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Free Download Now. However, in situations where standard practice varies, the parents should not be told that a mistake has been made. Melinda is a married year-old pregnant childless woman who has lost four previous pregnancies between 16 and 23 weeks gestation. She has ruptured her bag of waters and is now having labor that seems unstoppable with tocolytics. Delivery seems inevitable. Inform the parents that the fetus is not viable. Inform the parents that the week-old baby will either die or live with significant handicap.
Provide sufficient medical information to the parents about the care and possible outcome of the baby so they can make their own informed choice. Inform the parents to choose passive comfort care mode treatment for the baby rather than aggressive measures.
Accordingly, the parents have a choice to make. They can choose a passive comfort care mode treatment with non-survival being a virtual certainty or alternatively, assisted ventilation, pressors, antibiotics, parenteral nutrition, etc. The role of the physician is to provide information and guide the parents through the decision-making process. This situation 30 years ago would have presented no ethical dilemma.
Indeed, the Roe v. Wade Supreme Court case defined the limit of viability as 28 weeks gestation. Any form of aggressive care involving newborn infants below this gestational was thought to be futile. Barbara is a term female infant from an unexpected pregnancy. She has Down syndrome Trisomy 21 and also has a complex cardiac lesion that will require at least two major surgical procedures during early infancy for her to have a chance to survive beyond childhood.
Barbara's parents, ages 44 and 45, have three other children, all in college. They have considerable ambivalence as to what to do: continue to pursue potentially beneficial though burdensome and costly treatments, or forego such treatments in favor of a more conservative approach.
The parents consulted you as their physician. What would you advise the parents to do? The parents should base their decision on the child's best interests and weigh the burden of care against the benefits to be anticipated from medical treatment. The parents should make a decision based on Down syndrome. The parents should consider both the Down syndrome and finances. Nor is it appropriate to allow financial issues to play a major role. The parents, who are the decision-makers, should be apprised of the medical facts types of surgical interventions required, chances for success.
They should also be given a good understanding of the amount of suffering the child will experience during aggressive intervention efforts. They should then come to a decision based on the child's best interests. That is to say, does the burden of care outweigh the benefits to be anticipated or vice versa.
A 4-year-old with an obviously broken forearm is brought to the emergency department by her baby-sitter. Both the baby-sitter and emergency room staff have attempted to reach her parents without success. Can you treat this child without parental permission? The parents must consent first.
Because the parents can not be reached, the doctor should first obtain a court order before treating the infant. Having attempted to reach her parents for consent without success, you should proceed with x-rays and treatment of her fractured forearm. Rapid treatment of the child's pain and fracture are clearly in her best interest. When optimal treatment requires immediate intervention, treatment should not be delayed even if consent has not been obtained.
An ill-appearing 2-year-old with a fever and stiff neck appears to have meningitis. His parents refuse a lumbar puncture on the grounds that they have heard spinal taps are extremely dangerous and painful. Obtain an ethics consultation. Fully inform the parents, and should they refuse to give permission, the physician is justified in proceeding with the procedure and treatment of the child.
Obtain a court order to perform the lumbar puncture and treat the child. Complications from the procedure are very rare, and the benefit in this case is likely to be substantial. There is not time to obtain an ethics consult or court order. The physician should attempt to address the parents' misconceptions about lumbar punctures and to reassure them about the safety of the procedure and perhaps offer to use appropriate pain control methods.
A second opinion from another physician may prove helpful. Should these efforts not result in parental permission, the physician is justified in proceeding with the procedure and treatment of the child.
While parental authority to make medical decisions for their children is broad, it does not include choices that may seriously harm their children. As long as the physician has used reasonable clinical judgment in determining the need for the lumbar puncture, legal liability should be minimal. A 5-year-old child 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.
Obtain a court order to treat the child. Report the case as child abuse. In general, courts have been reluctant to overrule against parental wishes in most situations where that decision does not place the child at considerable risk. Though failure to start an anti-convulsant may increase the risk of further seizures, this does not pose a substantial enough risk to the child to justify overriding the parents' wishes, especially given the potential risks associated with the medication.
Though you may not agree with their decision, the decision is a reasonable one that does not place their child at substantial risk of increased harm. Margaret is a year-old graduate student, recently married, who comes into the student health clinic for a routine pelvic exam and PAP smear. During the course of the exam, the gynecology resident performing the exam obtains the PAP smear, but also obtains cervical cultures for gonorrhea and chlamydia.
The examination concludes uneventfully. Several weeks later, Margaret receives a postcard indicating that the PAP smear was normal, with no evidence of dysplasia, but that the cervical culture for gonorrhea was positive. The card instructs her to come into the clinic to discuss treatment, and that "public health authorities" have been notified for contact tracing.
The young woman is terrified that her husband will be contacted and complains to the Director of the student health clinic. Inform her that the culture was a routine procedure that is performed on everybody who comes for a routine Pap smear. Tell her how lucky she is that her gonorrhea was discovered and can now be successfully treated. Inform her that the treatment of gonorrhea will benefit her and her husband. Apologize to her for the error in obtaining the cervical culture without her consent.
Yet, in this case the patient was not told about the culture being obtained. When health-related information is obtained from individuals, they should have an opportunity to consent to or refuse such collection. In some instances, individuals may conscript to having their rights disregarded, such as in the military.
Similarly, other individuals do not have their rights recognized as a result of due process, such as prisoners. In this case, the physician should inform the woman what tests will be performed and why, and how that information will be handled. If she refuses to have the test obtained, her wish should be respected. Morley is a year-old man with multi-drug resistant tuberculosis. He is homeless, and has a pattern of missing many of his scheduled clinic visits.
Upon starting a multi-drug regimen for his TB, MW initially comes to his scheduled clinic visits, but after a few weeks begins missing them. The physician contacts the social work case manager, who arranges supervised drug administration. Nevertheless, Morley often cannot be found and this approach is deemed to be failing. Should Morley be forced into treatment against his will? The patient has a right to consent to or refuse treatment, and should not be forced to receive treatment.
The doctor has a right to hospitalize and treat the patient. Only supervised medication administration is allowed under these circumstances. If the patient completely refuses treatment, it would be justifiable to seek court permission to confine and treat the patient against his will. Multi-drug resistant tuberculosis has the potential of causing substantial morbidity and mortality for the population, particularly in large urban areas.
Thus the need for the individual patient to be treated for the good of the public is high. Similarly, the patient himself stands to benefit from the treatment. Ordinarily, patients have the right to refuse potentially beneficial treatment, provided they are competent and make an informed decision to do so.
The tension created in this case is that the patient's refusal to follow the medication regimen puts others at substantial risk of harm. Hence it may be justifiable to compromise his autonomy to protect the health of others. In such cases, every effort should be exhausted to enlist the patient's cooperation with the medical regimen.
Interventions such as supervised medication administration are often effective ways to achieve the desired result without compromising the patient's autonomy. Failing this, it would be justifiable to seek court permission to confine and treat the patient against his will. In the legal process that ensues, considerations will include the magnitude of harm, the degree to which specific individuals are exposed to harm, and the probability of harm.
During a visit to her family physician, a year-old woman discloses that she suffers from anorexia nervosa. She complains of fatigue, dizziness, depression, headaches, irregular menses, and environmental allergies. Each day, she uses 15 to 60 laxatives, exercises for several hours, and eats a salad or half a sandwich. At 5'2", she weighs 88 pounds. She demonstrates a good understanding of the diagnosis and the recommended therapy for anorexia.
Despite receiving a variety of resource information, the patient refuses any medical intervention. She continues to present to the family physician, offering a variety of somatic complaints. Does the patient's depression render her incompetent to refuse treatment for her anorexia? The family physician may consider the patient incompetent to refuse treatment because of her mental illness.
The family physician may consider the patient incompetent to refuse treatment but only if a psychiatrist determines that she is. The determination of incompetency is not made by physicians. Both a and b are correct.
Since this patient could rationally discuss her treatment options and her reasons for declining therapy, she could not be considered incompetent by a Judge. Respect for autonomy is a central principle of bioethics, and it takes precedence in this case. Although the principle of beneficence could be used to argue for coercion towards treatment, compliance may be better improved by providing an ongoing partnership with the patient.
Maintaining a therapeutic relationship with ongoing dialogue is more likely to provide this patient with the eventual ability to pursue therapy. A year-old female presents to a family physician to obtain a referral for family therapy.
She is estranged from her mother and stepfather, who see the same physician. For many years, this patient responsibly cared for her four younger siblings while their single mother worked.
Since her mother's marriage, the family has become involved in a fundamentalist church. The patient moved out when she felt the social and moral restrictions of the family's religion were too burdensome for her. The patient seemed quite mature; she maintained a 3. She demonstrated a genuine desire for reconciliation, and the therapy referral was provided. She also requested and obtained a prescription for contraceptives during the visit, with the assurance that her sexual activity would be kept confidential.
In follow-up, she reported that the therapist had informed her that if she mentioned anything about being sexually active with her adult partner, he would be obliged to report her to the state.
The patient was very concerned about the conflict between this statement and the family physician's prior assurance of confidentiality. Should this patient's confidentiality be broken? The patient's confidentiality may not be broken by the therapist under any circumstances.
The patient's confidentiality may be broken by the physician but not the therapist. The patient's confidentiality must be broken if the sexual activity with the adult partner is considered a crime by law.
None of the above answers are correct. The medical professional should research the law of the State. For example, the law states that sexual intercourse with a minor is a class C felony, and a reportable offense, if the offender is at least 90 months older than the victim. This patient's relationship did not actually meet the criteria for mandatory reporting. Had this not been the case however, the physician could be justified in weighing the balance of harms arising from the filing of such a report.
There is little justification for informing the family of the young woman's sexual activity. Due to the family's strong fundamentalist beliefs, significant damage would have occurred in the family reconciliation process with this discovery.
Although they would clearly disapprove of the patient's actions, her choices carry no risk of harm to them. Franklin, an year-old Alzheimer's patient hospitalized under your care has been asked to participate in a clinical trial testing a new drug designed to help improve memory. You were present when the clinical investigator obtained a signed informed consent from Mrs.
Franklin a few days ago. However, when you visit Mrs. Franklin today and ask her if she is ready to begin the study tomorrow, she looks at you blankly and seems to have no idea what you are talking about. What should you do? The signed informed consent for the clinical drug testing is in doubt, and should not be done. The primary investigator should be contacted to discuss Mrs. Franklin's participation in the trial. A surrogate who can give consent for her participation may be contacted if the clinical trial is deemed to be in her best interests.
Franklin to give an ethically valid informed consent is in doubt. You should contact the primary investigator to discuss Mrs. There may be a surrogate who can give consent for her participation if it is deemed to be in her best interests. Although she may be considered a vulnerable research subject because of her mental status, Mrs. Franklin does belong to the population the intervention is designed to assist, and her participation may benefit herself and other Alzheimer's patients.
However, a careful balancing of risks and benefits should occur. During the conduct of a large clinical trial of an investigational drug, preliminary analysis of results show that there were three times as many participants in the experimental group who experienced severe nausea and vomiting compared to the control group.
Two of the cases were severe enough to require that the participants be hospitalized. This is despite the fact that the preliminary analysis shows that there may be a moderate benefit with the drug.
What should be done? The large clinical trial should be stopped immediately. Complete the trial then report in details all the adverse events. The adverse events are not serious enough to report.
Investigators should consider reevaluating the balance of risks versus benefits. While these adverse events are probably not serious enough to suggest that the trial be terminated, these adverse events should be balanced by significant benefits. After having completed a study that involved the collection of tissue from the subjects, an investigator wishes to perform additional analysis of the archived tissue samples.
This nature of this analysis was not explicitly stated in the original consent form. Should the investigator be required to obtain explicit consent for the new research? The investigator is required to obtain explicit consent for the new research from the IRB. The investigator is NOT required to obtain explicit consent for the new research. The investigator is required to obtain a general consent. The investigator is required to obtain explicit consent for the new research from the patient.
Even if participants may be willing in general to have surplus tissue used for research purposes, they should still be asked for their consent. A year-old male is admitted with bacterial endocarditis and needs a replacement of his prosthetic heart valve. After his first replacement, he continued to abuse intravenous drugs. The medical team feels it would be "futile" and a waste of medical resources to replace this heart valve yet again.
Is the team's judgment appropriate in this case? The team's judgment is appropriate in this case. If the patient can pay for the heart valve replacement, it should be done. It is also likely that the medical team is using biased criteria to judge "wasted" vs. Thoughtful discussion may provide an opportunity for the team to voice their frustration and think through a treatment plan that will maximally support this patient's recovery.
On a busy night in the ER a member of the hospital board comes in with her sick child and asks that you see him right away. The child has a sore throat and red eye and he appears subdued, but alert.
You have a full waiting room. The ER doctor should see the sick child right away. The ER doctor should call the Chief of Staff and ask what to do.
The ER doctor should call the Hospital Administrator and ask what to do. As with the other people waiting in the ER, the sick child should be subject to triage criteria based on medical need. Do some people "deserve" special treatment over others? What would justify such a claim? In this case, the ER staff might be swayed by the powerful position the board member holds in their institution and want to do their best for her.
However, the other people waiting in the ER have been subject to triage criteria based on medical need. It would be unjust to waive these criteria on the basis of social position.
While this may seem unrealistic, one might also consider the effect on the hospital if the board member faces a long, tedious wait in the waiting room along with everyone else. A complaint voiced by this powerful person may enact change on staffing considerations more effectively than a number of patient complaints.
To let her sail through would be to create an impression of smoothness that is most likely not part of the everyday ER experience.
For further discussion of this case, please refer to Douglas S. Steven is a year-old man with end-stage COPD, admitted last month with pneumonia. His course was complicated by respiratory failure needing mechanical ventilation, and multiple efforts to wean him have been unsuccessful.
Awake and alert, he now communicates through written notes that he wants the ventilator taken off. Will you honor his request? His request should not be honored. The surrogate decision maker should make the final decision.
A court order is necessary because the outcome of taking him off the respirator is death certain. Steven with minimal pulmonary reserve. The approach to his request should start with an evaluation of his decision making capacity. Even though he is awake and alert, you should carefully probe the reasons for his request, with particular attention to making sure he understands the consequences of his decision. If you're concerned about depression or other mental illness affecting his thinking about this decision, you might request a psychiatry consultation.
You should ask Mr. Steven if he's discussed this with his spouse or family. If his decision making capacity is intact, you should honor his request. Hanes is a year-old woman with metastatic breast cancer. She was admitted with dehydration and weakness. Her cancer treatments have failed, as she now has a recurrence.
The oncologists are contemplating some new palliative chemotherapy. The nutrition team is concerned about her cachexia and recommends total parenteral nutrition TPN. Should the patient be started on TPN? The patient should be started on TPN. If the link is not working, do let us know using the comments section, we will readily update it. If you have any question then write it in comment below. Moreover Medicalstudyzone.
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