abuse cases
• Infectious diseases are treated as threat  At first encourage
the patient to work with you to tell the person who is at risk
 if pt still refuses then you should breach confidentiality
• STD’s – have to inform the sexual partner  try to figure out
a way and make the patient and partner to come to the office
 if it does not work, you should report to public health and
allow contact tracing

3. • “ However, confidentiality, like other ethical duties,
is not absolute. It may have to be overridden to
protect individuals or the public or to disclose or
report information when the law requires it. The
physician should make every effort to discuss the
issues with the patient. If breaching confidentiality
is necessary, it should be done in a way that
minimizes harm to the patient and that heeds
applicable federal and state law” ( ACP Ethics)

4. • “ Sometimes, a physician receives information from a
patient's friends or relatives and is asked to withhold
the source of that information from the patient  The
physician is not obliged to keep such secrets from the
patient  The informant should be urged to address
the patient directly and to encourage the patient to
discuss the information with the physician”
• “ The physician should use sensitivity and judgment in
deciding whether to use the information and whether to
reveal its source to the patient. The physician should
always act in the best interests of the patient.”

5. Case Study
• 45 year old man is hospitalized with gastroenteritis.
You get paged by the nurse saying the family is on the
phone and wishes to speak with you. When put
through, the family wants to know what illness it is and
how he is doing. you will...
a) Tell the family the condition of the patient and take
time to answer their questions
b) Ask the family to come in the next day so you can
tell them in person as you are busy right now
c) Refer the family to the nurse educator so she can do
a better job
d) Refuse to answer the family's questions until you
have had a chance to confer with the patient.

6. Medical Records
•
Medical records should contain accurate and complete information.
•
Ethically and legally, patients have the right to know what is in their
medical records.
•
The physician must release information to the patient or to a third party
at the request of the patient. Information may not be withheld because of
nonpayment of medical bills.
•
Physicians should retain the original of the medical record and respond
to a patient's request with copies or summaries as appropriate unless
the original record is required.
To protect confidentiality, information should be released only with the
written permission of the patient or the patient's legally authorized
representative, or as required under applicable law.
•
•
If a physician leaves a group practice or dies, patients must be notified
and records forwarded according to patient instructions

7. Case Study

8. Disclosure
• Disclose the information to pt whenever it is
considered material to the patient's understanding of
his or her situation, possible treatments, and probable
outcomes.  this information often includes the costs
and burdens of treatment, the experience of the
proposed clinician, the nature of the illness, and
potential treatments.
• However uncomfortable for the clinician, information
that is essential to and desired by the patient must be
disclosed.
• Upsetting news and information should be presented to
the patient in a way that minimizes distress
• If the patient cannot comprehend his or her condition, it
should be fully disclosed to an appropriate surrogate
• Should you admit your mistake?  ALWAYS
DISCLOSE THE ERRORS YOU HAVE COMMITTED
TOO!!! That might not only reduce the risk of lawsuit
but builds trust in relationship.

9. Religious beliefs
• Be accepting of benign folk medicine practices.
• Your goal is to make the patient comfortable.
• Ask the pt’s religious beliefs if you are not sure.
If possible participate in them because religion
is a source of comfort to many.
• Patients who pray and who are prayed for have
better outcomes.
• Refusal of blood products by a competent
jehovah’s witness pt is acceptable.

10. If pt request alternative
medicine?
• “ The physician should encourage the patient
who is using or requesting alternative
treatment to seek literature and information
from reliable sources. The patient should be
clearly informed if the option under
consideration is likely to delay access to
effective treatment or is known to be harmful.
The physician should be aware of the potential
impact of alternative treatment on the patient's
care. The patient's decision to select
alternative forms of treatment should not alone
be cause to sever the patient-physician
relationship. “

11. Disability Certification
• Disability evaluation forms should be completed
factually, honestly, and promptly.
• Physicians will often find themselves confronted with a
patient whose problems may not fit standard definitions
of disability but who nevertheless seems deserving of
assistance (for example, the patient may have very
limited resources or poor housing). Physicians should
not distort medical information or misrepresent the
patient's functional status in an attempt to help
patients.  Doing so jeopardizes the trustworthiness
of the physician, as well as his or her ability to
advocate for patients who truly meet disability or
exemption criteria

12. Informed consent
• Always obtain informed consent. This requires
that the pt has received and understood 5
pieces of information.
• Nature of procedure
• Purpose of procedure
• Benefits
• Risks
• Availability of alternatives
• Informed consent can be oral, written consent
can be revoked orally at any time.

13. Exceptions to informed
consent
•
•
•
•
Emergency
Waiver by patient
“Competence” is a legal term
Patient does not have “capacity” 
meaning the patient attempts suicide, pt
is grossly psychotic and dysfunctional,
pts physical and mental state prevents
simple communication.
• If you are unsure, assume that pt is
competent

14. Withholding/
Withdrawing Care
Ethical concerns

15. Withdrawing Care
•
Withdrawing and withholding treatment are equally justifiable, ethically
and legally.
•
Do not withhold Rx because of the mistaken fear that if they are started,
they cannot be withdrawn.  This practice would deny patients
potentially beneficial therapies.
•
Instead, use a time-limited trial of therapy to clarify the patient's
prognosis. At the end of the trial, you can hold a conference to review
and revise the treatment plan
•
Some health care workers or family members may be reluctant to
withdraw treatments even when they believe that the patient would not
have wanted them continued  You as a physician should try to
prevent/ resolve these situations by addressing with families their
feelings of guilt, fear, and concern that the patient may suffer as life
support is withdrawn.

16. Incompetent Patient
• If a pts condition is life threatening and the
physicians believe that the pt lacks the
capacity to decide, emergency facilities have a
policy to override refusals of life saving therapy
by incapacitated patients.
• Also consider this if pt is suffering mental
disorder like infections that makes her
dangerous to herself, involuntary treatment for
mental disorder may also be justified.
• If the pt is legally competent they have
absolute right to refuse. You have to withhold
care even if it is life saving.

17. • “Patients without decision-making capacity
have the same rights concerning life-sustaining
treatment decisions as mentally competent
patients. Treatment should conform to what the
patient would want on the basis of written or
oral advance care planning. If these
preferences are not known, care decisions
should be based on the best evidence of what
the patient would have chosen (substituted
judgments) or, failing that, on the best interests
of the patient. “
• Always Discuss “ADVANCED care planning
with the patient!

18. •
•
•
•
•
•
You are called to obtain surgical consent from an 84-year-old man
who is hospitalized after suffering a right femoral neck fracture, for
repair of that fracture. The patient has a long history of multiinfarct dementia and major depression. He lives with his daughter
and her husband. They report to you that he lost his footing while
walking and suffered a fall. There was no loss of consciousness
and no evidence by history that the fall was syncopal in nature.
You read the psychiatric evaluation in his chart that notes that the
patient, despite some dementia, confusion, and odd mannerisms,
is competent to make his own medical decisions and fully
understands the nature of his condition. When you enter the room
to obtain consent from the patient for surgery, he responds with
situation-inappropriate responses, fails to make eye contact with
you, and is not oriented to place or time. The patient has no power
of attorney or health care proxy listed in his medical record. The
most appropriate course of action is to
A. call a family member to consent for the patient
B. consent the patient for surgery, he has been cleared by
psychiatry
C. consent the patient for surgery with a note explaining his
condition in the chart
D. do not consent the patient for surgery
E. perform your own competency test on this patient

19. •
•
•
•
•
•
A 67-year-old woman has suffered a massive subarachnoid
hemorrhage. The patient was well until three days prior when she
had a sudden loss of consciousness. After emergent transport to
the local hospital where her trachea was intubated and a CT scan
disclosed a large grade 4 subarachnoid bleed, she was
transferred to the intensive care unit. Over the past 72 hours her
condition is unchanged. She in nonresponsive to deep painful
stimulus, there is no dolls' eye or gag reflex, and corneal blink
reflex is absent. She has had no narcotics, analgesics, or
paralytics. There is discord present within the family about
whether to withdraw care. The husband desires care to be
withdrawn whereas the children want to continue maximal
supportive care. You explain that the most important determining
factor in helping to direct future care is
A. the decision of a court appointed legal guardian
B. the decision of the medical and nursing team taking care of
the patient
C. the husband's wishes given that he is the health care proxy
D. the opinion of the hospital ethics committee
E. the patient's previously expressed wishes regarding life
support if known

20. End of life Care
• Do nothing to actively assist the pt to die
sooner.
• Allowing the pt is die is acceptable
,active killing is unacceptable.
• Do all you can to reduce the pts suffering
ex by giving pain medication.
• Patients decide when treatment stops
not the physicians.

21. Medical Futility
• If there are no treatment options i.e. the
pt is cortically dead and the family insists
on treatment – if there is nothing that the
physician can do; treatment must stop.
• If physician thinks that continued
treatment is futile – the pt shows no
improvement , but surrogate insists on
continuing treatment – the treatment
should continue.  but refer to ethics
committee

22. • “ In the unusual circumstance that no evidence shows
that a specific treatment desired by the patient will
provide any benefit from any perspective, the physician
need not provide such treatment.”
• “ The more common and much more difficult
circumstance occurs when the treatment will offer
some small prospect of benefit at a great burden of
suffering or financial cost, but the patient or family
nevertheless desires it  If the physician and patient
(or appropriate surrogate) cannot agree on how to
proceed, there is no easy, automatic solution.
Consultation with colleagues or with an ethics
committee may be helpful.  Timely transfer of care
to another care provider who is willing to pursue the
patient's preference may resolve the problem.
Infrequently, resort to the courts may be necessary. ““

23. Issues With Minors

24. Case study
•
•
•
•
•
•
•
A 17-year-old girl comes to the office for a complete physical examination
before going off to college. You have been the physician for her and her
brother since birth, and for both her parents for the past 20 years. The
patient has been very healthy and has had all of her immunizations. Her
mother is always in the waiting room as you obtain the history and
perform the physical examination. The patient admits to you that she has
had her first sexual experience after the prom a few weeks ago. After she
tells you this she becomes very worried that you will tell her mother. At
this time you should
A. advise her to tell her mother herself so you will not have to tell her
B. explain that you will not bring up the issue but that you cannot lie if the
mother specifically asks if her daughter is sexually active
C. perform a pelvic examination and obtain a Pap smear specimen
D. tell the patient that your conversations with her will remain confidential
E. try to convince her to talk about these issues with her mother
Explanation:

25. Ans.D
• In establishing and maintaining a good physicianadolescent relationship, the physician should tell the
patient that their conversations will remain confidential.
This way, the adolescent will be able to trust the
physician and will be willing to discuss issues, such as
sexuality, that they do not want their parents to know
about, but that may affect their health.
• An exception to the confidentiality rule is the duty to
warn and protect a third party from violence or
infectious conditions, such as tuberculosis and syphilis.

26. Issues with Minors
• Children less than 18 yrs are minors and are
legally incompetent.
• Parents cannot withhold life or limb saving
treatments from their children.
• If they refuse
• Immediate emergency  treat
• Not immediate , but still critical  refer to ethics committee or
seek court intervention. The child is declared a ward of the
court and court grants permission. Eg:- juvenile diabetes
• Not life or limb threatening  listen to parents.
• Childs refusal is irrelevant unless pt is an emancipated minor

27. Emancipated Minors
•
•
Statutes in every state  known as minor consent statutes/ medical
emancipation statutes  authorize minors to consent to care based
either on their status or based on the specific service they are seeking.
The following are the categories of minors authorized to consent to
medical care
• emancipated minors (sometimes defined as those who are married, who are
pregnant, who are parents, who have served in armed forces, are living apart
and financially independent from their parents)
• married minors;
• minors in the armed forces;
• mature minors;
• minors living apart from their parents ( if older than 13 yrs) ;
• high school graduates;
• pregnant minors
• minor parents.
•
The idea behind this is that because these minors are no longer under
effective parental supervision, parental consent is not a sensible
precondition to accessing care.

28. Services which don’t need parental
consent
There are some health services for which any minor can
give consent. The various services for which minors
are authorized to give consent in one or more states in
the USA are:
• emergency care;
• prenatal care;
• contraceptive services;
• abortion;
• diagnosis or treatment of venereal or sexually
transmitted diseases;
• diagnosis or treatment of reportable, infectious,
contagious or communicable diseases;
• HIV/AIDS testing or treatment;
• counseling or treatment for drug- or alcoholrelated problems;
• collection of medical evidence or treatment for
sexual assault; and
• in- or outpatient mental health services.

29. • “If a patient who is a minor requests termination of
pregnancy, advice on contraception, or treatment of
sexually transmitted diseases without a parent's
knowledge or permission, the physician may wish to
attempt to persuade the patient of the benefits of
having parents involved, but should be aware that a
conflict may exist between the legal duty to maintain
confidentiality and the obligation toward parents or
guardians  Information should not be disclosed to
others without the patient's permission . In such cases,
the physician should be guided by the minor's best
interest in light of the physician's conscience and
responsibilities under the law. “ ( ACP Ethics)

30. Case Study
1) ] A 4-year-old boy has just had his second
generalized tonic-clonic seizure in a 4 month period.
You have recommended starting an anticonvulsant.
The parents have concerns about the recommended
medication and would prefer to wait and see if their son
has more seizures. Your next step would be:
A) Comply with parents wishes
B) Start anticonvulsants
C) refer to ethics committee
D) seek legal advise from hospital attorney
E) Seek court support to start the patient on
medications
Ans. A ( Not life threatening)

31. Case Study
•
A 6-year-old with a fractured forearm is brought to the emergency
room by her baby-sitter. Both the baby-sitter and emergency room
staff have attempted to reach her parents to get their consent for
treatment without success. Your next step:
A) Await for the parents to call back
B) Keep trying to reach the parents
C) Refer to ethics committee
D) Take a consent from patients baby sitter before treatment
E) Get an x-ray of the forearm and treat the fracture appropriately
•
Ans E. Pain and possibility of deformity

32. Case Study
•
9 year old girl is brought to the ER for a foot infection which looks
serious. She needs IV antibiotics and debrideent, or you know that
her foot is in danger of amputation. the mother refuses consent for
antibiotics and debridement. You discuss the need for immediate
treatment and the risks in the presence of a witness. But mother
still refuses the treatment. Your next step:
1) order the antibiotic and the debridement, overruling the mother.
2) Get an emergency court order
3) get an emergency ethics consult
4) agree with the mother and not give the treatment
•
Ans. 1  limb threatening

33. Case Study
• 10 year old girl who is a Jehovah's witness is
brought to the ER after a car accident. She
needs IV fluids and transfusions. The mother
refuses consent for fluids and transfusions,
saying its against her religion. Your next step:
1) order the fluids and transfusions, overruling
the mother.
2) Get an emergency court order
3) get an emergency ethics consult
4) agree with the mother and not give the
treatment

34. Ans. A
• If there is a clear and imminent threat to life,
and a delay in treatment is likely to lead to the
death of a child  healthcare professionals
can overrule parents without judicial review
(eg, in this case of a blood transfusion for a
Jehovah's witness child with life-threatening
bleeding after a MVA).
• When differences of opinion arise between
health care providers and parents and if there
is time to obtain judicial review  Practitioner
must first try to explain and convince the
parents. If this fails, practitioners should
approach courts for guidance and authority.

35. Sexual Relations
Patient – Physician, Previous patient,
Pediatrician – child’s parents

36. Case study
• One of your 27 y/o female pt who is recently divorced has
been making approaches towards you. She is one of the
most beautiful women among your patients. She requests
that you go for a date with her the following weekend. Your
response should be:
A) Tell her that you will transfer her to your friend's care so
that you can get involved with her.
B) Tell her its unethical for a physician to get involved with his
own patients so you will not entertain such a thing
C) Tell her you could go for a dinner this weekend but you
will not get sexually involved as that part is unethical
D) Tell her its not appropriate for her to make such advances
towards her physician
E) Tell her you could definitely get involved with her provided
she signs a paper releasing you from any liability

37. Current Patient - Physician
• It's unethical for a doctor to become
sexually involved with a current
patient, even if the patient initiates it
• Ans. b

38. Case Study
2) Lisa was one of your patients 2 years ago. While Lisa was in
NJ she has been your regular patient for her depression. She
trusts and respects you a lot. She even told you earlier that
she would be very lucky if she could date a person like you at
least once in her lifetime. She is a beautiful 25 year old whom
any man would like at a first sight. You have lost contact with
Lisa and she has not been your patient for past 2 years
because she moved to Florida. She happens to meet you
incidentally at a mall and requests that you go for a date with
her the following weekend. Your response should be:
A) Tell her that since she no longer your patient you can get
involved with her.
B) Refuse her proposal because its not ethical for you to do it
C) Tell her you could go for a dinner this weekend but you will
not get sexually involved as that part is unethical
D) Tell her its not appropriate for her to make such advances
towards her past physician
E) Tell her you would definitely get involved with her provided
she signs a paper releasing you from any liability.

39. Past patients
• Relationships between patients and physicians may
also include considerable trust, intimacy, or emotional
dependence.
• The length of the former relationship, the extent to
which the patient has confided personal or private
information to the physician, the nature of the patient's
medical problem, and the degree of emotional
dependence that the patient has on the physician, all
may contribute to the intimacy of the relationship.
• The extent of the physician's general knowledge about
the patient (i.e., the patient's past, the patient's family
situation, and the patient's current emotional state) 
is also a factor that may render a sexual or romantic
relationship with a former patient unethical

40. Past Patient
• “A sexual relationship with a former
patient is unethical if the doctor "uses or
exploits the trust, knowledge, emotions
or influence derived from the previous
professional relationship."
• Ans. b

41. Case Study
• You are a busy pediatrician in the city. 6 year old John has
been your patient for past 3 years. John's mother Mary
brings him to your office for a recent upper respiratory
infection. You treat John appropriately but he gets to be
admitted to the hospital for serious pneumonia. You
continue to treat John at the hospital. One evening
Marissa calls you and requests that you go out for dinner
with her because she is feeling so alone and has been
getting quite attached to you. Which of the following is
most appropriate statement?
A) You can go out with Mary because she is not your
patient and you have never treated her in the past
B) You may want to avoid going out with her because she
might cling to you later on
C) You should avoid relationship with her because there is
potential for adverse effects on professional judgment and
family member behavior concerning the patient's health.
D) You should consult your colleague to take his advise on
this issue

42. Pediatricians – Relations
with child’s family
•
Pediatricians should maintain appropriate professional boundaries with
the families of their patients
•
There is an inherent risk of exploitation for patients or family members
who depend on the knowledge and authority of the physician
•
The success of the doctor-patient or doctor-parent relationship depends
on the ability of the patient or family member to trust the physician
completely.
•
Patients and family members legitimately expect to feel physically and
emotionally safe in professional relationships with physicians.
•
They should not feel vulnerable to romantic or sexual advances while
receiving medical care for themselves or their children.
•
Children should be free from concern that their treatment may be
compromised by a nonprofessional relationship between a parent and

43. Pediatricians – Relations
with child’s family
• “The clinical judgment of physicians who
become intimately involved with a patient
or family member may become clouded
and they may breach their professional
responsibilities”.
• Ans. C

44. Duty to Warn & Protect
• The concept of a duty to warn and protect
achieved widespread exposure following
Tarasoff I and Tarasoff II .
• In Tarasoff I,  If the clinician obtained
information from his patient that an identified
victim was at risk  he has a duty on the part
to warn the intended victim, even if that meant
breaking confidentiality.
• Tarasoff II extended the concept  “ the duty
to protect supersedes the duty to warn” 
meaning “warning in itself may not ultimately
be sufficient to protect the victim”

45. Reporting of Incompetent
Colleague
• Health care professionals who pose risk to
patients must be removed from patient contact.
Types of risk – infectious diseases, substance
abuse, depression and incompetence.
• Ask them to take time off, get them into
treatment, contact their supervisors if
necessary
• HIV infected worker meets obligation to inform
appropriate parties and modify work.
• Always patient comes first.

46. •
“ Physicians
provide medical care to health care
workers, and part of this care is discussing with
those workers their ethical obligations to know
their risk for such diseases as HIV or viral
hepatitis, to voluntarily seek testing if they are at
risk, and to take reasonable steps to protect
patients. The physician who provides care for a
seropositive health care worker must determine
that worker's fitness to work. In some cases,
seropositive health care workers cannot be
persuaded to comply with accepted infection
control guidelines, or impaired physicians cannot
be persuaded to restrict their practices. In such
exceptional cases, the treating physician may need
to breach confidentiality and report the situation to
the appropriate authorities in order to protect
patients and maintain public trust in the
profession, even though such actions may have
legal consequences. “

47. Case Study
•
•
•
•
•
•
A 33-year-old man with AIDS is brought by ambulance to the hospital
after collapsing on the street. Paramedics resuscitated and intubated
the patient for ventilatory support and transported him to the hospital
while in an incoherent, agitated state. Physical examination and
laboratory studies confirm an extensive pneumonia involving the
entire left lung. Shortly afterwards, his designee demands that the
patient be taken off the ventilator. The designee produces a copy of
the patient’s living will indicating the patient wishes no life support and
that his designee is to make all medical decisions if he becomes
incapacitated. The patient’s previous hospital record contains a copy
of the same living will. Which of the following is the best course of
action?
( A ) Maintain the patient on the ventilator
( B ) Contact the patient’s parents
( C ) Contact the hospital’s attorney
( D ) Remove sedation and wean the patient
( E ) Provide sedation and pain medication and extubate the patient

48. Ans. E
•
•
•
•
•
Unless there is evidence that a patient was not mentally competent when
executing a living will, had a change of mind, or named another health care
proxy to make medical decisions forhim or her, a designee has the right to
make medical decisions on behalf of a patient, including termination of
ventilatory support.
The patient has the right to make decisions about his own health care (principle
of autonomy).
Ethically, there is no difference between withholding or withdrawing medical
care
Although discontinuing mechanical ventilation may carry emotional
repercussions, it is ethically no different than making the initial decision not to
ventilate the patient. Bringing the patient’s parents into decision-making is
contrary to the patient’s wishes. Although the parents are not prohibited from
visiting the patient (unless he directed otherwise), the legal right to make
decisions has been assigned to the designee and is not bound by a family
relationship. If the patient executed the will properly, there are no grounds for
the hospital attorney to take the matter to court. It is unlikely a court will
consider the case.
The patient directed that no life support should be utilized, and delaying removal
from the ventilator in an attempt to avoid resulting death does not comply with
the patient’s wishes. If the patient is in pain or agitated and comfort medication
is removed, the physician likely is acting in an unethical and, in some legal
jurisdictions, an illegal manner

49. Duty to warn and protect
• The counselor / doctor should call the
police and should also try in every
possible way to notify the potential victim
of the potential danger.
• First try to detain the patient making the
threat. Next , call the police and finally
notify and warn the potential victim.
• All 3 actions should be taken or at least
attempted.

50. DNR Status
Verbal statement, Living will,
Substituted judgment, Doctrine of
durable attorney

51. DNR
• DNR refers only to cardiopulmonary resuscitation. Must
continue with ongoing treatments.
• DNR discussions should always occur early in
treatment . Explore the pts reasons for not wanting
CPR. CPR is done in the absence of DNR order.
• They are made by patient or surrogate (if the patient is
incompetent)
• A competent patient has every right to refuse even life
saving hydration and nutrition.
• If patient is INCOMPETENT physician may rely on the
following –
• Advance directives can be oral
• Living will – written document expressing wishes
• Health power of attorney – surrogate decision maker,
speaks with patients voice. It beats all other decision
rules.

52. • When SURROGATE MAKES DECISION for pt the
following should be used –
• Subjective standard – it is actual intent , advance
directive of pt. refers to what did the pt say in the past?
• Substituted judgment – it says who best represents the
pt? what would patient say if he/she could make a
decision. If the pt is unable to decide a decision maker
who is the best representative of the patients wishes
must be substituted.
• Best interests standard – used if the pt has always
been incompetent or no one knows the pt well enough.
Weighs the burden versus benefits. The issue here is
not who makes the decision…but all persons applying
the best interest standard should come to the same
conclusion.

53. •
•
•
•
•
•
A 94-year-old man is transferred from his nursing home to the hospital
because of an altered mental status over the past 10 days and little oral
intake. His past medical history is significant for diabetes mellitus,
coronary artery disease with 2 prior myocardial infarctions, congestive
heart failure with an ejection fraction of 20%, and chronic renal
insufficiency. He was diagnosed with a renal-cell carcinoma metastatic to
the brain, lungs, and liver 1 month ago. His temperature is 37.8 C (100 F),
blood pressure is 89/54 mm Hg, pulse is 128/min, and respirations are
36/min. His heart is tachycardic with a 2/6 systolic ejection murmur, lungs
have coarse breath sounds bilaterally, and his abdominal examination is
benign. It is felt that the patient will require endotracheal intubation in
order to survive. However, the patient is transferred with a living will that
was written up after his diagnosis with renal-cell carcinoma, which states
that he does not want any extraordinary measures taken to prolong his
life. Before a do not resuscitate (DNR) order is written, his son arrives and
says that everything medically possible should be done in order to save
his father's life. The most appropriate management at this time is to
A. call a family meeting and discuss with the son and any other family
members why he or they would like to override the wishes of his father
with regard to his terminal care
B. call the nursing home and have the patient transferred back
C. intubate the patient and admit him to the intensive care unit
D. politely ask the son to leave the room and start the patient on a
morphine drip to keep him comfortable in his final hours
E. tell his son that there is no way you are going to listen to him or do
anything to prolong the patient's life beyond the wishes set forth in the
living will, then transfer the patient to hospice care

54. Ans.A
•
•
When a patient can no longer speak for himself or herself, it is
always a very difficult ethical dilemma, when a close family
member wants to override the wishes set forth by a patient in a
living will. The best course of action is to get the appropriate
parties together to have a logical discussion about why or why
not, the wishes of the family member should be honored.. The
original decision is often better thought out at a time of less
emotional stress. Whereas, at a time when a patient may die, the
family will often change their decisions about care, when the fear
of losing a loved one is staring them in the face.
What will end up transpiring after a logical and calm discussion
with the family will often vary. It is always desirable to honor the
wishes of a living will. However, you never know when extenuating
circumstances may exist. It is important to treat the patient and
the family with the utmost respect. Telling the son that you won't
listen to him (choice E), is inappropriate. Similarly asking the son
to leave the room (choice D), politely or not, is also not
appropriate.

55. Organ Donation
• “ Another issue concerns who should make the organ
request  Under federal regulations, all families must
be presented with the option of organ donation when
the death of the patient is imminent. To avoid conflicts
of interest, however, those who will perform the
transplant or are caring for the potential recipient
should not be involved in the request. Physicians
caring for the potential donor should ensure that
families are treated with sensitivity and compassion.
Previously expressed preferences about donation by
dying or brain-dead patients should be sought.
However, only an organ procurement representative
who has completed training by an organ procurement
organization may initiate the actual request. This can
include physicians, if they have received specific
training “

56. • DON’T ACCEPT GIFTS FROM
PHARMA
• ACCEPTABLE THINGS INCLUDE
EDUCATIONAL SEMINARS

57. END