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Flashcards in CPS Bioethics Deck (20):
1

Which of the following statements is false?
a) organ donation from anencephalic infants should not be undertaken
b) alteration of brain death criteria for anencephalic infants should not be done
c) families who wish to donate the organs of their anencephalic infants should be explained why not, consider tissue and stem cell culture
d) consider using medical therapy and mechanical ventilation pending declaration of death in anencephalic infants

d) don't consider this

at one point, AMA considered supporting the donor of organs from anencephalic newborns, but recently more opposition based on the following:
- similar arguments for other brain injured patients
- risks of loss of public trust in transplantation
- deleterious effects on families and staff
- risk of public loss for respect of all human life
very few anenephalic babies born - folate + prenatal diagnosis and termination.
-

the use of supportive ventilation etc doesn't improve the chances of successful donation from anencephalic infants

AMA still says that mech ventilation is okay
organs of these babies die even before they do
won't meet brain death criteria since brainstem works fine, by the time brain death or somatic death declared, organs will have undergone ischemic changes

2

Which of the following is not part of the standard criteria for organ donation?
a) dead donor rule
b) consent by surrogate/patient
c) the physician involved in organ donation should be leading consent discussions with the family
d) many patients with dying newborns feel that the benefits of giving their child's life meaning outweigh the risks of organ donation

c) is false, to avoid coercion, the physician involved in organ donation should not be involved in consent discussions with the family

the rest true
a) must be declared brain dead thor somatically dead before removing organs


no longer do heart transplant for HLHS, now do Norwood

3

Which of the following indications for genetic testing is not appropriate in children?
a) genetic testing for Huntington's disease
b) symptomatic child to confirm medical diagnosis
c) genetic testing for child at risk of familial hyperlipidemia
d) genetic testing for multiple endocrine neoplasia

a) most recommendations not to test those

4

All but which of the following is a risk of genetic testing?
a) stigmatization by insurers and employers
b)clinically significant increase in depression scores after positive testing for familial adenomatous polyposis
c) misunderstanding of meaning of carrier status and implications for family planning
d) effect on family dynamics

b) not clinically significant but were outside normal, psych impact for children and their parents, their parents likely have some guilt also

the rest are true risks

down the line, people screened for Tay Sachs in high school were in favour of being screened, indifferent to results down the line

autonomy can be difficult since often need to test other family members
kids should only get tested when they can consent
teens can likely consent to testing

5

Which of the following is false?
a) parents do not have the right to make decisions for genetic testing for their children
b) carrier status in children should not be tested until the children can participate in the decision making
c) children in the adoption process should be tested for genetic diseases
d) timely medical benefit should guide genetic testing in children
e) testing for diseases that present in adulthood should be deferred until the child is competent to decide if they want the information

c) should not test for genetic diseases in adoption process, since these children have the same rights for genetic testing as other children, since could have negative effects in other ways

the rest are true

parents don't have authority over non therapeutic interventions, including genetic testing

genetic testing by well informed adolescent should be considered, for reproductive decision making, may want to include family for decision making

if parents insist on genetic testing where it isn't indicated, physician not obligated to do it, may want to consult ethics

6

Which of the following cases is it not appropriate to use email for l?
a)communicating with people who are not officially your patient
b)previously consulted for
c) simple non urgent issue
d) not sensitive or confidential information
e) patient within the same province

a) should not do for these patients, haven't done a hx/pe or investigations, the other criteria are appropriate, breaches professional, ethical and possibly legal standards

the rest are true
can only email patients in the same province/jurisdiction since medical licenses are provincial


electronic communication needs to be in line with federal and provincial legislation

personal and professional email should be kept separate, employers and online services have the right to go through emails that were passed through their system, even after deleted.
if you haven't seen a patient, should limit comments to particular disease, recent research, treatment modality (i.e. for curb side consultations)
Written policies should address how questions will be answered, who will respond, expected response times, how to ensure that the e-mail has been received, document retention practices and the limits of confidentiality
should inform patients of risk of email communication prior to starting to communicate with them

7

All but the following is a contributing reason to the lack of paediatric research?
a) financial disincentives
b) difficult recruiting numbers
c) perfectionist attitudes
d) orphan drug legislation

d) orphan drug legislation should actually increase drugs for rare conditions (including many paediatric conditions) and provide incentives to pharmaceutical companies, not clear how this will translate into direct benefits

currently limited funding for peds research and fewer researchers who are examining childhood diseases; 11% allocated

8

Which of the following statements is false?
a) all human research in public and private institutions in Canada is governed by the Tri-Council Policy Statement
b) all Canadian provinces have uniform legislation governing research in humans
c) Tri-Council Policy statement requires assessment of risk and steps taken to minimize that risk
d) component analysis distinguishes risks associated with therapeutic risks vs non therapeutic risks

b) false - different in each province, i.e. quebec has legislation for research in children

the rest are true
in Canada, most major funding agencies require consistency with Tri-Council Policy statement

allowable risk in therapeutic research is proportional to the prospect of direct benefit, because no benefit in non therapeutic research, risk can only be that which is present in everyday life.

9

Which of the following is not a role of an REB? Ensure that research has
a) respect for human dignity
b) well designed study
c) full board review of all studies
d)researcher has adequate control over the research

c) is not a role - do expedited review when risks are minimal, full board review when risks felt to be more than minimal; some provinces don't allow expedited review (i.e. Quebec article 21 of civil code)

free and informed consent
respect for privacy and confidentiality
respect for vulnerable persons
justice and inclusiveness
poorly conducted research is harmful

10

Which of the following has not been found to enhance understanding in the consent process in paediatric oncology research?
a) nursing support
b) encourage questions
c)audiovisual aids
d) detailed consent documents

d)
in fact, providing too much info might decrease how much children/families understand

assent is important, full consent is usually 14 and beyond, and little ability to assent/consent before age 9, therefore in this age group (9-14) important to assess these issues in this group. Should respect dissent, even if not fully articulated.
Even adult have lots of flaws in informed consent process.

conflict of interest - lots of examples
arms length consent might help - i.e. the oncologist explains a study but a R.A does the final form, clinicians must honour the fiduciary responsibilities of the patient (patient's well being comes first ) regardless of how it affects their research

11

Which of the following statements is false?
a) reconsent is likely not necessary in the case of children who have had tissues banked for future research
b) when a child becomes mature (i.e. a mature minor) the results of their research studies can be sent to both them and parents or to just them in most cases
c) most experts agree that a high degree of validity should be present before sharing research results with an individual
d) the offer of research results to patients is increasingly recognized as an important obligation of researchers

a) likely should reconsent for these children

benefits and risks - may help decisions but if negative results may cause individual anxiety
parents and participants should be made aware of the risks and benefits of receiving research results

12

Which of the following correctly pairs the research phase and description?
a) phase 1 - preliminary efficacy assessment
b) phase 1 - expanded toxicology profile in patients with advanced disease
safety profile and toxicity information
c) phase 1 - apply tissue/animal research to humans with advanced disease to figure out safety profile and toxicity information
d) phase 2- apply tissue/animal research to humans with advanced disease to figure out safety profile and toxicity information

c) is the answer

phase 1 - safety profile and toxicity information of new drugs in patients with advanced disease for which there is no cure, translate experimental models in tissue culture/animals to humans

international research, needs both Canadian REB and local board approval; vulnerable populations include aboriginals, emergency care, incarcerated, early or genetic research, international settings, socially disadvantaged children - risk of coercion

13

Which of the following statements is false?
a) artificial hydration and nutrition may be withheld for the same reasons that other medical interventions are withheld
b) there are situations where withholding or withdrawing medical hydration and nutrition are ethically required
c) may be withdrawn in children who cannot permanently interact with the environment, as well as in cases where artificial fluid and nutrition can actually be causing more discomfort/pain
d) when artificial nutrition and hydration are withheld, imperative to keep patient comfortable with oral swabs and adjustion of meds for pain and dyspnea

b) false are morally permissible but not morally required

decision should always be made in best interest of the child
kids with vegetative state/anencephaly, should be certified by a neurologist
cases where it could make worse - final stages of dying, certain heart conditions where only few months survival/heart transplant only cure, renal a genesis, major gI destruction with palliative care
should make decisions with parents , ethics if hard decision, always make decision in best interest of child, benefits

legally and ethically permissible
support parents, may take weeks for child to die; certain providers might be against withdrawing artificial nutrition and hydration, they might need to step away so care can be provided according to child and parent wishes

14

Which of the following is a good idea?
a) friending a patient on facebook
b)accessing a patient's blog without their consent
c) using Facebook to promote therapies that you offer
d) use high privacy settings on online sites

d) is a good idea

the rest are not

a) should politely decline
b) shouldn't, and even if they consent should be careful because people can have ulterior motives
c) don't promote therapies for personal gain

issues of civil liability relating to breaches of patient confidentiality by health care providers [9]; the posting of unprofessional content [10][11]; job loss because of a damaging disclosure by a profiled individual or some third party; and finally, physicians have not always applied appropriate privacy options, making personal information public inadvertently [11].

15

A 4 year old does not want to be a standardized patient for medical education. The parent agrees to it. What is the correct approach?
a) force the child to do it
b) allow the child to decline
c) get the parent to convince the child to do it
d) none of the above

b) respect their dissent, they need to consent
for younger child he child or his/her parent/guardian must be fully informed of what is proposed and give voluntary, noncoerced consent. For a younger child who is not considered fully competent, his/her assent is required and dissent should be respected.
verbal consent is fine, rarely written consult needed for case presentation
should respect privacy and confidentiality at all times

There are also issues of distributive justice relevant to medical education, in which limits should be set for the number of times a child with ‘good findings’ should be expected to volunteer for educational activities.

16

Which of the following should not be part of the role of a resident providing care in a physician's office?
a) informing patients that a trainee may provide care under the staff's supervision
b) trainees should explain their role and position to the patient
c) if parents make a request that trainees not be involved in their child's care, the request should be declined and patients should not receive any care by the team
d) intimate examinations by junior trainees should be done under the supervision of a experienced clinician
e) trainees who are doing procedures should only do so after their supervisor has obtained informed consent, and patients should have the right to refuse a junior trainee doing a procedure

c) false, if these requests are made then a discussion should be had about the limits of these requests, since trainees often provide significant parts of care

17

In which situation is it appropriate to examine a 3 year old who does not want a physical exam?
a) to examine a 2 year old patient referred for failure to thrive who does not want to be examined
b) in an educational session
c) a standardized patient who does not want to volunteer for an abdominal exam
d) none of the above

a) in patient care it is appropriate, when this happens to a trainee who is scared/crying they should try to be respectful/sensitive to the patient's feelings, and seek guidance from parent and supervisor regarding the appropriateness of continuing the exam. not in the other settings need assent for all teaching scenarios including OSCEs

18

Which of the following is not an important part of using patient cases for case discussions?
a) de-identifying patient information that is presented
b) obtaining consent and assent from the child for photos that are presented
c) obtain consent for cases that are published in a journal
d) always get written consent from patient and parents

d) don't necessarily need written consent but should let them know that they will be discussed so that their trust is not eroded

the rest of the measures are true and should be done

SPs should get debriefed, should respect them and treat them well, should be allowed to withdraw at any time
they should get paid (even as children )but not so much that it is coercive
for younger kids need to figure out how the best way to get consent is

19

Which of the following is false?
a) school age children should never be allowed to make their own medical decisions
b) many adolescents have the decision making capacity of adults
c) parents should make medial decisions for pre-school age children
d) mature minors should be allowed to make their own treatment decisions

a) false some school age children, particularly those with experience with illness, might have enough medical experience and cognitive skills to make their own medical decisions
greater risk of harm from an intervention, greater the level of decision making capacity that should be determined
standard of ‘reasonableness’ should apply: one that most rational people of goodwill would choose after full consideration of all factors that influence the situation
acute situation - life saving is the default

In some provinces and territories, the age of legal majority is presumed to also be the age of consent. Some provinces stipulate an age of consent, while others follow a process whereby one’s right to consent depends on decision-making capacity, rather than age. In all jurisdictions, the “mature minor” principle is relevant.

need to always make sure that decision are in best interest of child - when there is conflict between this and what the parents want, should consult ethics, and if ethics not available, consider informing child protection for help

20

Which of the following is false?
a) most provinces don't have legislation granting validity to advance directives made by mature minors
b) the stipulated legal age for advance directives in Ontario is 16
c) in British Columbia, no person less than age 19 is able to be a substitute decision maker (even if they are a parent)
d) In Ontario, no person less than 18 years is able to be a substitute decision maker (even if they are a parent)
e) In Ontario, the DNR confirmation form must be filled out in order for a paramedic to honour DNR wishes of a patient

d) false - in Ontario there is no age limit for the parent of a child to be a substitute decision maker (same in PEI), however, in other provinces, must be the age of majority even if a parent. for cases where they are not a parent, must be at least 16 to be a substitute decision maker

a)true
b) true - also 16 in Saskatchewan, PEI, New Brunswick, Newfoundland
c) true
e) true - this is only recent that these providers are able to honour these wishes, and they must have this form filled out (province wide standard) - 2008
same as in other health care encounters – respect for autonomy, beneficence and nonmaleficence.

quebec age 14 to make own decisions, and need a court order to make a 14 or older person undergo care they don't want (except if emergency)