Week 13 Ethics, Malpractice, and Professional Issues Flashcards

1
Q

What is an important part of patient care that can minimize the risk of a formal patient complaint even when a mistake is made?

A Ensuring informed consent for all procedures

B Maintaining effective patient communication

C Monitoring patient compliance and adherence

D Providing complete documentation of visits

A

B Maintaining effective patient communication

Effective patient communication is key to building trust and rapport and ineffective communication is a predictor for malpractice claims. The other items are important aspects of care and may help the provider during the investigation of a claim, but do not minimize the risk.

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2
Q

What are some causes for failures or delays in diagnosing patients resulting in malpractice claims? (Select all that apply.)

A Failing to recognize a medication complication

B Failing to request appropriate consultations

C Improper performance of a treatment

D Not acting on diagnostic test results

E Ordering a wrong medication

A

B Failing to request appropriate consultations

D Not acting on diagnostic test results

Failing to obtain consultations when indicated or not acting on diagnostic test results can lead to diagnosis-related failures. Failing to recognize medication complications and ordering a wrong medication lead to medication prescribing allegations. Improper performance of a treatment can lead to treatment-related malpractice claims.

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3
Q

malpractice

A

Must have duty to patient
Must deviated from standard of care
Harm or damage must occur as a result

NO injury, then NO malpractice

A duty owed and duty breach that resulted in harm or injury= Malpractice

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4
Q

most malpractice claims are

A

dx related

misdiagnosis

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5
Q

Jane is a 30-year-old female, newly married, and not typically a patient of your practice. As your sister, she calls you while at work reporting 3 days of dysuria, typical for her previous experience of UTIs. She expresses frustration about urgent care wait times, ER costs, and unavailability of her primary care provider, which is why she’s asking if you will call-in a prescription for treatment.
All of the following would be concerns you respond to your sister with EXCEPT:

A You do not typically call in prescriptions for patients, so wouldn’t want to for her

B You are concerned that your personal relationship may limit both of your comforts in discussing critical information to treat this case appropriately

C The guiding AMA ethics strongly discourages this practice

D Without appropriate testing and follow-up established, starting an empiric treatment could cause her harm

E All of the above would be concerns to express

A

A You do not typically call in prescriptions for patients, so wouldn’t want to for her

While calling in such prescriptions for your patients may be part of your typical practice, there are several compelling reasons to object to this request of a family member. While state administrative rules governing the Board of Medicine may vary, the guiding principles from the AMA in this regard are clear. Treating family members is fraught with problems. Most notably is the limited comfort and interrogation of potentially sensitive information such as sexual/behavioral history and potentially relevant but previously unknown medical comorbidities. Physical examination is often sorely limited when involving family members for similar reasons. Furthermore, because of the blurring of personal and professional boundaries, this can introduce a slippery slope where one called-in prescription develops into enabling deleterious healthcare utilization (e.g., missing the opportunity for her primary care provider to track health maintenance and screening exams). Of additional legal and logistical concern is the under-documentation of such encounters.

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6
Q

Under what circumstances may it be appropriate to engage in such treatment of family members?

A. When the patient’s primary physician refuses to provide a prescription for a medicine your family member requests (e.g., Xanax for anxiety)

B. When no other provider is reasonably available due to the isolated, rural community (e.g., nearest primary clinic is 30 miles away and your aging aunt doesn’t drive out of town)

C. The trivially innocuous request on the part of the family member (e.g., left BP medication at home while out of town traveling for the weekend)

D. There is a minor, urgent need of the family member (e.g., needs sutures removed)

E. B, C, and D

A

E. B, C, and D

The rural family provider may find himself/herself in a unique circumstance of limited alternative resources for patients in the community to utilize. This can create a legitimate logistical exception to the ethical concerns surrounding treatment of family members “B.” It is prudent to anticipate how these relationships should be managed in the healthcare setting, setting up referral alternatives should there be such a conflict.
In addition to this, there may be appropriately innocuous circumstances that can be considered ethically appropriate (Answers “C” and “D”). Documentation of such medical encounters—be them with family or otherwise—should be approached in a consistent way. Particular concern should be paid to controlled substances (e.g., mental health and pain medications) as these often have further legal restrictions. It would also be entirely appropriate, and supported by the AMA Code of Ethics to answer “none of these” as permissable, at least in part because of the risk of such inconsequential encounters escalating to serious problems.

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7
Q

A 54-year-old married female, Charlene, has insulin-dependent diabetes and has seen you for her care for the last 7 years. In the last year, she has developed diabetic retinopathy and neuropathy. To your great frustration, Charlene continues to resist the recommended lifestyle changes required to control her diabetes.
She is a casual, friendly woman known as the “candy lady” in her neighborhood where she lives with her husband of 30 years. She loves children and volunteers at the local elementary school, where she is well known for a quick smile, a reassuring hug, and a piece of candy in her large, full pockets. In fact, she is noted during most of her appointments to be munching on M&M’s—her favorite candy. She has had dietary consults and many education-oriented doctor appointments but says, “I know I shouldn’t eat the way I do, but I just don’t have the heart to change who I am, even if it does help my eyes and legs. Who I am is about what I eat and do.”
You wonder about Charlene’s capacity for decision-making, given her frank noncompliance with care, even in the setting of serious complications from her diabetes.
All of the following variables are necessary in decision-making capacity (DMC) EXCEPT:

A. Ability to communicate a choice

B. Voluntary choice (e.g., absence of coercion)

C. Understanding of the variables involved in the decision

D. Ability to appreciate the personal impact of choices

E. Family agreement that the patient is competent

A

E. Family agreement that the patient is competent

All of the other options are considered important for determining decision-making capacity (DMC). Certainly family concerns need to be addressed, but family agreement has nothing to do with determining a patient’s DMC. One additional necessary element for respecting DMC is freedom from coercion or other external threats to a person’s right to self-determination (autonomy). In this regard, coordinating family agreement to pressure the patient into changing their decisions could be undermining the patient’s autonomy.

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8
Q

Which of the following is TRUE about decision-making capacity (DMC)?

A Patients who have been found legally incompetent do not have DMC

B A patient’s DMC may vary according to the circumstances of the situation

C A minor’s DMC is not clinically relevant since there is a surrogate who bears the responsibility for decision-making

D DMC should not be evaluated in cases in which the patient makes a conventional, recommended choice

E Patients with psychiatric disease, who are involuntarily committed to a treatment facility do not have DMC

A

B A patient’s DMC may vary according to the circumstances of the situation

DMC is largely considered on a sliding-scale, rather than an “all-or-none” distinction, since the threshold for reaching DMC can vary widely from case to case or setting to setting. Even patients who have been declared legally incompetent or who have been legally and involuntarily committed may still have a measure of DMC (for example, meal choices, etc.). Moral theory typically urges clinicians to consider the wishes and reasoning of their patients as morally and clinically relevant, regardless of the placement of a legal guardian or the state as a surrogate decision-maker. DMC may ultimately be overridden in certain kinds of legal circumstances, but it should not be done lightly as it suggests a fundamental denial of patient autonomy.

Just as no legal determination removes our responsibility to respect a patient’s autonomy, no particular diagnosis does either. As such, many patients with psychiatric illness still have the right to make choices, even with diagnoses such as schizophrenia. Additionally, making unconventional choices can sometimes be a marker that DMC is not intact, but does not automatically lead to this conclusion (a classic example would be an adult Jehovah’s Witness patient who refuses a blood transfusion; while this is an unconventional choice, DMC may be intact). Finally, though minors technically cannot make many healthcare choices, their wishes should be taken into consideration as they are often able to articulate a preference. In minors, this is termed “assent,” rather than consent. Children may not be able to understand enough to consent on their own but they can “assent” to (or protest) a particular plan of treatment.

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9
Q

Charlene continues to have a slow decline over time but remains in good spirits despite the complications of her uncontrolled diabetes. One day her husband brings her to the emergency department. He had found her in the bathroom, unconscious, and called an ambulance. She has had a stroke and remains unresponsive and is on a ventilator in the ICU. Her prognosis is poor.
What are appropriate considerations for making a treatment decision about end-of-life care for Charlene?

A Oral statements to her husband about her end-of-life care

B Her husband’s wishes for her care as designated proxy healthcare decision-maker

C Written advance directives

D Oral statements to her physician about her end-of-life care

E All of the above

A

E All of the above

Written advance directives are considered the most binding, since they are the patient’s own declaration of their preferences, although all of these considerations are relevant in making end-of-life decisions since all of them could inform the family and treating medical team on what the patient would have wanted given her critical illness. Since the family is likely also grieving about her poor prognosis, emotions could cloud their recollection of her previously informally expressed wishes. This underscores why anticipatory discussions and advance directives can be profoundly helpful.

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10
Q

Which of the following statements can be used to describe medical futility?

A No worthwhile goals of care can be achieved

B The likelihood of success is negligible (any intervention would be “futile”)

C The patient’s quality of life is unacceptably burdensome

D All of the above

A

D All of the above

All of the above meanings have been explicitly or implicitly drawn into discussions about medical futility. Because of its variable interpretations and explanations, many theorists have objected to the use of the term “futility” as a justification for decisions and urge clinicians to be precise when “futility” is used as an argument to withhold care (e.g., the patient has metastatic lung cancer including to the brain, has been resuscitated two times already, may be resuscitated for this particular cardiac arrest but will never regain consciousness, will likely arrest again within the next 8 hours due to the underlying disease, and will never be able to be weaned successfully from a ventilator).

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11
Q

After discussion with her husband, you decide to discontinue ventilation. Charlene dies.

This intervention is appropriately considered:

A Active, involuntary euthanasia

B Physician-assisted suicide

C Withholding medical intervention

D The principle of double effect

E Withdrawing medical intervention (passive euthanasia)

A

E Withdrawing medical intervention (passive euthanasia)

While the answer might seem intuitive to you, many persons (including physicians) do not recognize the differences between these various interventions. Active euthanasia (“A”) is when the physician both supplies the means of death and is the final human agent in the events leading to the patient’s death (e.g., the physician administers the lethal drug). Whether or not active euthanasia is voluntary, involuntary, or nonvoluntary depends on the DMC of the patient and their consent to the process. Assisted suicide (“B”) occurs when the physician provides the means of death but the patient carries out the act, such as taking an overdose of phenobarbital. Withholding medical intervention (“C”) means not initiating care for a disease state so that the disease itself results in death (e.g., not placing a gastric tube for artificial feeding in a patient with end-stage dementia). Withdrawing medical intervention (“E”) means discontinuing an intervention that has already been used, although the disease state itself results in death with the intervention’s discontinuation. Both of these (“C” and “E”) are forms of passive euthanasia, where withdrawing life-sustaining treatment, or not starting it, leads to death. The principle of double effect (“D”) is an ethical theory that suggests that if there is an unintended but anticipated bad consequence (e.g., earlier death) while pursuing an intended purpose (e.g., pain relief), there is diminished moral responsibility for the unintended outcome. This principle is sometimes used to justify the use of high-dose opiates or sedatives in patients with intractable pain or dyspnea, even when the unintended effect is respiratory depression and death.

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12
Q

Which of the following is TRUE about the role of law in life-sustaining interventions?

A Courts must be involved in decisions after a patient has been declared to not have capacity

B Life-sustaining treatment may be withheld only if patients are terminally ill or permanently unconscious

C Physicians may face criminal charges for providing appropriate palliative care and not treating the underlying disease

D The most prudent legal advice is to continue treatment in medically futile cases

E The law presents few barriers to physicians withholding life-sustaining interventions

A

E The law presents few barriers to physicians withholding life-sustaining interventions

Sometimes physicians inappropriately provide treatment to patients who have made their end-of-life choices clear and have stated that they do not want prolongation of life. Respecting the patient’s prior wishes will not result in legal liability for the physician, but the converse is not true; one can be legally liable for treating a patient who does not want treatment (e.g., transfusing a Jehovah’s Witness patient who refused transfusion). While they are exceedingly rare, there are case reports of “wrongful life” malpractice suits against providers who ignored advanced directives to withhold life-sustaining treatment. There is still a risk-management, and likely professional and moral preference to “err on the side of life” when there is ambiguity about the patient’s advance directives. While state laws vary, generally speaking “A” is incorrect, since surrogates for the patient have the authority to make decisions after the patient is declared not to have capacity. This may be a relative, a healthcare provider, or court-appointed surrogate. “B” is also incorrect as treatment may be withheld at any time at the request of a competent patient.

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13
Q

Robert, a 27-year-old married nurse from your hospital, is referred to your emergency department for an urgent evaluation by his supervisor. In the past 2 weeks, he has been noted to be increasingly distressed while at work, with occasional tearfulness, distractibility, and irritability.

During the initial assessment, Robert reveals that there is a specific reason that he has been so preoccupied. He indicates that 2 weeks ago he was jailed for operating a vehicle while intoxicated and that he feels ashamed. He is afraid that his coworkers have read about it in the newspaper, although no one on his floor has indicated that this is the case. This is his first legal infraction of any kind and he describes it as humiliating.

On further questioning, Robert indicates that he uses alcohol regularly. While it has not overtly affected his work as far as he can tell, it has caused significant marital strife. He reports that his pattern is to stop by the bar on the way home from work to “relax and let go of the hospital stuff that I worry about.” He typically drinks three beers and then drives home, where he continues to drink beer throughout the evening. He notes that his wife and kids complain that he is emotionally absent and even irritable with them, but he says that his family simply doesn’t understand the stress of the workplace and his need to “forget about it for a few hours.” He and his wife have started arguing lately about his alcohol use, especially since the driving charge. He takes special exception to her stating that he is an “alcoholic.”

As you take the history, Robert begins to be more guarded in his responses and more restricted in his affect. Suddenly, he blurts out, “I don’t think I’m an alcoholic, but I don’t want you to put anything in my record about any of this stuff! And I want you to tell my supervisor that there are some personal problems going on at home and that I’ll be fine in a few days.”

Which of the following statements is TRUE about your obligation with regard to documentation in the chart?

A You are obligated to document the visit as it occurred so far as the medical facts are concerned, including the concern about alcohol abuse

B You can enter incorrect information into the chart in order to protect the patient

C You are under no obligation to document anything said and can withhold information from the chart at the patient’s request

D Hospital administration or legal counsel should be involved if information is going to be purposefully left out of the chart

E You can lie in the medical record … we’re pretty sure perjury, liable, and slander don’t apply to doctors

A

A You are obligated to document the visit as it occurred so far as the medical facts are concerned, including the concern about alcohol abuse

The ethical principles of beneficence, nonmaleficence, and justice drive the decision here. A patient may legitimately ask for nonactive medical problems (e.g., distant history of sexual abuse) to be withheld from current documentation of an active problem. However, a patient cannot legitimately ask to have information withheld from the record if that information is pertinent to an ongoing condition currently being evaluated and treated. In this case, Robert is receiving care simply by virtue of being seen in the emergency department and disclosing the chief complaint and its associated variables. It is important for you to be forthcoming in explaining why the information may not be withheld from the medical record and also in reassuring him that irrelevant medical information will be omitted from the record if he feels that this is necessary. For example, the specifics of the argument with a wife need not be detailed beyond the comment that there is nonviolent marital conflict over the patient’s alcohol use—important because it supports an alcohol abuse disorder. Furthermore, the patient can be reassured that many institutions have specific policies on managing sensitive medical information and there may be a formal mechanism for increasing the security of the patient’s medical record.

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14
Q

Why is protection of confidentiality important in medical practice?

A It shows respect for patient autonomy

B It helps prevent stigmatization and discrimination against patients based on private medical issues

C It helps solidify trust within the physician–patient relationship

D It helps establish a boundary between the physician–patient relationship and the rest of the medical system

E All of the above

A

E All of the above

The physician–patient relationship is a long-honored tradition in medicine that is increasingly fragile in a medical system with numerous competing obligations. Nevertheless, it is prudent to remember the aspect of the Hippocratic Oath, which states, “What I may see or hear in the course of the treatment … which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.” This is not only important to the tradition of medicine itself but also to the physician–patient relationship. There is no doubt that loss of confidentiality may cause harm to the patient when others are in possession of confidential medical information. Such harms may be as overt as denying insurance coverage for certain genetic conditions or as subtle as devaluing a person waiting to see the psychiatrist. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) codified confidentiality and disclosure of protected health information to respect individual privacy.

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15
Q

Which of the following are legally protected exceptions to the rule of maintaining patient confidentiality?

A Reporting tuberculosis to public officials without patient consent

B Warning a third party at risk of imminent and serious bodily harm from the patient without patient consent

C Reporting a patient’s alcohol abuse to a work supervisor without the patient’s consent

D A and B

E All of the above

A

D A and B

Under current national and state laws, physicians are mandatory reporters of some infectious diseases, of intent to harm another, and of child / dependent-adult abuse. In most other cases, provision of protected health information without the patient’s written consent is not legally protected, although there may be cases in which it is felt to be morally justifiable. Physicians need to weigh violations of patient confidentiality very carefully, even when legally sanctioned. Ethicists typically agree that if a physician is going to compromise a patient’s confidentiality for an overwhelming moral obligation, the patient needs to be notified out of respect for his/her autonomy. In many situations in which a physician hopes to communicate confidential information to a third party even when the patient is unwilling, a process of education and negotiation with the patient occurs such that respect for autonomy is acknowledged while simultaneously making the patient aware of competing moral obligations.

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16
Q

Which of the following interferes with protecting patient confidentiality in the medical structure?

A Involvement of managed care organizations in patient care and medical payments

B Electronic records and transmissions

C Group practices and/or teaching hospitals with multiple care providers

D A and B

E All of the above

A

E All of the above

While individual physicians and patients continue to prize the tradition of respect for confidentiality, the multiple players in healthcare make it nearly impossible to restrict all information to the dyad of physician and patient. Insurance companies will not provide payment without, at least, information about the diagnosis, and notably, insurance companies are not legally bound by the same codes of conduct that apply to physicians regarding patient privacy. Electronic records and transmissions by e-mail, cellular phones, faxes, and other means are much more easily accessed by the curious or unintended recipients who have no reason to have confidential information. Open waiting rooms and multiple providers of care mean that larger and larger numbers of the community are aware that a patient is being seen in certain clinics for certain purposes. Once information is in written form, it is more difficult to control who might, either now or in the future, have access to the details of the report. For this reason, some physicians try to err on documenting only that which is considered absolutely necessary to patient care, although the distinction between the “absolutely necessary” and unnecessary can be a difficult line to draw in the sand, especially without the ability to appreciate how multiple variables may play out in the patient’s future medical care.

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17
Q

Back to the patient at hand … Robert is asking you to be deliberately deceptive with the supervisor. You disagree with this.

Which of the following is FALSE?

A Trust in the physician–patient relationship depends on allowing the patient to make such a directive about communication with outside persons

B A physician who establishes a precedent for deception may be expected to practice deception in a future situation in which the harms greatly outweigh the benefits

C A physician who deceives may undermine general trust in the profession

D All of the above

A

A Trust in the physician–patient relationship depends on allowing the patient to make such a directive about communication with outside persons

Another way of phrasing the question is, “What drives a physician to be honest even when what the patient really wants is not honesty?” Will the patient trust you more if you are deceptive for him? Will this help him (aside from allowing him to keep his job)?
The physician–patient relationship is generally not considered an adequate reason to lie to a third party about the nature of a patient’s illness and treatment. There has been concern that a physician who deceives a third party, even in the immediate interest of the patient’s confidentiality or other concerns, establishes himself or herself as a physician who may not be trustworthy in other matters. A patient may not consider this at the time a deception is requested. These kinds of ripple effects from the decisions of an individual physician can affect the profession in general, ultimately producing fears that physicians will take the self-serving path rather than the higher moral ground.

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18
Q

You tell Robert that he has alcohol dependence and then provide education about the diagnosis and treatment options. You recommend outpatient treatment in Alcoholics Anonymous (AA) and a chemical dependency program. Robert agrees, more for the sake of his family stability rather than because of any true insight into the severity of his problem. You then arrange for follow-up with one of your partners.

At the next appointment, Robert meets his new physician, Dr. Pincus. At this appointment, Robert indicates that he did attend two AA meetings but was very uncomfortable with the aspect of the 12-step program that requires acknowledging a “higher power.” Robert indicates that he is an atheist and secular humanist, believing that the locus of self-control comes from within the individual human spirit. He has refused to continue in AA due to his rejection of its theistic foundation. He has had no further legal problems and reports that work is still going fine, with diminished irritability once he resolved in his mind that his coworkers were unaware of his previous driving violation. However, he continues to drink six to nine alcoholic beverages per night and admits that he occasionally needs a shot of whisky in the morning to “make sure I don’t lose it with all the work stress” (this is where his self-control theory really comes together). He also works a night shift about once per week and does use approximately the same amount of alcohol before beginning the night shift, although he denies being intoxicated while on the job on these nights (“My tolerance is high and six beers are no big deal”). He doesn’t think this is a problem because “things are quiet at night and everyone just helps each other keep the patients comfortable.” He reports that his family is satisfied with the decrease in consumption and that he considers the matter of alcohol abuse resolved.

Dr. Pincus has had her own problems with alcohol in the past. She has had a rocky course over the past many years but found AA to be very helpful. She has become very active in her Jewish synagogue and community, where she receives support and is accountable to her friends. Her own alcohol history has been marked by difficulty with alcohol bingeing, such that when she starts to drink, she drinks to intoxication. Only with aggressive honesty at a professional-group AA, as well as a substance abuse protocol through the state board of medical examiners, does she feel that she’s been able to remain completely abstinent for the last 4 years.

Dr. Pincus is considering revealing to Robert some of her own struggles as a healthcare professional with a substance abuse disorder. She believes that this will help him reevaluate the role of AA in sobriety and the importance of very tight control of alcohol consumption to prevent relapsing illness.

Self-disclosure is best described as involving the ethical issues of:

A Deception and nondisclosure

B Privacy and boundaries

C Informed consent

D Impaired colleagues

E Autonomy

A

B Privacy and boundaries

There are explicit and implicit boundaries that exist between a physician’s private experiences and the physician–patient relationship. One of these boundaries has to do with preventing physician needs and private matters from encroaching into the visit in a way that is not therapeutic to the patient and does not respect the physician’s boundaries. While it would appear that Dr. Pincus has therapeutic reasons—for Robert, not for herself—for crossing the boundary of self-disclosure, both physician motivation for self-disclosure and the immediate and potential effects of the self-disclosure need to be weighed very seriously before private matters are revealed. If there is even a potential of harm, crossing the boundary in this way should be considered a violation of professional norms.

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19
Q

How could Dr. Pincus appropriately respond to Robert’s refusal to participate in AA on the basis of his religious impulse?

A “AA is still shown the best intervention for preventing relapsing alcohol use. I hope you can go and get something out of it without acknowledging your acceptance of the ‘higher power’ explicitly”

B “AA has important group support from others who understand how difficult it is to stop using alcohol . It is not meant to be religious, but rather a community of care”

C “I have found both AA and a theistic world-view to be very helpful in understanding my own powerlessness to control some of my behaviors. Would it be helpful to you to hear more about this?”

D “I understand how the religious aspect of AA is inconsistent with your own philosophy. Would you be willing to investigate nonreligious group meetings for alcohol abusers?”

A

D “I understand how the religious aspect of AA is inconsistent with your own philosophy. Would you be willing to investigate nonreligious group meetings for alcohol abusers?”

AA is an example of a prescribed treatment that involves an active theological component. AA’s first step involves acknowledgment of a higher power, traditionally invoking a specific monotheistic conception of the divine as a necessity to surrendering the illusion of control. In the interest of respecting a patient’s religious rights in a diverse community, and of optimizing treatment options, it would be disrespectful and ineffective to have the patient participate in AA, while ignoring the first step of the program and the foundational philosophy of AA. While there are fewer studies about the efficacy of nonreligious alcohol treatment groups, it is appropriate to respect Robert’s beliefs by investigating nonreligious alternatives. As to option “A,” the Cochrane database concludes, “No experimental studies unequivocally demonstrated the effectiveness of AA.”

Whether or not self-disclosure of one’s own religious beliefs is appropriate is an important question. As mentioned in the discussion in the question above, it is very important for the physician to measure the intent of the disclosure. Also, physicians need to be exquisitely sensitive to the power differential that exists between a physician and a patient such that strong individual viewpoints might become threatening or coercive in the physician–patient relationship. In certain religious traditions, sharing one’s faith is an important step, demonstrating courage and integrity; nevertheless, physicians should be strongly cautioned to pay heed to the virtue of practical wisdom and the unique circumstances of the medical relationship that makes proselytizing most often inappropriate. A better strategy, if a physician feels that a patient might be seeking additional spiritual or philosophical direction, is to ask open-ended questions and then make an appropriate referral to pastoral care or a spiritual counselor who will be sensitive to the issues the patient has raised as relevant.

20
Q

Which of the following is true about intervening with an “impaired colleague,” like Robert?

A Impairment should be reported only to a state licensing board if the colleague’s patients are placed at known and documentable risk

B Because alcohol abuse is a confidential matter, it is inappropriate for a treating physician to report a colleague’s impairment to a licensing board

C Removing a colleague from direct patient care and increasing supervision during patient care are reasonable first-step interventions for a colleague who is actively engaged in substance treatment(e.g., a report has already been made)

D It is preferable to contact a state licensing board directly as opposed to discussing the matter with the patient or institutional administration. This protects both the reporter and the colleague from unnecessary negative repercussions

A

C Removing a colleague from direct patient care and increasing supervision during patient care are reasonable first-step interventions for a colleague who is actively engaged in substance treatment(e.g., a report has already been made)

Legal statutes on reporting impaired colleagues vary from state to state, with some state laws making physicians mandatory reporters of impaired physician colleagues, while others simply recommend reporting. Furthermore, state laws are even less prescriptive with regard to nonphysician health professionals with impairments. Any impairment should be treated seriously, preferably with support from the institution’s administration. It is imperative to protect patients from harm. While reporting the impaired colleague may result in anger and disappointment from the colleague or even supervisors who are reluctant to tackle such a difficult question, physicians should consider the needs of vulnerable patients and the patients’ rights to adequate care.

Confidentiality adds an additional ethical dimension when an impaired colleague reveals his or her impairment to his treating physician. In an effort to respect patient autonomy, physicians will often urge impaired colleagues to report themselves as well as voluntarily engage in treatment protocols. Many states have less-restrictive policies for treatment and monitoring for impaired colleagues who self-report. If a physician intends to report her patient’s impairment without the consent of the patient, the physician is obligated to be truthful with the colleague about her intentions and rationale for reporting.

21
Q

A colleague may be impaired in her practice by all of the following EXCEPT:

A Substance use

B Major depression

C Dementia

D Deficits knowledge

E Barely passing the board examination

A

E Barely passing the board examination

Well, “barely passed,” is what is needed to achieve certification. All of the others, whether acute or chronic, may impair a health professional’s ability to practice, but none of these automatically imply global impairment in medical practice. Each has its own implications for a colleague’s medical practice. Special attention should be given to the colleague’s actual and possible consequences in practice, given her specific job requirements and compensatory skills/supports, while assessing the presence and degree of impairment. One might say that dementia is OK in physicians working for insurance companies (or at least it seems so!).

22
Q

John is a 32-year-old newly practicing physician in your group. As friends on social media, you see his posts from time to time, typically about his family or sharing the latest current events in medicine. On one occasion, however, you notice a posting to a medical group discussing a “hypothetical” clinical case that clearly seems to be a recent real diagnostic dilemma he faced. He has, of course, de-identified the patient, but the clinical context (recurrent asthma attacks at public sporting events) is important as he seems to be crowdsourcing input on how to distinguish true bronchoconstriction from social anxiety.

Which of the following could pose problems for your colleague’s social media activity?

A De-identification of the patient’s information may not be sufficient to protect the patient’s privacy

B Crowdsourcing can result in unreliable and unverifiable information

C Any publicly available dialogue may be held to a higher standard as a physician in terms of the potential to violate confidentiality

D There may be relevant guidelines or rules that your partner has broken

E All of the above

A

E All of the above

All of the above are true. In addition to the patient’s name and other identifiable demographics, the circumstances, time, location, and other public records (e.g., police or news reports) could converge to threaten a patient’s confidentiality. Additional caution and restrictions are needed to respect patient privacy on social media “A.” Crowdsourcing,“B,” occurs when a question is posed to a large group in hopes of generating more clinical insight, can indeed provide a diversity of opinions and perspectives but with unreliable and unverifiable references. Consensus in this platform can falsely reassure a provider. Physicians are de facto held to a higher standard of public discourse than the general public, with tangible consequences (e.g., state medical board investigations) for inappropriate behavior “C.” Most hospitals and healthcare organizations have social media policies which this provider may be inadvertently violating; additionally, many medical societies are generating best practices and recommendations in this regard too.

23
Q

Ms P, a 59-year-old woman who lives in a remote, low-income region, has worried about cancer ever since her mother died from metastatic breast cancer a year ago. As the family’s sole income earner, she would not be able to support her children if she developed a serious illness. When visiting Dr A for her child’s earache, she tells Dr A that she wishes she could get a mammogram so that any cancer could be detected and treated early.

There are only 2 clinics in the country where mammography is available, and Ms P has access to neither without making a long journey that she cannot afford. However, Dr A does have an ultrasound machine. Although ultrasound is generally not accepted as a way to screen for breast cancer, Dr A has experience using ultrasound in a variety of diagnostic and screening contexts, and perhaps using it would ease Ms P’s mind. Dr A wonders whether to offer to examine Ms P via ultrasound.

Given what you know about breast cancer screening modalities, what would you recommend?

Is it ethically appropriate to pursue tumor detection when treatment options are not available to her?

A

Screening for breast cancer in Low-income countries (LIC) presents a paradoxical dilemma. On the one hand, no screening would lead to increased odds of presentation at advanced-stage disease for which treatments are unavailable, unaffordable, and cost ineffective. On the other hand, LICs are not equipped to both implement a screening campaign effectively and deal with the downstream consequences of screening-detected lesions, most of which end up not being cancer. Debate persists even about whether mammography screening is appropriate in HICs.

The United States Preventive Services Task Force (USPSTF) assigns a grade B recommendation for biennial mammogram screening for women aged 50 to 74 who are not at high risk

For screening to be appropriate, it “must be acceptable, equitable, accessible, sustainable, and economically efficient for the target population.”

Therefore, although mammography reduces breast cancer-related deaths among women in Ms P’s age group, overall life expectancy for women in LICs is less than that of HICs. The upshot here is that, while it is important to address Ms P’s concerns, it is also important to consider that screening mammography has failed to improve all-cause mortality, even in HICs.

If we consider the costs, inconvenience, and inaccessibility of mammography in LICs, together with the infrastructure needed to implement it, there is arguably less justification to spend limited resources for this screen, given its limited evidence of effectiveness and potential for harm. In sum, the inconvenience of a mammogram could be justified for diagnostic purposes if Ms P has symptoms, but probably not for screening.

ultrasound is not recommended as a screening modality. Even when ultrasound is used as an adjunct to mammography, its effect on reducing breast-cancer mortality is uncertain, and screening with adjunct ultrasound actually increases false positives in women at high risk.

For Ms P, there is a small chance that ultrasound would be helpful and a risk of harm of a false positive.

If Ms P’s local center doesn’t have mammography, it probably doesn’t have sufficient resources for biopsy, surgery, radiation, and other procedures. Given the lack of follow-up capacity, the risk of harm from a false positive should be regarded as clinically and ethically prominent.

To address the needs of women like Ms P and the population needs of LICs, clinical breast examination (CBE) could be a reasonable middle-ground approach.For Ms P, CBE would likely be more appropriate than mammography.

24
Q

LJ is a 64-year-old woman with a history of hypertension, osteoporosis, and major depressive disorder who fractured her left tibia and fibula and had an open reduction and internal fixation 12 weeks ago. Since the operation, she has been taking oxycodone for pain, and though she has reduced the number of pills she takes from 2 every 6 hours to 1 every 8 hours, she still feels it’s helpful to take 2 pills before bedtime each night to sleep. At her follow-up visit, her radiographs do not definitively show complete healing. Since it is difficult to determine whether there has been adequate healing of the bone, a decision is made to have her continue physical therapy and follow up in one month with more radiographs. She is running low on oxycodone and requests more to get through the next 4 weeks.

Her surgeon, Dr M, is concerned that LJ still requires 2 pills at night and worries that LJ is developing opioid dependence. Dr M is running over an hour behind clinic schedule, and new state opioid prescribing laws now require more paperwork and counseling with a patient before prescribing more oxycodone this long after an operation.

Dr M feels conflicted: LJ might not be fully healed from her injury and could be experiencing ongoing pain from an unhealed fracture, or LJ could be developing opioid dependence. Ordinarily, Dr M would prescribe more oxycodone, but new laws have made normal practice less expedient. It has also been Dr M’s typical practice to engage in shared decision making with patients when prescribing narcotic pain medications. Now, however, she is unsure how to balance her obligation to follow new legal requirements with her obligation to take a patient’s claim of pain seriously.

How should Dr M respond?

What are the ethical considerations in this case?

A

Dr M should consider that providing a refill would likely express respect for LJ’s autonomy and do good by offering pain relief and enabling continuation of LJ’s physical therapy. Dr M would likely weigh these autonomy and beneficence concerns against nonmaleficence: by not prescribing opioids, Dr M could help LJ avoid suffering opioid dependence and substance use disorder. Additionally, Dr M could consider the principle of justice and whether prescribing more opioids for this particular patient at this particular time could constitute overprescription that exacerbates an ongoing crisis. The situation faced by LJ and Dr M is a common one in outpatient practice in the United States and presents several conflicts for both physician and patient.

It seems reasonable for Dr M to prescribe more opioid medication for LJ in hopes that it would support this patient’s continued healing and physical therapy. Adequate pain control in the short term can lead to long-term, opioid-free pain relief. The indication, after all, was for an acute bone fracture and LJ’s pain seems to be secondary to inadequate healing of the fracture.

However, in opioid-naïve patients, recovery from surgical pain frequently leads to long-term opioid use1 and dependence

Dr M could recommend an opioid taper and non-opioid pain medications, such as acetaminophen or nonsteroidal anti-inflammatory drugs, assuming LJ has no contraindications for such therapies. While an opioid taper could be helpful, particularly given Dr M’s concern that LJ is developing dependence, several considerations suggest that continuing opioid therapy could also be appropriate. It will be important for Dr M to gather more information about LJ’s opioid use and, ideally, engage LJ in a process of shared decision making to arrive at a treatment plan.

25
Q

Ms B is a 65-year-old homeless woman with 2 years of progressively worsening altered mental status, anxiety, depression, and paranoia. After several prolonged involuntary admissions at an inpatient psychiatric center, during which her altered mental status was refractory to multiple modalities of treatment, psychiatrists began to suspect an organic cause of her altered mental status and psychiatric symptoms. She was admitted to the hospital for further workup. During her hospitalization, she intermittently refuses tests and medications. She yells, “Get out!” to anyone who enters her room. All blood tests and imaging are negative. After consultation with neurology, it is determined that Ms B needs a lumbar puncture for further workup, which she consistently refuses. After a thorough assessment, the primary team determines that Ms B does not have capacity to refuse a lumbar puncture. No family members or friends have been identified during this hospitalization or during previous admissions at the inpatient psychiatric facility.

The primary inpatient physician, Dr C, is unsure about who should make decisions on Ms B’s behalf and researches the hospital’s guidelines and the recommendations of several professional organizations regarding unrepresented patients. She finds that the hospital has a process in place for assigning public guardians to patients. She discovers that the American Medical Association suggests consulting an ethics committee about making decisions on behalf of an unrepresented patient, the American Geriatrics Society recommends that a patient’s treatment team should make such decisions, and the American College of Physicians posits that a court-appointed guardian should always be utilized. Dr C wonders what to do.

How should the clinician navigate decision making for unrepresented patients? What are the ethical challenges?

A

For all incapacitated patients, treatment teams should determine whether an advance directive names a durable power of attorney and, if not, work with a surrogate who is selected by a process that varies from state to state. In situations in which no surrogate is identified, such as in this case, health care professionals typically find diverse legal requirements that vary by jurisdiction. For example, in some states, treating clinicians assume authority to make decisions for their unrepresented patients, but other states expressly forbid this practice.

We suggest that health care organizations implement protocols to facilitate decision making for unrepresented patients based on professional guidelines and state law (where available) and on assessments of the risks and benefits of proposed treatments, particularly when care is provided despite a patient’s objection. Unilateral decision making should be avoided in order to mitigate organizations’ and physicians’ potential conflicts of interest and biases. We advocate engaging multidisciplinary teams (such as ethics committees, when available) or volunteer advocates to assume decisional authority or at least contribute to decision making.

Respect patient autonomy. Ms B intermittently accepts tests and procedures, suggesting fluctuating adherence to recommendations. Since Ms B is alert and sporadically cooperative with her care team, constant reassessment of her decision-making capacity is indicated, as it is important to recognize that capacity is decision specific and not “all or none.

Assess risks and benefits of treatment. Risks and benefits of any treatment plan or intervention should be carefully evaluated. The procedure discussed in this case, lumbar puncture, carries relatively little risk, although conscious sedation might be necessary for the patient’s and clinician’s (given Ms B’s resistance) safety and to maximize the procedure’s chance of success. However, we should also ask whether the procedure is essential for Ms B’s care, especially considering her refusal to provide consent.

Ethical issues in Ms B’s case include assessing her capacity to make decisions at different points in time, honoring her preferences, and balancing the benefits of respecting her autonomy against the risks of refusing recommended treatment. Dr C and the team can choose from among several approaches to guide decision making about her care, including pursuing a judicially-appointed guardian and enlisting assistance from an ethics committee. Decision makers for unrepresented patients should strive for consistency in treating like cases alike, consider a patient’s interests as fully as possible, and attempt to prevent personal or organizational sources of biases from unjustly influencing decisions.

26
Q

Ms D presents with her daughter, Ms W, for an adolescent medicine appointment with Dr N. Ms W is 14 years old and on weigh-in at Dr N’s office has a recorded weight of 175 pounds and a height of 5′1″. As Dr N reviews Ms W’s records, he notes that her body mass index (BMI) is 33 and discusses with Ms D and Ms W that Ms W meets criteria for being labeled obese. He reviews with Ms W and Ms D the long-term ramifications of obesity and encourages the patient to enact a diet and exercise routine with a goal of losing 10% of her body weight over the next year. At that same appointment, Dr N obtains a hemoglobin A1c (6.0), a total cholesterol of 310, and verifies that thyroid stimulating hormone levels are within normal limits.

At her next visit 1 year later, Ms W excitedly reports to Dr N that she has joined the track team and has been running 3 miles a day and lifting weights. She notes that she has been eating more protein and has mostly stopped eating candy. Her weight at this visit is 191 pounds and her BMI is 36. Dr N discusses with Ms D and her daughter that her BMI now defines her as morbidly obese. Although she is young for bariatric surgery, Dr N notes that she has already made a myriad of lifestyle modifications to no avail and should strongly consider bariatric surgery in an effort to prevent the long-term sequelae of obesity.

Ms D refuses the bariatric surgery referral, stating that her daughter is healthy—she has prediabetes but her blood pressure is excellent. “We are all big in my family—bigger than my daughter by a lot. My grandmother is 85 years old and 300 pounds, and I’m not going to let a skinny doctor tell me or my family we aren’t healthy just the way we are.” Ms W isn’t sure she wants the surgery but when her mother leaves the room, she does report to Dr N that she wishes she was thinner because she is being made fun of by people in school.

Is the physician correct in stating that obesity is a disease when future morbidity and mortality are uncertain?

A

It is essential for physicians to counsel patients and families effectively regarding the risks of obesity and the importance of lifestyle changes. Challenges in counseling youth in these situations are compounded when lifestyle modifications prove insufficient and future health risks are uncertain. The patient-clinician relationship is best served by a collaborative approach to weight management strategies, especially when a clinician suggests alternative weight management treatments such as medication or bariatric surgery that have risks.

In this case, the physician labels the patient as obese based on her BMI,3 and when her BMI has increased one year later, he notes that she is morbidly obese. In using these labels, the physician classifies the patient as having a disease requiring treatment. This classification serves as the basis for his further recommendations for lifestyle modifications, and, ultimately, for a more extreme intervention—bariatric surgery—when those lifestyle modifications do not result in measurable improvements

There has been considerable debate regarding whether obesity should be called a disease. The Obesity Society supported the classification of obesity as a disease in 2008 and the American Medical Association officially recognized obesity as a chronic disease in 2013. But should physicians have the power to diagnose a disease when future morbidity and mortality are not guaranteed?

Despite the possibility that this patient could “beat the odds,” it is the physician’s responsibility to provide recommendations based on the most probable outcomes. With increasing BMI and prediabetes, this patient is undoubtedly at high risk for adverse health outcomes. By diagnosing her as obese and thus naming a disease, the physician is better able to recommend appropriate, evidence-based treatments. Moreover, by naming obesity as a disease—effectively acknowledging that the patient cannot entirely control her weight through behavioral choices and willpower—the physician might be attempting to reduce the stigma and shame often associated with obesity, as Ms W is being bullied in school regarding her weight

27
Q

Is recommending bariatric surgery ethical?

A

In this case, the physician is recommending bariatric surgery, an invasive procedure that entails known risks with unclear benefit to the patient. While there is some evidence of effectiveness of bariatric surgery for weight loss in the adolescent population,14 current pediatric obesity guidelines recommend bariatric surgery only in cases in which the patient meets certain developmental criteria and “has a BMI of > 40 kg/m2 or has a BMI of > 35 kg/m2 and significant, extreme comorbidities.”8 This patient currently has a BMI of 36 kg/m2 and prediabetes without extreme comorbidities, and it is not possible to predict with precision her future risk for development of complications.

28
Q

is it ethical for the physician to use the words obese and morbidly obese when talking to the patient, particularly when the patient is a child or adolescent?

A

Persons with obesity, as with any other chronic disease, should not be blamed for their medical condition. This argument has helped facilitate expansion of research, medical treatments, and insurance coverage for obesity and its complications.

While it is certainly beneficial for the physician to use these labels for the purpose of diagnostic coding in the medical record, he can choose to use different terminology when conversing with the patient and her parent. In studies of patient and parental perceptions of words commonly used to describe excess body weight, the terms fat, obese, and extremely obese were rated as undesirable and stigmatizing compared to terms like unhealthy weight or BMI
The Obesity Society recommends using people-first language to reduce the use of potentially stigmatizing words; for example, the physician should say “a child with obesity” rather than “an obese child.”

29
Q

What is the best approach to this patient’s care when the parent and clinician disagree?

A

The physician should start by recognizing his and the mother’s common goals in order to partner with her and keep her as an ally in her daughter’s care. Undoubtedly, both the mother and the physician desire to promote good long-term health and quality of life for the patient.

While the patient expresses desire to be thinner, it is unclear whether her primary motivations for weight loss are well aligned with the physician’s intentions. In his counseling, the physician emphasizes the potential long-term health consequences of obesity. The patient, however, voices fear of bullying as a significant factor contributing to her desire to lose weight. Particularly when counseling adolescents, physicians must consider how social stigma and poor body image can influence patients’ eagerness to engage in treatment

The physician should continue to promote the patient’s demonstrated efforts at healthy lifestyle changes. Follow-up visits every 3 to 4 months would also give him the opportunity for continued discussion with Ms D regarding her daughter’s health and potential interventions to help her with weight reduction. An interdisciplinary approach to management could be helpful, with a team including a nutritionist, physical activity specialist, and social worker or psychologist. Counseling services could also be particularly beneficial in addressing the bullying that the patient has experienced.

30
Q

WHAT CODE OF ETHICS DO NURSES USE?

A

ANA CODE OF ETHICS

31
Q

WHAT IS DUTY OF CARE OWED MEAN?

A

A LEGAL OBLIGATION WHICH IS IMPOSED ON AN INDIVIDUAL, REQUIRING ADHERENCE TO A STANDARD OF REASONABLE CARE WHILE PERFORMING ANY ACTS THAT COULD FORESEEABLY HARM OTHERS

32
Q

AN NP MADE A MISTAKE AND ACCIDENTALLY GAVE THE WRONG ANTIBIOTIC TO A PATIENT. THE PATIENT RECOVERED, NO HOSPITALIZATIONS AND NO LONG TERM EFFECTS OCCURRED TO THE PATIENT. IS THIS MALPRACTICE?

A

NO! NO INJURY? NO MALPRACTICE!

33
Q

A PATIENT WITH NEWLY DIAGNOSED HIV PRESENTS TO YOUR CLINIC. SHE STATES SHE HAS BEEN HAVING SEX WITH A NEW PARTNER AND ONLY OCCASIONALLY USES PROTECTION. CAN YOU TELL THE PARTNER?

A

DEPENDS ON THE STATE, REQUIRED BY LAW TO TELL THE DEPARTMENT OF HEALTH.

34
Q

A 97 yo patient is not able to make an informed decision due to cognitive incapacity. He does not have advanced directives, only a durable power of attorney (DPA). How should the provider proceed?

a. Allow the family to make a decision regarding medical care.
b. Allow the DPA to make a decision based upon the patient’s known values.
c. Allow the NP to make a decision is there is disagreement between the family and the DPA
d. Have the family and DPA come to an agreement regarding care.

A

b. Allow the DPA to make a decision based upon the patient’s known values.

35
Q

The NP examines a patient with a cat bite wound. A 4 cm gaping laceration was present and sutured by the NP. The patient subsequently became infected, needed hospital admission, and required IV antibiotics with incision and drainage. How can this situation be characterized?

a. This is a clinical judgment with unexpected complications.
b. The NP’s actions followed the standard of care.
c. The act of suturing this type of wound represents malpractice.
d. This is poor judgment, but not malpractice.

A

c. The act of suturing this type of wound represents malpractice.

36
Q

In the outpatient practice setting, the most common reason for a malpractice suit is failure to

a. Properly refer
b. Diagnose correctly in a timely fashion
c. Obtain informed consent
d. Manage fractures and trauma correctly

A

b. Diagnose correctly in a timely fashion

37
Q

Legal authority for advanced practice nursing rests with which body?

a. The Health Care Financing Administration
b. Federal statutes
c. State laws and regulations
d. Certifying bodies

A

c. State laws and regulations

38
Q

What must you do as an APRN before billing for visits?

a. Establish a collaborative agreement with a physician
b. Obtain a provider number and familiarize yourself with the rules and policies of third-party payer
c. Provide evidence of continuing medical education
d. Have a Drug Enforcement Agency (DEA) number

A

b. Obtain a provider number and familiarize yourself with the rules and policies of third-party payer

39
Q

Regulation of the APRN consists of four essential elements. They are:

a. Licensure, certification, education, and accreditation
b. Clinical performance, prescriptive privilege, preceptorship, and practice setting
c. Examination, continuing education, discipline, and awards
d. Workplace, collaborations, licensure, and prescriptive privilege

A

a. Licensure, certification, education, and accreditation

40
Q

ethics

A

what one ought to do when there is a dilemma

41
Q

bioethics

A

when a moral choice must be made in healthcare

42
Q

dilemma

A

situation where there are more than 1 unequally satisfying solutions, or conflict within one’s values

43
Q

beneficence

A

requires positive action, to act for the benefit of the pt, balancing harm vs benefits

44
Q

veracity

A

truth telling, use language pt understands

ex. honestly explain advanced directive

45
Q

justice

A

fairness, individual rights, complex & diff to apply in healthcare