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patient autonomy

- respect patient as individuals (truth-telling, confidentiality)
- allow for autonomous choice (informed consent)
- honor their preference in accepting/not accepting medical caer


beneficence definition

ethical (fiduciary) duty to act in the patient’s best interest.
-May conflict with autonomy (an informed patient has the right to decide) or what is best for society (traditionally, patient interest supersedes societal interest)


Nonmaleficence definition

“Do no harm"
Balance against beneficence; if benefits > risks, patient may make an informed decision to proceed (most surgeries and meds fall into this category).


what is this an example of?
stopping a treatment that has shown to be harmful to the patient

Nonmaleficence - “Do no harm"


what is this an example of?
encouraging a patient to lose weight and stop smoking

beneficence - ethical (fiduciary) duty to act in the patient’s best interest


what is this an example of? refusing to provide treatment that has not been shown to be effective

Nonmaleficence - “Do no harm"


what is this an example of? educating the community about STDs

beneficence - ethical (fiduciary) duty to act in the patient’s best interest


what is this an example of?
resuscitating a drowning patient

beneficence - ethical (fiduciary) duty to act in the patient’s best interest


what is this an example of?
providing vaccination to the community

beneficence - ethical (fiduciary) duty to act in the patient’s best interest


informed consent involves

mental capacity
voluntariness (freedom from coercion and manipulation)


exceptions to informed consent

patient is incompetent
emergency (ie ectopic pregnancy)
therapeutic privledge


what is therapeutic priviledge

withholding information when disclosure would severely harm the patient or undermine informed decision-making capacity


what is a waiver?

patient explicitly waives the right of informed consent


When is consent required for minors?

DEPENDENTS less than 18yo


When is consent NOT required for minors?

1) minor is legally emancipated (married, self-supported, or is in the military)
2) getting treatment for
- Sex (contraception, STDs, pregnancy)
- Drugs (addiction)
- Rock and roll (emergency/trauma)


What must a physician do when involved in decision-making capacity

determine whether the patient is psychologically and legally capable of making a particular health care decision.


What is an advance directive?
What are the 3 types?

Instructions given by a patient in anticipation of the need for a medical decision
-Oral advance directive
-Living Will (written advance directive)
-Medical Power of Attorney


What is an oral advance directive? Problems with this?

Incapacitated patient’s prior oral statements commonly used as guide.

Problem: differences in interpretation


What is a written advanced directive?

aka Living Will.
Describes treatments the patient wishes to receive or not receive if he/she loses decision-making capacity


What is a medical power of attorney?

Agent/person designated to make medical decisions in the event that one loses decision-making capacity.

Can be revoked anytime patient wishes (REGARDLESS OF COMPETENCE); more flexible than a living will


Surrogate decision maker
priority of surrogates?

individuals (surrogates) who know the patient determines what the patient would have done if he/she were competent; usually done in the case where there is no advance directive prepared

adult children
adult siblings
other relatives


exceptions to confidentiality? 4

1) physical harm to SELF or OTHERS others is serious and imminent - Tarasoff decision
2) reportable diseases
3) child/elder abuse
4) impaired drivers (ie one with epilepsy)


Patient is not adherent.

dentify the reason for nonadherence and determine his/her willingness to change

do NOT
- coerce the patient into adhering
- refer him/her to another physician


Patient desires an unnecessary procedure (or does not want a necessary treatment)

understand why the patient wants or does not want the procedure and address underlying concerns.

do NOT
- refuse to see the patient
- refer him/her to another physician
- avoid performing unnecessary procedures


Patient has difficulty taking medications.

KISS - keep it simple, stupid

- provide written instructions
- simplify treatment regimens
- use teach-back method to ensure patient comprehension.


Family members ask for information about patient’s prognosis.

Avoid discussing issues with relatives w/p patient permission


patient’s family member asks you not to disclose the results of a test if the prognosis is poor because the patient will be “unable to handle it.”

Explain that as long as the patient has decision-making capacity and does not indicate otherwise, communication of information concerning his/her care will NOT be withheld


A child wishes to know more about his/her illness.

Ask what the parents have told the child. Parents of a child decide what information can be relayed about the illness.


A 17-year-old girl is pregnant and requests an abortion.

get parental notification or consent for minors

Unless she is at medical risk, do NOT
- advise a patient to have an abortion regardless of her age or the condition of the fetus


15-year-old girl is pregnant and wants to keep the child. Her parents want you to tell her to give the child up for adoption.

patient retains the right to make decisions regarding her child, even if her parents disagree

- provide info about the practical issues of caring for a baby
- discuss the options, if requested
- encourage discussion between the teenager and her parents to reach the best decision.


A terminally ill patient requests physician assistance in ending own life.

refuse involvement in any form of physician- assisted suicide.
May prescribe medically appropriate analgesics that coincidentally shorten lifespan


Patient is suicidal.

Assess the seriousness and if it is serious, hospitalize patient voluntarily or involuntarily


Patient states that he/she finds you attractive.

Ask direct, closed-ended questions and use a chaperone if necessary.

Never say: “There can be no relationship while you are a patient," - implies that a relationship may be possible if the individual is no longer a patient


A woman who had a mastectomy says she now feels “ugly.”

Find out why the patient feels this way.

do NOT offer falsely reassuring statements (e.g., “You still look good.”).


Patient is angry about the amount of time he/she spent in the waiting room.

Acknowledge the patient’s anger and Apologize for any inconvenience

Avoid explaining the delay.


Patient is upset with the way he/she was treated by another doctor, or staff.

Doctor: suggest that the patient speak directly to that physician regarding his/her concerns.

Staff: tell the patient you will speak to that person.


A drug company offers a “referral fee” for every patient a physician enrolls in a study.

Eligible patients who may benefit from the study may be enrolled - however, it is never acceptable for a physician to receive compensation from a drug company.
Patients must be told about the existence of a referral fee.


A physician orders an invasive test for the wrong patient.

regardless of how serious or trivial the error, ethically obligated to inform a patient that a mistake has been made.


A patient requires a treatment not covered by his/her insurance.

Never limit or deny care because of the expense in time or money. Discuss all treatment options with patients, even if some are not covered by their insurance companies.


Apgar score of >7



Apgar score of >4-6

assist and stimulate


Apgar score of


If it remains


low birth weight is defined as:




Of the three types of Advance Directives, which is the most specific? Which is the most flexible? Which is the most sketchy?

(Jen's interpretation to help her remember)
-Most specific seems to be the Living Will (written advance directive). written by patient and says what to do in various situations if she loses decision-making ability.
-Most flexible seems to be the Medical Power of Attorney. Can be revoked at any time regardless of patient competence.
-"Oral advance directive" kinda sounds like everyone's best guess.


APGAR stands for what?



moro reflex disappears at

3 mo


rooting reflex disappears at

4 mo


palmar reflex disappears at

6 mo


babinski reflex disappears at

12 mo


social smile?
stranger anxiety?
separation anxiety?

social smile = 2 mo
stranger anxiety = 6 mo
separation anxiety = 9 mo


separation anxiety from mom
rapprochement (moves away from and returns to mom)
comfortably spends part of day away from mom

separation anxiety from mom = 9 mo
rapprochement (moves away from/returns to mom) = up to 2.9 mo
comfortably spends part of day away from mom = 3yo and on


when does children do parallel play (play side by side)? cooperative play (play together)?

parallel play (play side by side) = 1.0 - 2.9 yo
cooperative play (play together) = 3.0 - 5 yo


how do developing countries differ in terms of overall disease morbidity compared to developed countries?

developing countries = younger population

developed countries = older population


how does REM and slow wave sleep change in the elderly?