Ethics

Question 1

True or False: There is no ethical difference between withholding or later withdrawing treatment

Answer 1

True

Question 2

True or False: The opinion and guidelines of the family prevail over your opinion as the physician

Answer 2

True

Question 3

What should be done in cases where there is conflict between you and family (interests of the child in your opinion differ from the parent/guardian’s opinion)?

Answer 3

Get ethics committee involved

Question 4

True or False: It can be appropriate for a “mature minor” (>14) to have a say in their treatment

Answer 4

True

Question 5

What happens in terms of parents wishes in cases where they are perpetrators of child abuse?

Answer 5

Alternate guardian is assigned and hospital ethics committee must be involved to determine who makes decisions

Question 6

What determines when and how to implement DNR orders?

Answer 6

Family values and decisions

Question 7

What are beneficial interventions or required reconsiderations in terms of DNR?

Answer 7

Temporary revisions to standing DNR orders (for instance, what is allowed in the OR if a child with a DNR is having a surgical procedure)… these need to be planned in advance and very specific

Question 8

What do beneficial interventions or required reconsiderations allow parents to do?

Answer 8

Distinguish between interventions they feel comfortable with and the resuscitative efforts they wish to avoid (guidelines should try to encompass any possible occurance).

Question 9

Whose responsibility is it to meet with and educate everyone (parents, school providers, ect) about what is and is not considered resuscitation and what interventions are allowed within the DNR context for a child?

Answer 9

The PCP

Question 10

Any question dealing with cost containment (AKA conflict of interest between insurance companies and needs of patients) should be answered with what?

Answer 10

Advocating for the patient

Question 11

What is cost sharing?

Answer 11

Insurance companies provide financial incentive for limiting the use of consultants and resources

Question 12

What is the most common and most challenging conflict of interest in terms of health care costs?

Answer 12

Cost sharing

Question 13

What are loyalty conflicts?

Answer 13

When you need to refer outside your ongoing network of specialists and affiliated institutions

Question 14

What is paperwork burden?

Answer 14

Time consumed getting prior authorization and appeals for rejected services (this time isn’t reimbursed and represents a financial disincentive)

Question 15

Loyalty conflicts and paperwork burden are examples of what in pediatrics?

Answer 15

Conflicts of interest (pediatricians financial interests are in conflict with child’s needs)

Question 16

In the NICU, all decisions are based on what?

Answer 16

Newborn’s best interest, factoring in parental wishes (in the end, newborn’s best interest overrides parental wishes)

Question 17

What happens in the NICU if parents wishes aren’t in the best interest of the newborn?

Answer 17

Get ethics involved

Question 18

What should you do in the NICU if treatment is clearly futile and parents want to continue?

Answer 18

Override parents with ethics committee help

Question 19

What should you do in the NICU if the best interests aren’t clear, but parents wish to withdraw care?

Answer 19

Defer to parent’s authority

Question 20

Withdrawal must be based on what?

Answer 20

Best long term interests of the infant

Question 21

True or False: In terms of extreme prematurity, the gold standard is the % survival with maximal care rather than gestational age alone

Answer 21

True

Question 22

True or False: Taking cost into consideration is unethical

Answer 22

False- on a global level, this is very ethical

Question 23

Which unit typically has costs that are disproportionately high?

Answer 23

NICU

Question 24

True or False: If there is no chance of survival, don’t code

Answer 24

True

Question 25

What rules if there is a good prognosis for a child?

Answer 25

Parental preference

Question 26

What must be implemented if a good outcome is likely?

Answer 26

Resuscitation and treatment

Question 27

True or False: Withdrawing and witholding support are inappropriate terms to be used around a family

Answer 27

True

Question 28

True or False: Good outcome is a subjective term

Answer 28

True

Question 29

What is the dead donor rule?

Answer 29

Removal of both paired/vital organs and a non-paired organ cannot precede or cause death

Question 30

What is considered to be a controversial definition of death?

Answer 30

Cardiorespiratory death

Question 31

What cannot factor into the donor status of a patient?

Answer 31

DNR order

Question 32

True or False: Children can be stem cell donors for siblings

Answer 32

True

Question 33

True or False: Parents who decide to conceive another child so the new child can become a savior sibling is unethical

Answer 33

False- this is not considered to be unethical in and of itself

Question 34

Name 5 conditions that have to be met when siblings are considered as stem cell donors

Answer 34

1. No adult or other donor options are available 2. A strong positive relationship between siblings 3. Both the donor and recipient are to benefit 4. Risk to donor is minimal 5. In addition to parental permission, the child, if old enough must also agree (assent)

Question 35

What involves wakefulness and awareness of self and environment?

Answer 35

Consciousness

Question 36

Patients with what state lake wakefulness and also lack awareness of self and environment?

Answer 36

Coma

Question 37

Patients in what state lack awareness, but do have wakefulness?

Answer 37

Vegetative

Question 38

In order to declare brain death what must be done?

Answer 38

Conditions that can mimic brain death must be treated or excluded (metabolic derangements, intoxication, hypothermia)

Question 39

What 6 factors must be considered for a child who could be a solid organ donor?

Answer 39

1. No adult or other donor options are available 2. A strong positive relationship between siblings 3. Both the donor and recipient are to benefit (benefit to donor is largely psychological) 4. Risk to donor is minimal (surgical risk) 5. In addition to parental permission, the child, if old enough must also agree (assent) 6. The absence of coercion must be verified by a 3rd party

Question 40

Why would a sibling with severe cognitive disabilities not serve as a solid organ donor for a sibling?

Answer 40

Sibling with disabilities wouldn't likely benefit psychologically from this (needs to have mutual benefit)

Question 41

Why do children <11 get priority on kidney donor waiting lists?

Answer 41

Due to the impact of renal disease on growth and development

Question 42

True or False: Autonomy and bodily integrity of the mother is critical and must be honored

Answer 42

True

Question 43

True or False: Pregnant women have the same rights to make medical decisions as those who are not pregnant

Answer 43

True

Question 44

For anything questions regarding conflict of maternal-fetal interest, what is the key thing to do?

Answer 44

Discussion of all aspects of the conflict and respect Mom's decision

Question 45

What is assent?

Answer 45

Willingness to accept treatment

Question 46

True or False: Assent is mandatory before treatment begins

Answer 46

False- it is preferred, but not mandatory (consent is mandatory)

Question 47

True or False: Immunizations aren't considered to be life saving

Answer 47

True

Question 48

True or False: In situations where the treatment is likely to prevent substantial harm, the child's right to treatment outweighs parental religious freedom

Answer 48

True

Question 49

True or False: In situations where treatment will happen regardless of the child agreeing to it (assent), the child should be told this

Answer 49

True

Question 50

True or False: Newborn screening is mandatory

Answer 50

False *Parents give passive permission by doing nothing...they must sign a waiver to opt out of newborn screening

Question 51

What 3 things should be considered when deciding if a disease should be included in newborn screening?

Answer 51

1. Does it have significant deleterious effect on the child 2. Does it have effective treatment available if diagnosed early 3. Is there a screen that is acceptable to the population

Question 52

True or False: Newborn screens are diagnostic

Answer 52

False *False positives are common...this triggers need for more definitive testing

Question 53

True or False: Some cases of disease get missed by newborn screening

Answer 53

True- If presentation is classic, workup the child for the disorder in question

Question 54

True or False: If the newborn screen comes back positive, you should refer for genetic counseling

Answer 54

False

Question 55

What do you need to do in cases of testing for carrier status of a disease or fetal testing of certain diseases?

Answer 55

Make sure parents have all the information needed to make a decision and you have not pressured them in any way

Question 56

Name 1 example of a condition for which ethics committees will refuse genetic testing in siblings until they are 18

Answer 56

X-linked adrenoleukodystrophy

Question 57

Who should be involved in determining which gender to raise a child with a disorder of sex development?

Answer 57

Multidisciplinary approach

Question 58

What are two important factors to consider in the management of a child with a disorder of sex development?

Answer 58

1. Any genital surgery as a child should be potentially reversible if the patient would want to change gender in adulthood 2. Fertility should be preserved if possible

Question 59

How should you tell a child about a disorder of sex development?

Answer 59

Gradually and based on developmental level (don't surprise them with this when they are older)

Question 60

What type of medicine is intended to be based on knowledge of safety and efficacy obtained from randomized, controlled trials?

Answer 60

Conventional *This excludes all treatments that aren't supported by such studies/evidence

Question 61

What are treatments that are outside of conventional treatments and include chiropractic treatments, herbs, bioelectronics remedies, and nutritional therapy?

Answer 61

Alternative medicine

Question 62

What type of medicine uses both alternative treatments and conventional treatments?

Answer 62

Complementary medicine

Question 63

What form of medicine blends conventional medicine and alternative therapies (has some evidence of safety and effectiveness)?

Answer 63

Integrative medicine

Question 64

What is the difference between complementary and integrative medicine?

Answer 64

Integrative includes things that were initially alternative, but now are evidence based (probiotics, omega 3's, ect)

Question 65

True or False: Some herbs and vitamins can interfere with metabolism and elimination of medications

Answer 65

True (think about this if there is a medication that isn't as effective as it was in the past)

Question 66

What basic rule applies whether you are discussing conventional or non-conventional treatment?

Answer 66

Risk-Benefit

Question 67

True or False: Courts won't interfere with the use of alternative treatment unless it's life-threatening or coupled with refusal to use conventional treatment

Answer 67

True

Question 68

True or False: Meds that are less effective than proven conventional treatments shouldn't be used instead of these proven conventional treatments

Answer 68

True

Question 69

If a doctor isn't comfortable with an alternative therapy, is transfer to another physician who is comfortable appropriate?

Answer 69

No

Question 70

What should you counsel parents on in situations regarding enhancement therapies?

Answer 70

- Importance of individualism | - Happiness is independent of extrinsic factors

Question 71

What are 4 conditions for which growth hormone is FDA approved?

Answer 71

1. Turner 2. Chronic renal insufficiency 3. Prader-Willi 4. Non-growth hormone deficient idiopathic short stature

Question 72

True or False: It is okay to accept small gifts from pharmaceutical reps

Answer 72

False

Question 73

True or False: A gift textbook is appropriate

Answer 73

True- but only if it helps to improve treatment

Question 74

When is a sponsored CME lecture beneficial?

Answer 74

If the speaker has complete and unbiased control of what is presented

Question 75

True or False: Are samples to a patient appropriate

Answer 75

Yes, it helps the patient

Question 76

When are patient samples not appropriate?

Answer 76

If this leads to the prescription of a costly medication when a less expensive alternative is available

Question 77

What is an important thing to remember for patients in terms of cost of healthcare?

Answer 77

Anything leading to increased cost when less expensive and equally effective treatments are available means the patients needs aren't being met

Question 78

What are 3 things to remember regarding ethics committees?

Answer 78

1. Members should be from different backgrounds and perspectives 2. Subcommittees should answer to main ethics board 3. CME on ethics topics are needed to keep members qualified

Question 79

How should you tell a child that they are HIV positive?

Answer 79

Slowly over time and consistent with the developmental stage of the child

Question 80

What is really important for HIV positive teens and helps to ensure treatment compliance?

Answer 80

Support

Question 81

What activity modifications should you recommend for HIV + patients?

Answer 81

Against close contact sports where bloody/bodily fluid transmission is likely (boxing, wrestling, ect.)

Question 82

True or False: Parents are required to disclose a child's positive HIV status to school

Answer 82

FALSE *Schools need to handle every situation with universal precautions

Question 83

What measure should teens with HIV do in terms of decisions regarding health care?

Answer 83

Identify a health proxy to make decisions for them if they become incapacitated

Question 84

Children who are exposed to what are at risk for physical injury, likely to be aggressive with their peers, prone to separation anxiety as toddlers, at risk for school failure as adolescents, and at risk for risky sexual behavior?

Answer 84

Intimate partner violence

Question 85

True or False: Children exposed to intimate partner violence are more likely to be shy and withdrawn

Answer 85

FALSE *More likely to be agressive

Question 86

What behavior might you see from an infant exposed to intimate partner violence?

Answer 86

A lot of crying, resistant to comforting

Question 87

What behavior might you see from a toddler exposed to intimate partner violence?

Answer 87

Extreme separation anxiety

Question 88

What needs to be done within 72 hours of placement in foster care?

Answer 88

Health care screen

Question 89

What should be done within 30 days of entry into foster care?

Answer 89

A comprehensive health assessment

Question 90

Who represents children at court hearings for child abuse?

Answer 90

A law guardian (may be a trained volunteer- Court Appointed Special Advocate/CASA or and actual attorney

Question 91

True or False: Screening for intimate partner violence is recommended as part of routine encounters

Answer 91

True

Question 92

When is screening for intimate partner violence particularly crucial?

Answer 92

Cases of children with frequent non-specific symptoms (stomach aches and headaches)

Question 93

True or False: You only need to screen Mom's for intimate partner violence of they are depressed or anxious

Answer 93

False

Question 94

True or False: Only mothers are victims of intimate partner violence

Answer 94

False

Question 95

In screening for intimate partner violence, should the questions be specific or general?

Answer 95

Specific

Question 96

True or False: You have to report suspicion of intimate parter violence even if there is no evidence or suspicion of child abuse?

Answer 96

True- As mandated reporter because children are likely being exposed to violence too

Question 97

At what age should you ask guardians about intimate partner violence with children not present?

Answer 97

If the child is over 3 and verbal

Question 98

True or False: In any cases of suspected abuse it isn't a good idea for you to interview the child

Answer 98

True- Authorities should do this

Question 99

What is the preferred place for foster placement?

Answer 99

With relatives (versus a non-relative home)

Question 100

What is always the primary goal of Child Protective services?

Answer 100

Reunification of the family (as long as the child is in a safe environment)

Question 101

True or False: Healthy children cannot participate in studies that involve more than minimal risk

Answer 101

True

Question 102

When can children with a condition or disorder participate in a study that poses more than minimal risk?

Answer 102

If there is potential benefit to them from the study Ex: Experimental treatments when no other proven-effective treatments exist

Question 103

When is a study that poses more than minimal risk for patients if there is no direct benefit?

Answer 103

Only is there is a "minor" increase over the minimal risk

Question 104

What is a deviation from standard practice?

Answer 104

Malpractice

Question 105

What action results in a breach of the physician's duty to act reasonably, and results in injury to the patient?

Answer 105

Malpractice

Question 106

Who helps to prove breaches in a physician's duty in court?

Answer 106

Expert witnesses

Question 107

What 4 things do pediatricians serving as expert witnesses have to be?

Answer 107

1. Thorough 2. Fair 3. Objective 4. Impartial

Question 108

True or False: An expert witness's compensation cannot be contingent on the outcome of the case

Answer 108

True

Question 109

True or False: Situation in practice that might lead to litigation should be reported to the malpractice carrier as early as possible

Answer 109

True

Question 110

True or False: Disclosing errors to families is legally and ethically mandated

Answer 110

True