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Medical Ethics for the Boards

Conrad Fischer

Chapter 1

Practice Question - all with Video Answers

Educators

Chapter Questions

Problem 1

An 80 -year-old man is admitted to the hospital with a massive intracranial bleed. He has been placed on a ventilator because of the respiratory failure associated with intracranial herniation. When you try to remove the ventilator, there are no respirations. The patient makes no purposeful movements. There is no pupilary reaction when you shine a light in his eyes. There is no nystagmus on cold caloric testing. Oculocephalic and comeal reflexes are absent. He left no specific wishes for his care.
Which of the following is the most appropriate action regarding this patent?
a. Remove the ventilator.
b. Make the patient DNR.
c. Place a nasogastric tube to prevent aspiration.
d. Get a court order authorizing you to remove the ventilator.
e. Do an EEG (electroencephalogram) three times separated by six hours each time.

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Problem 2

You are a resident in the emergency department. An irate parent comes to you furious because the social worker has been asking him about striking his child. The child is a 5 -year-old boy who has been in the emergency department four times this year with several episodes of trauma that did not seem related. Today, the child is brought in with a child complaint of "slipping into a hot bathtub" with a burn wound on his legs. The parent threatens to sue you and says "How dare you think that about me? I love my son!"
What should you do?
a. Give reassurance to the parents and treat the patient's injury appropriately.
b. Ask risk management to evaluate the case.
c. Admit the child to remove him from the possibly dangerous environment.
d. Call the police.
e. Ask the father yourself if there has been any abuse.
f. Speak to the wife privately about possible episodes of abuse.
g. Explain to the parents that the next time this happens you will have to call child protective services.
h. Report the family to child protective services.
i. Give the parents a referral to a family therapist they can see with the child the following week.

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Problem 3

You are working at the desk in your hospital when another employec of the hospital asks for information about a patient who was admitted last night with a pulmonary embolus secondary to cancer. You know the details of the case. The person requesting the information states that he is a close friend and co-worker of your patient. He shows you proper identification proving he really is a co-worker of your patient who also works in the hospital.
Which of the following is the most appropriate response to this request?
a. Give him the information on the patient.
b. Give him the information only if he is a relative of the patient.
c. Inform him that you are not at liberty to give details regarding the patient without the patient's permission.
d. Have him sign a release or consent form before revealing the information.

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Problem 4

You are seeing patients in clinic when two men in dark suits and dark glasses come in and show you badges marking them as members of a federal law enforcement agency. The identification is legitimate. These "men in black" inform you that they are making a "minor investigation" of one of your patients. They ask to look at the patient's chart for a few minutes, saying, "You wouldn't want to interfere with a federal investigation, would you?"
What should you do?
a. Give them the chart.
b. Give them the chart but watch what they do with it.
c. Ask them to sign a release for the chart so you are absolved of responsibility.
d. Tell them you cannot show them the chart unless there is a signed release from the patient.
e. Tell them that you can give copies but not the original record.
f. Don't give them the chart but read the relevant information to them.

Emily Himsel
Emily Himsel
Numerade Educator

Problem 5

You are a psychiatrist in session with a patient who tells you he thinks his boss at work is persecuting him. The paticnt has had mild schizophrenia. The patient asks you if you can keep a secret and then tells you that he is planning to kill his boss "when the time is right." You say. "Of course, everything you tell me during the session will always be confidential."
What should you do?
a. Keep the patient's session confidential but make attempts to discourage the patient from his plan.
b. Inform your medical director and let him handle it.
c. Inform law enforcement agencies of the threat to the patient's boss.
d. Inform the patient's boss that he is in danger.
e. Inform both the patient's boss as well as law enforcement of the threat.

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Problem 6

You are discussing the care of an elderly woman with her family. Although she is awake and alert, the patient is very ill and physically fragile. You are awaiting the results of a biopsy for what will likely be cancer, which has already metastasized throughout the body. The family asks that you inform them first about the results of the biopsy. They are very loving and caring and are constantly surrounding the patient. They do not want to depress the patient further, and because there will be no hope for a cure they see no reason to ruin her remaining life with this information.
What should you tell them?
a. You will honor their wishes.
b. You agree with their wishes and you ask them to give you the necessary written request.
c. You ask them to involve the ethics committee for the hospital.
d. You tell them that you are obligated to inform the patient of all the findings.
e. Explain to them that that decision can only be made by the health-care proxy.

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Problem 7

Your patient has just recently been diagnosed with familial adenomatous polyposis (FAP). This disorder is chronic, progressive, and fatal. There is a genetic test that can tell whether children of parents with the discase will develop it. The test is very accurate. The patient has become divorced and refuses to give you his consent to inform his ex-wife who now has custody of their three children. He threatens to sue you if you reveal elements of his medical care to his ex-wife.
What should you do?
a. Respect the patient's right to confidentiality.
b. Transfer the patient's care to another physician as long as the patient agrees.
c. Ask the health department to inform the patient's ex-wife about the disease risk.
d. Seek a court order to inform the patient's ex-wife.
e. Inform the patient's ex-wife of the risk to the children.
f. Inform the ex-wife's doctor.

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Problem 8

You are seeing a patient in clinic who has developed tuberculosis. He is an undocumented (illegal) immigrant. His family will need to be screened for tuberculosis with PPD skin testing. He is frightened of being deported if the Department of Health learns his immigration status.
What should you tell him?
a. "Don't worry, the Department of Health does not ask for or report immigration status."
b. "Only people who are noncompliant with medications are reported to the government."
c. "Don't worry, I will fully treat you before we deport you."
d. "I am sorry but there is nothing I can do about it; there is mandatory reporting to the government.

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01:09

Problem 9

A couple comes to see you after having tried in-vitro fertilization and artificial insemination. They are very happy because they have recently been successful in giving birth to a child. They have a significant amount of leftover sperm, eggs, and some fertilized gametes/cmbryos and they are thinking about selling them.
What should you tell them?
a. It is legal to sell only the eggs.
b. It is legal to sell only the sperm.
c. It is legal to sell both the sperm and eggs but not the embryos.
d. It is illegal to sell any of them.
e. It is legal to sell all of them.

Aditya Sood
Aditya Sood
Numerade Educator

Problem 10

You are a fourth-year medical student with a patient who has been in a severe motor vehicle accident. The patient has a subdural hematoma that led to cerebral herniation before it could be drained. Over the last few days, the patient has lost all brainstem reflexes and is now brain dead. You have the closest relationship with the family of anyone on the team. The ventilator is to be removed soon and organ donation is considered.
Who should ask for consent for organ donation in this case?
a. You, because you are the person with the best relationship with the family
b. The resident because you are only a student
c. Attending of record
d. Hospital administration
e. Organ-donor network

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Problem 11

A 50-year-old male gambler owes moncy to cveryone and is secking a rapid source of cash. He answers an advertisement in a foreign newspaper offering $$\$ 30,000$$ for one of his kidneys. He comes to see you for medical evaluation prior to the approval to be a donor.
What should you tell him?
a. It is never acceptable to receive any money for solid organs or bone marrow.
b. It is acceptable as long as the recipient truly need the organ.
c. It is okay as long as the donor's remaining kidney is healthy.
d. It is acceptable if the surgery for both the donation as well at the implantation in the recipient is occurring in a foreign country.
e. Reimbursement for cost of travel and lodging for the donation is acceptable, but profiting from the donation is unacceptable.

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Problem 12

A man arrives at the emergency department on a ventilator after an accident. He is brain dead by all criteria. He has an organ-donor card in his wallet indicating his desire to donate. The organ-donor team contacts the family. The family refuses to sign consent for the donation.
What should be done?
a. Remove the organs anyway.
b. Wait for the patient's heart to stop and then remove the organs.
c. Stop the ventilator and remove the organs.
d. Seek a court order to overrule the family.
e. Honor the wishes of the family; no donation.

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Problem 13

You have a patient with severe muitiple sclerosis that is advanced and progressive who now develops renal failure secondary to diabetes. The patient is alert and has elected to put the DNR order in place at her own discretion. The patient's potassium level is now markedly elevated at 8 meq/L.
Which of the following is the most appropriate management of this patient?
a. Dialysis cannot be done because of the DNR order.
b. You can do the dialysis if the DNR is reversed for the procedure.
c. Go ahead with the dialysis; ignore the DNR order.
d. Give kayexalate until the DNR status is discussed with the family.

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Problem 14

A patient from a skilled-nursing facility is admitted to the hospital for severe upper gastrointestinal bleeding. The patient has a DNR order in place. The bleeding has not stopped despite multiple transfusions, octreotide, proton pump inhibitors, and endoscopy. He needs monitoring and evaluation in an intensive care unit.
What should you do?
a. Reverse the DNR order and transfer to the ICU as needed.
b. You cannot be DNR and be in the ICU.
c. Transfer to the ICU as needed; okay to be DNR in the ICU.
d. He can go to the ICU with the DNR but cannot go to surgery.
e. He can go to the ICU with the DNR but cannot be intubated.

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Problem 15

A man is admitted for acute appendicitis. He is elderly and has had a home DNR order in place since he had a previous admission for another reason last year. He needs urgent surgery for the appendicitis. He still wishes to be DNR.
What should you do about the surgery?
a. No surgery can be done with a patient who is DNR.
b. Reverse the DNR order for the surgery.
c. DNR is acceptable only if the surgery does not require intubation.
d. Surgery is acceptable while DNR if an additional consent is signed.
e. DNR does not preclude surgery; proceed with the appendectomy.

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Problem 16

An 84-year-old woman is seen by you in clinic for routine management of her multiple medical problems. She comes alone and you notice that she has been losing weight and has several contusions. She is a widow and lives with her granddaughter and her granddaughter's husband who recently lost his job. On questioning she tells you that her granddaughter's husband does occasionally strike her when he is drunk.
What should you do?
a. Report the abuse only at her specific request.
b. Arrange for a meeting with your patient and the grandson-in-law.
c. Remove the patient from the home and place her in an adult home.
d. Have a home health aid placed to keep an eye on the patient.
e. Arrange for an order of protection from the police.
f. Report the grandson-in-law's abuse to adult protective service.
g. Speak directly to the grandson-in-law about the problem.

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02:03

Problem 17

You are the staff physician in a state penitentiary in a state where capital punishment is legal. An execution is in process and the warden calls you because the technician is unable to start the intravenous line that is necessary for the lethal injection. The warden wants you to start the line and supervise the pharmacist.
What should you tell him?
a. "No problem, I will start the line right away."
b. "I can start the line, but I cannot push the medications."
c. "I can start the line, but I cannot prepare or inject the medications."
d. "I am sorry; I cannot participate in the execution at all as a physician."
e. "I can take care of all of it."

Aparna Shakti
Aparna Shakti
Numerade Educator
02:37

Problem 18

You are preparing a clinical trial of different doses of a certain medication. This medication has already been proven to be clinically effective and is already approved by the Food and Drug Administration (FDA). You are only studying to see whether a higher dose of the medication will lead to enhanced benefit.
Which of the following is true concerning your study?
a. Institutional review board (IRB) approval is not necessary.
b. Informed consent is required to participate.
c. Informed consent is not required because the medication has already been FDAapproved.
d. Informed consent is not required because you are trying to demonstrate benefit, not harm.

Courtney Burson
Courtney Burson
Numerade Educator
02:07

Problem 19

Which of the following most accurately describes the participation of prisoners in clinical trials and research?
a. There is no need for informed consent.
b. No monetary compensation may occur.
c. Prisoners are not permitted to participate as research subjects.
d. Their rights are identical to those of a nonprisoner.
e. Research on prisoners is always considered unethical.
f. Participation in research is an accepted means of winning early release from prison.

Brittany Scott
Brittany Scott
Numerade Educator
01:14

Problem 20

You are in the process of finalizing the results of your research for publication. You are the principal investigator of a clinical trial studying the effects of HMG-CoA reductase inhibitors on cardiac mortality. A prominent manufacturer of one of these medications provided major funding for the study.
Which of the following is the most accurate in an ethical preparation for authorship of the publication?
a. Accepting money from a company prohibits you from being listed as an author.
b. Funding source has no impact on publication requirements.
c. You can be listed as the author after the institutional review board checks the paper for evidence of bias.
d. There are no restrictions on your authorship as long as you disclose the financial affiliation.
e. There are no requirements as long as the data are accurate.
f. You do not have to do anything as long as the checks were written to the institution and not to you.

Aisha Abdullah
Aisha Abdullah
Numerade Educator
03:13

Problem 21

Which of the following most accurately describes the primary role of an institutional review board (IRB)?
a. Protect the institution from liability
b. Protect the physician from liability
c. Ensure the ethical and humane treatment of human subjects in experimentation
d. Ensure the study is scientifically accurate
e. Ensure that the study is financially feasible for the institution

Emily Himsel
Emily Himsel
Numerade Educator

Problem 22

A 35 -year-old female patient comes to your office with a large form to be filled out certifying that her health is within normal limits. This is as a part of pre-employment evaluation and is required in order for the patient to get the job. The form also asks for the results of the patient's APC (adenomatous polyposis coli) gene. This is in order for the company to determine which of its long-term employees will need expensive care. What should be your response?
a. Perform the test.
b. Perform the test, but do not share the results with the employer.
c. Do not perform the test.
d. Ask the patient if she wants the test performed and the results reported.
e. Perform the colonoscopy; the employer is entitled to know about current health problems but not future ones.
f. Include the test only if the patient has family members with colon cancer.

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Problem 23

You have a patient with a strong family history of breast cancer. As a matter of the patient's request, you perform a BRCA genetic test to see if there is an increased risk for breast cancer. The patient's employer is requesting a copy of any genetic testing that may have been done.
What should you do?
a. Give the employer the information.
b. Refer the employer to the hospital lawyer.
c. Bring the request to the ethics committee.
d. Refuse to provide the information to the employer.
e. Give the information if it is positive on a repeat exam.

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Problem 24

You are a resident invited to a dinner given by a pharmaceutical company. In addition to the dinner there is a lecture given on a medical subject as well as a $$\$ 500$$ gift certificate to a department store for attending the presentation.
Which of the following is the most appropriate action in this case?
a. It is entirely unethical to accept any of it; refuse everything.
b. It is only ethical to attend the lecture.
c. Do not accept the money, but the dinner and the lecture are ethically acceptable.
d. You may accept all three components.
e. Cash payments from industry are acceptable as long as they are not tied to prescribing specific medications.
f. You can accept because you are a resident and not an attending.

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Problem 25

You have been asked to give Grand Rounds at a hospital. A manufacturer of a new medical device is sponsoring you. In exchange, you are being offered a $$\$ 1,000$$ fee for your talk.
What should you do?
a. You must refuse the money.
b. You may accept only as long as you donate it to charity.
c. You may accept as long as you don't reveal the honorarium to the audience.
d. It is permissible to take the money as long as you disclose any other financial or business connection with this or any other company.
e. You may accept the money as long as you submit the content of your talk to an independent panel for review to ensure objectivity.

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Problem 26

You have been taking care of a patient admitted with palpitations from a panic attack. He is somewhat hypomanic with pressurcd spccch, anxiety, and flight of ideas. After several days he is feeling much better and he is extremely grateful for your help. He is quite wealthy and he offers to borrow five million dollars from the bank "to help you with your research."
What should you tell him?
a. "I accept!"
b. "Thank you very much, but I cannot accept."
c. "I accept, but only for a study of bipolar disorder."
d. "I would be happy to take your money, but I must have you evaluated by psychiatry first."

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Problem 27

You have a patient in your clinic who is an elderly woman with multiple medical problems. Her family is extremely grateful for your care and they bring you a meal they cooked at home, a cake, and a scarf.
What should you do?
a. Accept the gift but report it.
b. Accept the gift.
c. Offer payment for the food.
d. Refuse the gift.
e. It is ethical to accept the gift if you share the food with the rest of the house staff.
f. Accept the food but not the scarf.

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03:13

Problem 28

You have been invited to participate in a "Medical Jeopardy" game sponsored by a pharmaceutical manufacturer. The winners are to receive $$\$ 100$$ gift certificates to the medical school's bookstore. All of the participants are to receive a stethoscope. The audience and all the participants are offered a free meal.
Which of the following is most appropriate to accept?
a. All the gifts
b. Only the meal
c. Only the stethoscope
d. The meal and stethoscope, but not the gift certificate
e. None of the gifts

Emily Himsel
Emily Himsel
Numerade Educator

Problem 29

A 32-year-old pregnant woman comes to your prenatal clinic. She has a history of syphilis and gonorrhea in the past but her VDRL/RPR is negative now. An HIV test is offered as a routine part of her prenatal evaluation as well as because of the history of previous STDs. You explain to her the importance of the test for her baby's wellbeing. She refuses the test when offered.
What should you do?
a. No test; she has the right to refuse.
b. PCR RNA viral load testing as an alternative.
c. Consent for HIV testing is not needed in pregnancy because it is to protect the health of the baby.
d. Add the test to the other routine tests that are to be drawn.
e. Administer empiric antiretroviral therapy to prevent perinatal transmission.
f. HIV testing is now part of routine prenatal care and no specific consent is needed.

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Problem 30

You have a patient who is an HIV-positive physician. He has recently found out that he is HIV-positive. He is very concerned about confidentiality and you are the only one who knows he is HIV-positive. He asks you who you are legally obligated to inform.
What should you tell him?
a. His insurance company
b. State government
c. His patients
d. His patients, only if he performs a procedure such as surgery where transmission can occur
e. No one without his direct written consent
f. His employer
g. The hospital human resources department

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Problem 31

You have an HIV-positive patient in need of drainage of a dental abscess. There is a dentist in your multispecialty group practice. He knows you are an infectious diseases/HIV specialist. Your office manager tells you the dentist and his staff are "scared of your HIV-positive patients" and they don't want to see them.
What is your response?
a. This is illegal; the dentist is liable and can be sued.
b. You contact the medical director and have him instruct the dentist to see the patient.
c. You prescribe the use of oral antibiotics alone instead.
d. Refer your patient to another dentist outside of your group practice.

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Problem 32

You are evaluating a new patient that has come to your clinic for management of his HIV infection. He has high CD4 cells and a low viral load and does not require treatment. He is married and does not practice safe sex with his wife. His wife is unaware of her husband's HIV status.
What is your duty?
a. Encourage discussion between the husband and wife and strongly suggest he disclose his HIV status to his wife.
b. You must keep his HIV status entirely confidential at all times
c. Have the city Department of Health inform the wife.
d. Send the wife a letter to come to your office because of an "urgent health issue" and then inform her yourself.
e. There is no need for partner notification as long as they are practicing safe sex.

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Problem 33

You have an HIV-positive patient in the office. You ask her if she has informed her partner that she is HIV-positive. She has repeatedly resisted your attempts to have her inform the partner. She is pregnant with his child. The partner is in the waiting room and you have met him many times.
What should you do?
a. Inform the partner now.
b. Respect her confidentiality.
c. Refer your patient to another physician who is comfortable with her wishes.
d. Tell the partner to practice safe sex from now on but don't tell him her HIV status

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Problem 34

An 87-year-old man comes to see you for follow-up to a minor concussion sustained a few weeks ago. He was in a minor motor vehicle accident in which his head hit the dashboard but he did not lose consciousncss. Your patient has glaucoma and presbycussis. He renewed his driver's license by mail two ycars ago and the only restriction is that he must wear glasses. You are uncertain whether the patient should be driving.
What should you do?
a. Inform the patient's family and explain to them that they should not allow the patient to continue driving because it is dangerous for him.
b. MRI of the brain.
c. Neurology evaluation.
d. Start aricept to improve his memory.
e. Discuss the issue with the patient and encourage him to find alternate methods of transportation.
f. Remove his license from him.
g. Mandatory reporting to the police.

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Problem 35

A 37-year-old man comes to your office for his regular visit. He has seemed severely depressed for some time but refuses to discuss either his feelings or treatment options of any kind. He does not want to use antidepressant medications. His only medications arc vitamins. Your relationship with him is excellent but he just won't confront his feelings of depression although he firmly denies suicidal ideation. You prescribe a serotonin reuptake inhibitor for him and tell him that it is a vitamin. Over the next several months his mood markedly improves and he feels much better.
Which of the following most appropriately characterizes your action toward the patient?
a. Your action is appropriate because it benefited the patient.
b. Your action is appropriate because there were no side effects.
c. Your action is not appropriate because you are not a psychiatrist.
d. Your action is not appropriate because you treated the patient without his consent.
e. Your action is appropriate because you are sincerely trying to help the patient.
f. Your action is acceptable as long as you inform the patient now that he is feeling better.

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Problem 36

A 67 -year-old woman is diagnosed with breast cancer. She is fully alert and very specifically both verbally and in writing tells you that she does not want to have surgery on her breast to remove the tumor. She fully understands her condition and treatment options. This is a decision her husband and son both disagree with. Over the next several weeks the patient becomes confused and loses the capacity to understand the details of her medical care. The husband and son now approach you to perform the surgery.
Which of the following is most appropriate?
a. Refuse to do surgery and follow the original advance directive.
b. Perform the surgery only if the request is in writing.
c. Honor the family's request and perform the surgery.
d. Consult the ethics committee.
e. Ask the family to seek a court order.
f. Perform the surgery only if you really believe that it will benefit the patient in the long term.

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Problem 37

A 52 -year-old man with cerebral paisy is being evaluated for screening colonoscopy. He has a mental age of 8 and a second grade reading level in terms of comprchension. He lives alone and survives on a combination of public assistance and a lowpaying part-rime job sweeping floors. You have thoroughly explained the procedure to him in terms of risks and benefits. He repeatedly refuses the procedure entirely on the basis of "I just don't want it."
What should you do?
a. Perform the procedure.
b. Seek consent from the family.
c. Honor his decision and do not do the colonoscopy.
d. Seek a court order mandating the procedure.

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Problem 38

Mr. M. consents to a procedure on his left ear. After the patient is anesthetized Dr. W. discovers that the right ear is in greater need of surgery. What should the surgeon do?
a. Perform the procedure on the right ear if it is clear that it is more necessary.
b. Wake the patient up and seek consent for a different procedure.
c. Seek a second opinion from another surgeon and proceed with the more necessary procedure.
d. Perform the procedure on both ears.

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03:11

Problem 39

A 52-year-old Spanish-speaking woman has arrived for the first day of a clinical trial of chemotherapy for breast cancer. You suddenly remember the need for signing a consent form. You ask a medical student to "get the consent." He walks up to the patient and says in English, "Sign this," and she signs. She completes the trial but her hair falls out and she files suit against you for an improper informed consent.
Why will this lawsuit be successful?
a. The risks of the treatment were not explained.
b. The explanation was not in a language you were sure she could understand.
c. She experienced harm from the study medication.
d. Someone who didn't understand the study obtained the consent.
e. All of the above.

Briana De La Torre
Briana De La Torre
Numerade Educator
02:29

Problem 40

An unconscious man is brought to the emergency department for a motor vehicle accident hemorrhaging profuscly, hypotensive, and stuporous. You have never mes the patient before and no one at your institution knows him. He is wearing a T-shirt that says "Kiss me, I'm a Jehovah's Witness."
What should you do about the blood transfusion?
a. Give the blood.
b. Wait for him to awaken enough to sign consent.
c. Wait for the family.
d. Seek a court order.
e. Give intravenous fluids alone.

Bryan Valdivia
Bryan Valdivia
Numerade Educator

Problem 41

A 34-year-old man is brought to the emergency department with fever, headache, and a change in mental status leading to significant disorientation. His head CT is normal and he is in need of an urgent lumbar puncture and intravenous antibiotics. He is agitated and is waving off anyone who tries to get near him. Co-workers accompany him. The resident informs you that the patient is pushing away the lumbar puncture needle.
What should you do?
a. Sedate the patient with lorazepam and perform the lumbar puncture.
b. Wait for the family to obtain consent.
c. Use blood cultures as an alternative.
d. MRI of the brain.
e. Ask the co-workers to sign consent.

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02:29

Problem 42

A man is admitted for the management of ncutropenia and fever from aplastic anemia. His anemia is severc and his medical care requires blood in addition to antibiotics. He is suffering from a profound dclirium from the fever and has lost capacity to understand his problems. His brother is his health-care proxy. The patient is a Jehovah's Witness and is adamantly opposed to transfusion even ir he dies, and the brother is not opposed. The patient has clearly told both you and the brother this in the past. The patient's brother believes that the proscription against transfusions is "barbaric and stupid."
What should the patient's brother do?
a. Arrange a Jehovah's Witness meeting to discuss the situation.
b. Ask their parents to make the decision.
c. Ask the doctor to make the decision.
d. He should not give consent for the transfusion.
e. He should give consent for transfusion.

Bryan Valdivia
Bryan Valdivia
Numerade Educator

Problem 43

Mr. Sakiewiec is a 32 -year-old man with severe mental retardation who has been institutionalized since childhood. He is noncommunicative and has never been able to verbalize his preferences on any decision. His parents are dead and the institution and a court-appointed guardian manages him. He has developed leukemia that is severe and incurable. Chemotherapy involves significant risk and discomfort and only a small chance of prolonging his survival.
What should be done in terms of his medical treatment?
a. Proceed with the chemotherapy.
b. Confer an "expert panel" to determine therapy.
c. Bone marrow transplantation.
d. Ask the guardian what is in the best interests of the patient.

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Problem 44

A 27 -year-old pregnant woman presents in her last trimester of pregnancy with severe cephalopelvic disproportion. Her physicians have recommended a caesarian section. She does not want to undergo the surgery. She fully understands the procedure and she is unwilling to suffer the discomfort of surgery. She has been informed that without the $\mathrm{C}$-section her fetus may not survive childbirth.
What should you do?
a. Honor her wishes and do not perform the C-section.
b. Psychiatry evaluation.
c. Sedate her and perform the surgery.
d. Obtain a court order to perform the surgery.
e. Explain the situation to the baby's father and ask him for consent.

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Problem 45

A 52-year-old man sees you in follow-up after a radical prostatectomy. He had been fully informed about the risk of the procedure such as incontinence and impotence. Neither of these adverse effects occurs. While searching on the Web he finds that there is treatment without surgery involving the implantation of radioactive seeds or pellets in the prostate. He files suit against you because of an improper informed consent.
What will be the most likely outcome of the suit?
a. He will lose because there were no adverse effects.
b. He will lose because all the risks of the surgery were explained to him before he signed consent.
c. He will lose because radical prostatectomy is a standard procedure.
d. He will win because you did not inform him of the risks and benefits of alternative therapy to surgery.
e. He will win because radioactive seeds are the superior form of therapy.

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Problem 46

A 58 -year-old man is out of town on business in New York. He has a myocardial infarction and deteriorates despite thrombolytics and angioplasty. He is intubated and is disoriented and unable to understand his condition. He needs a coronary bypass. His wife is the health-care proxy but she is in another city. You would like her consent in order to perform the surgery because she is the designated surrogate.
Which of the following is true in this case?
a. She must come to the hospital to sign consent in person.
b. The wife must designate a local guardian until her arrival.
c. You must repeat the angioplasty instead.
d. Telephone consent is only valid for minor procedures.
e. Take consent for the bypass over the phone and have a second person witness the telephone consent.

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02:29

Problem 47

Mr. Dorone is a 22 -year-old man who sustained a subdural hematoma and a brain contusion in a motor vehicle accident. He needs blood in order to have the necessary lifesaving surgery done. His parents refuse to allow the transfusion based on their religious beliefs.
What should be done?
a. Honor the parents' wishes and do not give the blood.
b. Give the blood.
c. Wait for a formal hearing with a judge and a court.

Bryan Valdivia
Bryan Valdivia
Numerade Educator
02:29

Problem 48

A 27-year-old Jehovah's Witness is in labor and bleeding heavily. She categorically refuses all transfusions and signs a refusal to consent form indicating that she understands she may die without the blood. When she loses consciousness her husband, who is not a Jehovah's Witness, says to give the blood and he will sign consent.
What should you tell him?
a. You will honor his wish if he is the proxy.
b. You will honor his wish and give the blood.
c. You will give the blood only if the patient is unconscious.
d. You cannot give the blood.

Bryan Valdivia
Bryan Valdivia
Numerade Educator

Problem 49

A medical resident admits a patient overnight with uncontrolled blood pressurc. He means to write an order for the angiotensin receptor blocker Diovan at $10 \mathrm{mg}$ once a day. Because of his sloppy handwriting the nurses and pharmacy administer digoxin at $10 \mathrm{mg}$ a day. This is a drug that is rarely used at a dose above $0.5 \mathrm{mg}$ a day. Three days later, the patient develops a hemodynamically unstable rhythm disorder that the resident very sincerely tries to decipher but is unable to until the patient transfers to the intensive care unit. At this point they discover the overdose of digoxin. The patient and the family never discover the overdose.
Which of the following most accurately describes this situation?
a. There is no liability for the resident because the overdose was unintentional.
b. There is no liability for the resident because the pharmacy should have detected the error.
c. No liability exists because the error is unknown to the patient.
d. No liability exists because it was an accident.
e. The resident and hospital are both liable for harm to the patient.
f. No liability exists because there was no permanent harm to the patient.

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Problem 50

Which of the following most closely represents the role of risk management in the hospital?
a. To ensure proper ethical management of patients
b. To ensure proper clinical care of patients
c. To act as a patient advocate
d. To clarify communications from the medical staff to the patient
e. To minimize the legal risk to the hospital from litigation

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Problem 51

You explaincd the risks and benefits of bone marrow transplantation versus chemotherapy to a woman with leukemia. This was part of an IRB-approved trial. You told her that the transplant has the highest chancc of cure of the disease but also the highest risk of immediate death. She understood what you said and signed the consent for transplantation. She dies as a result of the bone marrow transplant and her husband sues you for wrongful death.
What will be the most likely outcome?
a. He loses the lawsuit because BMT is the standard of care for this patient's age and disease.
b. He wins because he was not informed.
c. He wins because chemotherapy has less risk of death.
d. He loses it because the patient was fully informed about the risks and benefits of both alternatives.
e. He loses because the trial was IRB-approved.

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Problem 52

A 57 -year-old corporate executive comes to the emergency department with an ST segment elevation myocardial infarction. He receives thrombolytics but has persistent chest pain, worsening left ventricular function, and a new S3 gallop. The patient asks you about the risks and benefits of angioplasty. You tell him he could have a hematoma or a coronary rupture as an adverse effect of the angioplasty balloon. You tell him that the benefit will be that it stops the chest pain. He opts for further medical management without angioplasty because of fear of adverse effects. He dies and his estate sues you.
What will be the most likely outcome?
a. You win because you fully informed him of the adverse effects of the procedure.
b. You win because he refused the treatment offered.
c. You lose because patients cannot refuse lifesaving therapy.
d. You lose because you should have done the angioplasty before the thrombolytics.
e. You lose because you did not inform the patient of the serious consequences of forgoing angioplasty.

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Problem 53

A 72-ycar-old woman is admitted to the hospital with gastrocnteritis and dehydration. There are no indications in the chart of her having dizziness. She also docs not dircetly inform the nurses of her dizziness. She asks to be brought to the bathroom. She is left alone on the toilet when she becomes lightheaded, faints, and hits her head against a wall sustaining a laceration. The patient and her family subsequendly file suit against the hospital for negligence.
What will be the most likely outcome?
a. She wins secondary to the negligence of the nurses.
b. She wins secondary to the negligence of the physicians.
c. She wins if she has sustained significant brain damage.
d. She loses because there was no significant injury.
e. She loses because she did not inform the nurses she was dizzy or lightheaded.

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Problem 54

A 70 -year-old man is admitted to the hospital with endocarditis. At seven days of therapy the antibiotic order expires and you forget to reorder the medication for two days in the middle of a four-week course of intravenous antibiotics. There is no clinical deterioration and the antibiotics are restarted.
What should you tell the patient?
a. Tell the patient it was a clerical error.
b. Because it was not clinically significant you do not have to say anything to the patient.
c. Apologize and tell the patient that you forgot to reorder the antibiotics, but that he will be all right.
d. Inform your chief resident but not the patient.
e. Ask the nurse to tell the patient about the error.

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Problem 55

You are a resident managing a private patient with cellulitis. The patient has a history of congestive heart failure and a normal EKG. The patient is on digoxin, an ACE inhibitor and a diuretic, but not a bera-blocker. You cannot find a contraindication to the use of beta-blockers either in the chart or in discussion with the patient. You ask the private attending why there is no beta-blocker and he looks at you as if you had anoxic encephalopathy. He says, "I have been in practice for 40 years. Don't you think I know what I am doing? Beta-blockers are dangerous in congestive failure." The patient looks proudly at the attending and says, "I have the smartest doctor in the world."
What should you do about this disagreement?
a. Wait for the attending to leave and give the patient a prescription for carvedilol.
b. Suggest to the patient that he should find another doctor.
c. Report the physician to the state licensing board.
d. Do nothing; he is the attending of record.
e. Bring the disagreement to the chief of service.
f. Help the patient find a good lawyer and volunteer to testify.

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Problem 56

A patient of yours has gone to the hospital to obtain a copy of her medical record for her own review. The hospital refuses to release them to her on the grounds that she must provide an adequate reason for wishing to see the records. She has come to see you to ask if this is true and how can she get her records.
What should you tell her?
a. You, as the physician, can get the records for yourself to view, but she cannot.
b. The hospital will give her the records as long as you ask.
c. She has the right to have her own records as long as she has a legitimate reason.
d. She has the right to her own records even without giving a reason.
e. Only another physician, hospital, or insurance company can have free access to her records.
f. She can have the records as long as she has fully paid her hospital bills.

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Problem 57

Which of the following most accurately describes the ownership of the medical record?
a. The record is entirely the property of the patient.
b. The record is entirely the property of the health-care provider.
c. The information is the property of the patient and the physical paper or electronic record is the property of the health-care provider.
d. The information is the property of the health-care provider and the physical paper or electronic record is the property of the patient.

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Problem 58

A man comes to the emergency department after a stab wound. Your notes document a $500-\mathrm{mL}$ loss of blood. Later that night the patient develops asystole and dies. You find the loss of blood was originally really $3,000 \mathrm{~mL}$, which was not recorded by you.
What should you do to correct the documentation?
a. Use correction fluid to eliminate the original note.
b. Erase the original note.
c. Remove the original note from the chart.
d. Write a new note timing and dating it at the same time as the original note.
e. Write a new note with the current date and time.

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Problem 59

The neighbor of a 14 -year-old boy brings him to the emergency department after sustaining a slight laceration to the scalp from head trauma. You evaluate him and determine that suturing of the scalp will be necessary.
Which of the following is the most accurate?
a. He is an emancipated minor; the patient can give consent.
b. The neighbor can give consent.
c. Wait for the consent of at least one parent.
d. Wait for the consent of both parents.
e. Seek a court-appointed legal guardian.
f. Consent is not necessary in this case.

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Problem 60

A 15 -year-old girl comes to the clinic for dyspareunia and a vaginal discharge. On speculum examination you find she has cervicitis. The pregnancy test is negative. The infection is modest and there is no emergency.
Which of the following is the most appropriate action to take?
a. Ceftriaxone/azithromycin now in a single dose.
b. Make at least a "good faith" effort to notify her parents and treat her.
c. Wait to inform at least one parent.
d. Treat only if the patient agrees to inform her parents.
e. Treat her now and inform the parents later.

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02:29

Problem 61

A 12-year-old boy and his father are involved in a motor vehicle accident that results in a severe hemorrhage requiring an urgent blood transfusion. Both of them are clearly alert and understand that without the blood they may die. They are both Jehovah's Witnesses and are refusing blood transfusion on religious grounds.
What should you do?
a. Honor their wishes; no transfusions for either one.
b. Obtain a court order to transfuse the child.
c. Give blood to the child but not to the father.
d. Psychiatric evaluation.
e. Use intravenous iron in both of them as a blood substitute.
f. Explain the situation to the child and ask him for consent for the transfusion.

Bryan Valdivia
Bryan Valdivia
Numerade Educator

Problem 62

A 16-year-old female comes to the clinic after missing a period. Her pregnancy test is positive and she wants to start prenatal care with you. She is adamant that you keep the pregnancy confidential from her parents.
What should you tell her?
a. "I will give you the care you need and keep it confidential."
b. "I will not mention it to your parents unless they ask. I can't lie."
c. "I am sorry, but I must tell them."
d. "I will not tell your parents, but I must inform the father of the baby."

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Problem 63

A 12 -year-old girl presents with severe right lower-quadrant abdominal pain and marked tenderness and is found to have acute appendicitis. The child is at a sleepaway camp. You are not able to locate her parents. They are not at home and you cannot reach them on the cell phone. The camp counselor and the director of the camp bring in the child.
What should you do?
a. Do not do the surgery without parental consent.
b. Ask the camp counselor or director for consent.
c. Ask the patient for consent.
d. Perform the appendectomy.
e. Give intravenous antibiotics alone.

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Problem 64

A 16-year-old female comes in for treatment of severe cystic acne with Accutane (isotretinoin). She lives alone and is self-supporting with a job as a waitress. She has been out of her parents ${ }^*$ house for a year and pays all her own bills. You have just finished informing her of the potentially severe teratogenicity of isotretinoin. Her acne is severe and she would still like the isotretinoin.
What should you tell her?
a. "This medication cannot be taken by women of reproductive age."
b. "Use benzoyl peroxide topically instead."
c. "I will give you the isotretinoin if your parents accompany you."
d. "I will give you the isotretinoin as requested."
e. "I will treat you with isotretinoin if you have a consent signed by your parents."

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Problem 65

A 65 -year-old man comes to see you because he wants your help in committing suicide. The patient has recently been diagnosed with metastatic colon cancer but he is not in pain or nauseated. He found out because of a screening colonoscopy and a subsequent staging evaluation. He denies depression and seems to have a normal mood. He is asking for a prescription or combination of medications that he can take to end his life. He says he will wait for a few weeks or months until he starts to feel weak and then he wants to end his life before he becomes debilitated, bed-bound, or a burden to his family.
Which of the following is most appropriate in this case?
a. Provide the pain medications as appropriate but not the means to end his life.
b. Provide the patient with medications he wants to end his life.
c. Have him undergo psychological screening first.
d. Refer him to a specialist in this area.
e. In-patient psychiatric evaluation for suicidal ideation.
f. Start antidepressants.

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Problem 66

A 79-year-old man comes to see you for assistance in ending his life. The patient is fully competent and has been suffering from progressively worsening amyotrophic lateral sclerosis for several years. He is not immediately preterminal. Despite this, he finds his quality of life to be unacceptable. More important, he correctly predicts that his level of function will deteriorate over the next several months and that he may become ventilator dependent. He is requesting that you administer a lethal injection in his home. He is not depressed. His family is aware of his desire and they are willing to honor the patient's wishes. You have discussed appropriate palliative care issues.
What should you tell him?
a. You tell him that you will honor his wish because he is competent and not depressed.
b. You tell him that you will honor his wish because his condition will worsen over time.
c. You agree to his wish because he has a right to a better quality of life.
d. You tell him that you cannot help him because there is no state law authorizing it.
e. You tell him that under no circumstances can you participate in euthanasia.
f. You say that it is okay as long as it happens in Oregon.

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Problem 67

You are a fourth-year medical student on a subinternship in obstetrics. You notice that the resident has come in with alcohol on his breath and some abnormal behavior. No one except you seems to notice.
What should you do?
a. Nothing; you are subordinate to the resident.
b. Talk to the resident directly alone but don't mention it to the program director.
c. Tell the dean of students.
d. Report him to the state licensing board.
e. Report him to the chairperson or program director of his department.
f. Immediately inform his patients whom you feel are at risk.

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Problem 68

You are an attending physician at a university hospital. One of the attendings from another division seems to be having memory difficulty. You have found him twice in the hallway having forgotten where he was going. The residents tell you on the side that they don't rely on him at all because "he forgets everything we say anyway." The chief of service knows but doesn't have enough attendings to fill the yearly schedule so he remains in place supervising both resident performance as well as patient care. What should you do?
a. Nothing; the chief of service already knows.
b. Talk to him directly.
c. Tell your division head.
d. Report him to the state licensing board.

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Problem 69

You are an attending at a large program in New York. You are out at a bar on Saturday night when you notice one of your residents in the same bar. She is clearly drunk. The resident is sitting behind you, too intoxicated to notice your presence. She is kissing a man who you know is not her husband. You leave before she notices you. The following day you see her at the hospital managing patients and supervising interns. Her behavior and medical management seem completely normal.
What should you do?
a. Speak to her directly about her behavior.
b. Discuss it with her program director or department chair.
c. Report her to the committee for physician impairment.
d. Do nothing.

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Problem 70

A physician in a busy inner-city environment has developed his practice over the years to the point where he no longer needs to solicit new patients. He does not want to expand his hours of work so he decides to limit his practice. He instructs his office staff to begin refusing to accept new patients.
Which of the following most appropriately describes his action?
a. It is both legal and ethical.
b. It is ethically acceptable, but illegal.
c. He is within his legal rights to refuse patients, but it is considered ethically unacceptable.
d. It is both illegal and unethical to refuse to accept new patients.
e. It is ethical as long as he arranges transfer of care to another physician.

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Problem 71

You have a patient who has recently been diagnosed with myeloma and he is discussing treatment options with you. You are the full-time employee of an outpatient facility run by a managed-care plan and you have recently received written instructions not to bring up subjects such as bone marrow transplantation in myeloma with patients. The reasoning was that they are outrageously expensive and do not cure the disease, although it may extend survival. The data that they extend survival are not entirely conclusive. In addition, in a private meeting with the medical director, you have been told that the expenditures per patient load of care of each of the physicians would be examined yearly to determine which physician would be promoted.
What do you do?
a. Fully inform the patient about the risks and benefits of bone marrow transplantation.
b. Refer your patient to an oncologist to have this discussion.
c. Transfer the patient to another primary-care provider.
d. Advise the patient to file suit against the managed care plan.
e. Give the patient treatment with melphalan or thalidomide.
f. Inform the patient about bone marrow transplantation if he asks you about it.

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Problem 72

You have a patient who is a 57 year-old man with a history of HIV who has recently been found to have severe coronary artery disease. He has three vessels with more than 90 percent occlusion and left ventricular dysfunction. He is referred for bypass surgery. The cardiothoracic surgeon at your hospital refuses to operate on your patient because he is scared of touching HIV-positive patients for fear of seroconversion. He is already on a beta-blocker, ACE inhibitor, and aspirin.
What should you do?
a. Add calcium channel blockers.
b. Perform angioplasty and stenting.
c. Add clopidogrel.
d. Have his chief of service compel him to do the procedure.
e. Refer the patient to another cardiothoracic surgeon.

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Problem 73

A 60 -year-old male physician who is an internist has had a female patient for the last 20 years. Both lost their spouses several years ago. They start spending time together outside the office. The female patient wants to begin a sexual/romantic relationship with the physician.
What should he tell her?
a. "I can never do that with you, ever."
b. "We can be social, but not sexual."
c. "We need the ethics board's approval first."
d. "I cannot date you and be your doctor-maybe in the future we can date, after you get another doctor."
e. "Because this is your initiative we can begin dating."

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00:53

Problem 74

Which of the following does not need to be reported to the health department?
a. Salmonella
b. Gonorrhea
c. Herpes simplex
d. Tuberculosis
e. Measles

Tate Hilken
Tate Hilken
Numerade Educator

Problem 75

A 38-year-old bus driver is seen in clinic for fever, cough, and sputum with an apical infiltrate as well as sputum positive for acid-fast bacilli. The paticnt is unwilling to take tuberculosis (TB) medications consistently and his sputum remains positive for TB. Directly observed therapy while in his home has failed. You continue to cajole, discuss, encourage, threaten, educate, advise, and beg him to take the medications but he refuses.
What should you do?
a. Nothing, he has a right to autonomy.
b. Arrest the patient and put him in prison.
c. Remove the family from the house.
d. Remove the patient from his job as a bus driver and incarcerate him in a hospital to take medications.
e. Physically restrain the patient and place a nasogastric tube to give the medications.

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02:12

Problem 76

A 27-year-old man is seen by you after the diagnosis of syphilis. As you are administering his treatment you find he is quite promiscuous. You inform him that you must notify the Department of Health and that his sexual contacts need to be treated. He is extremely embarrassed and asks how they will find out.
What should you tell him?
a. You will notify them yourself but you will not give his name.
b. You will notify them and must let them know he was the contact.
c. You will tell the Department of Health but he himself must tell the contacts.
d. The Department of Health will send a letter or call the contacts and let them know they have a serious health issue. They will test and treat the partners but will not reveal his name.
e. He doesn't have a choice; he has to give the names.
f. Their individual doctors will inform the contacts.

Ummatul Choudary
Ummatul Choudary
Numerade Educator

Problem 77

You are the general internist in a large, multispecialty physician group. The officebased pregnancy test on your patient has just become positive and you estimate the gestational age of the fetus at eight weeks. You are a very deeply religious person in a conservative, midwestern city and you are opposed to abortion because you believe life begins at conception. After extensive discussion about the options, your patient asks to be referred for an abortion.
Which of the following is the most appropriate action?
a. Inform the patient that you are morally opposed to abortion and you cannot make the referral.
b. Terminate your relationship with the patient as her physician.
c. Propose social work/psychological evaluation of the patient.
d. Tell her you will make the referral after a 30-day consideration period in which she may change her mind.
e. Refer the patient for the abortion.

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Problem 78

A 16-ycar-old female is in your office because she has just found out she is pregnant. She discusses her options and asks you to refer her for an abortion. She states that her parents do not know she is pregnant and she does not want them to know.
What should you do?
a. Refer her for the abortion without parental notification.
b. Make a "reasonable effort" to contact the parents, but still refer for the abortion if you cannot contact them.
c. Do not refer for abortion without parental consent.
d. Seek a court order declaring her emancipated.
e. Strongly encourage her to discuss the issue with her parents.

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Problem 79

A young husband and wife visit your office to discuss methods of contraception. The wife decides that she wants a tubal ligation for sterilization. Her husband is shocked and strongly objects stating that they have no children. His wife is clear that she wants the sterilization and that she wishes to be referred for the procedure.
What should you do?
a. Refer for the tubal ligation as requested by the wife.
b. Refer after a psychological evaluation.
c. Do not make the referral because she is young.
d. Do not make the referral because she may change her mind.
e. Refer only with the husband's consent.

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Problem 80

A 35-year-old married woman with four children is in your oftice sceking a termination of an unwanted pregnancy in the first trimester. Later in the day after you give the patient the referral, her husband calls and is very distressed because he docs not want the abortion to occur. He very much wants to keep the baby and tells you that he even has a name picked out.
What should you tell him?
a. You will try to talk his wife out of the abortion.
b. You will cancel the procedure immediately.
c. You say you cannot hold up the termination without a court order.
d. You cannot prevent the abortion without paternity testing confirming that he is the father.
e. You say you have an absolute duty to the mother to honor her wishes no matter what his personal feelings are.

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Problem 81

A 30 -year-old woman presents to the clinic during her third trimester. The estimated gestational age of the fetus is 28 weeks and she is seeking an abortion. The patient is generally healthy. An ultrasound of the fetus at 26 weeks and routine genetic testing showed no abnormalities.
What should you tell the patient?
a. It's okay; you will go ahead with the abortion.
b. You will be happy to comply if she can get a court order.
c. No way, third-trimester abortions are prohibited.
d. Legally you can only do it if her life is at risk.
e. No, you can't do it because the fetus is normal.

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Problem 82

A 42-year-old man comes to see you for routine management when you inquire about multiple scratches and contusions as well as a black cyc. He says his wife routinely abuses him and is "beating me up prctty rcgularly, doc." He denies hitting his wife. You see him a few weeks later and he has a new version of the same injuries. You are very concerned about his injuries and you tell him that you are planning to report the injuries. He very clearly states that he does not want these injuries reported.
What do you tell him?
a. You have no choice but to report the injuries because you are a mandatory reporter.
b. You will report the injury only with his consent.
c. You will honor his wish but must report it if there is another episode.
d. There is no spousal abuse reporting.
e. You will report it if you find evidence that the wife was really the attacker.

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Problem 83

A 68 -year-old man attempted suicide by driving his car into a telephone pole with the intentional purpose of ending his life. He was found severely hemorrhaging and in the emergency department he refuses to give his consent for surgery necessary to stop the bleeding. He states that he wants to die. He was recently diagnosed with cancer and refused surgery to remove it. He states that his life had been complete and now, he wishes to end it.
What should you do about the surgery to stop the bleeding now?
a. Follow his stated wish and withhold surgery.
b. Perform the surgery.
c. Obtain a court order to force the surgery.
d. Ask the farnily members for consent.

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01:51

Problem 84

You are a civilian physician and you have been asked to participate in the interrogation of a prisoner suspected of carrying out a terrorist attack. There is very significant evidence to prove his participation in planning subscquent attacks. You have been asked to monitor the patient's oxygen level during a simulated "hanging" and "strangulation" of the patient to determine if supplemental oxygen or intubation is necessary.
What should you do?
a. It is ethically permissible to participate.
b. Participation is permissible only if he has been convicted of the crime.
c. You can participate if there is a court order.
d. You must have a release signed by the military prior to your participation.
e. You cannot participate in the purposeful torture of a prisoner.

Courtney Makdad-Light
Courtney Makdad-Light
Numerade Educator

Problem 85

A group of prisoners is brought to a military hospital in which you work. They are to be screened prior to transfer either to long-term imprisonments or, in some cases, to be released. You notice that several of the patients have burns that look like cigarettes were put out on them as well as several broken bones that have started to heal.
What should you do?
a. Report the injuries as signs of possible torture.
b. Report the injuries only on the patients to be released.
c. If you are a military physician, you should report the injuries.
d. If you are a civilian physician, you should report the injuries.
e. Your only duty is to treat the injuries.

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Problem 86

An elderly patient with multiple medical problems has been admitted to your care in the intensive-care unit. The patient is in a persistent vegetative state sccondary to anoxic encephalopathy and has now devcloped sepsis, hypotension, gastrointestinal bleeding, and respiratory failure requiring intubation. There is no improvement expected in the underlying severe brain damage. Renal failure develops to the point of needing dialysis but you feel the dialysis would be completely futile.
Which of the following is the most appropriate step in management?
a. Hemodialysis
b. Peritoneal dialysis
c. Renal transplantation
d. Give albumin
e. Recommend that dialysis not be performed

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Problem 87

A 33 -year-old female boxer sustains a cervical spine fracture during the welterweight championship match in Las Vegas. She has a fracture of $\mathrm{C} 1$ and $\mathrm{C} 2$ resulting in paralysis from the neck down and is ventilator dependent. She is fully alert and understands her medical condition. There has been no improvement for the last three months and there is no hope of recovery. Her manager is the health-care proxy. She is frustrated but not depressed and is repeatedly and clearly requesting removal from the ventilator. She understands that she will not survive without the ventilator.
What should you do?
a. Remove the ventilator as she requests.
b. Obtain a court order to continue the ventilator.
c. Seek family consensus on removing the ventilator.
d. Seek approval of the health-care proxy.
e. Sedate the patient and continue the ventilator.

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Problem 88

A 48-year-old woman has developed stage III non-Hodgkin's lymphoma and nceds combination chemotherapy for treatment. Without therapy she has no hope of survival beyond a few weeks or months. With therapy she has an 80 percent chance of complete remission. She understands this entirely but insists that she simply does not want the therapy. There is no evidence of depression.
Which of the following is the most appropriate action?
a. Psychiatric evaluation.
b. Ask the family for their opinion.
c. Seek a court-appointed guardian.
d. Honor the patient's wishes.
e. Offer radiotherapy instead.
f. Risk management evaluation.

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Problem 89

An elderly patient with progressive Parkinson's disease comes to see you because of fever, cough, shortness of breath, and sputum production consistent with pneumonia. The patient's Parkinson's disease has been worsening and he has become quite depressed. He has insomnia, early morning waking, and weight loss as well as anhedonia. He is refusing antibiotics and is asking for palliative care only to help him die.
What should you do?
a. Psychiatric evaluation.
b. Sedate the patient.
c. Comply with the patient's wishes.
d. Seek the opinion of the family.
e. Refer to the ethics committee.
f. Comply with the patient's wishes as long as he is DNR.

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Problem 90

A 55 -year-old man has been admitted to the hospital for worsening of his mental status, poor nutrition and inability to eat when fed. The patient has Creutzfeld-Jakob disease and will not likely improve. Over the last several months the patient has told you repearedly that he does not want to be "kept alive as a vegetable" whth artinclat nutrition and hydration by any method. The health-care proxy form specifically states there is to be "no placement of a nasogastric or gastric tube for enteral feeding." The health-care proxy agent is a nurse. The proxy insists that you have a jejunostomy (J-tube) placed for feeding telling you the proxy form only excludes the NG and G-tubes.
What should you do?
a. Place the J-tube.
b. Tell the proxy she needs to get a court order for the J-tube.
c. Tell the proxy she needs an ethics committee evaluation.
d. Do not place any form of tube for artificial nutrition or hydration.
e. Transfer the patient's care to another physician who feels comfortable placing the J-tube.

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Problem 91

A 35 -year-old homosexual man is a victim of a motor vehicle accident in which he sustains head trauma resulting in a large subdural hematoma. His breathing is becoming worse and endotracheal intubation is being considered for mechanical ventilation. His family including his mother as well as his male domestic partner is present. His mother insists on the intubation being performed. The domestic partner is the healthcare agent. The agent states unequivocally that the patient stated both verbally and in writing that he wished never to be placed on a "breathing machine for any purpose."
What should you do?
a. Honor the proxy and do not intubate.
b. Honor the mother's wishes and intubate the patient.
c. Consult the ethics committee.
d. Neurology evaluation.
e. Try intubation for 24-48 hours to see if he recovers.
f. Ask the opinion of the rest of the family.

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Problem 92

A 75 -year-oid man is admitted for a myocardial infarction and a stroke that leaves him in a persistent vegetative state. He is a widow, never designated a health-care proxy, and left no written evidence of his wishes for himself. His nephew and daughter want to continue all forms of therapy including artificial nutrition and hydration. His son and the patient's brother want to stop everything. Both parties believe they know the wishes of the patient.
What should you do?
a. Encourage discussion amongst the family.
b. You, the physician, make the decision in the best interest of the patient.
c. Stop all forms of therapy.
d. Obtain a court order seeking a court-appointed guardian.

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Problem 93

An 84-year-old woman with severe Alzheimer's disease is admitted to your skillednursing facility. She has lost the ability to communicate, is bed-bound, and unable to eat. She did not appoint a proxy and there is no written or clear verbal advance directive of what she wanted for herself. Multiple family members routinely visit her and you are unable to achieve a clear consensus amongst the family of what the patient's wishes were.
What should you do in terms of her care?
a. Follow the wishes of the eldest child.
b. Follow what you think is best.
c. Ask another attending physician's opinion.
d. Ask the hospital administrator for consent.
e. Pursue an ethics committee evaluation.

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Problem 94

A 72-ycar-old man comes to see you because of severe pain from metastatic prostate cancer to the bones. His pain has become progressively more severe and has not responded to localized radiation, flutamide, or goserilin. In addition, numerous pain medications have failed to achieve an acceptable level of analgesia. He nocds morc intense pain management with subcutancous or intravenous opiates. He also has severe COPD and there has been concern about the effect of the opiate medications on the patient's respiratory drive. In other words, the only way to achieve a sufficient amount of pain relief is to use medications that may shorten his life, inadvertently, because of respiratory depression. The patient is fully alert and has the capacity to understand the problem.
Which of the following is the most ethical way to approach his pain management?
a. It is all right as long as he is DNR.
b. It is acceptable as long as the patient understands the risks.
c. It is unacceptable to shorten life with physician-administered medications.
d. Intubate the patient then give the pain medications.
e. Leave him in pain as long as the respiratory drive is not impaired.
f. Offer to end his life with pain medications.

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Problem 94

A 77-year-old woman is admitted with a stroke that renders the patient dependent on endotracheal intubation and mechanical ventilation. There is no hope of recovery and the patient is unable to communicate. There is no health-care proxy and the patient lacks the capacity to understand her problems. Her husband produces a living will signed by the patient on which is written the statement, "I do not wish to be maintained on a ventilator if there is no hope of recovery." He does not recall ever discussing the subject with his wife.
What should you do?
a. Continue the ventilator.
b. Risk management evaluation.
c. Remove the tube and the ventilator.
d. Seek a court order to remove the ventilator.
e. Ask the rest of the family what they think.

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Problem 96

An 84-year-old woman is admitted with abdominal pain. On the second hospital day she becomes febrile, severely hypotensive, and tachycardic from an intestinal perforation. The patient is disoriented with no capacity to understand her medical problems. There is no response to antibiotics, fluids, and dopamine over the next 48 hours and there are signs of significant anoxic encephalopathy. Although there is no health-care proxy, the family is in uniform agreement on what the patient would have wanted for herself had she been able to speak for herself.
Which of the following cannot be stopped at the direction of the family?
a. Ventilator
b. Blood tests
c. Dopamine
d. Fluid and nutrition
e. Nothing

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Problem 97

A 73-year-old man has been brought to a chronic-care facility for long-term ventilator management. The patient has advanced COPD and is unable to be weaned from the ventilator. A tracheostomy has been placed. A nasogastric tube is in place to deliver tube feeding. The patient is fully alert, and understands the situation. He is asking to have the nasogastric tube removed because of discomfort.
What should you tell him?
a. "I will get that tube out right away, sir."
b. "Let's see how much you are able to eat first."
c. "I will pull it out if you let me put in a gastric tube."
d. "Let me talk to your family first."
e. "Do you have a health-care proxy?"
f. "No way dude, we make the decisions around here, not you."
g. "Only if you promise not to sue me."
h. "Are you crazy? Do you think I am going to let MY patient starve to death?"

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Problem 98

A 47-year-old man with end-stage renal failure has asked you to stop his dialysis. The patient fully understands that he will die if he stops dialysis for more than a few days or weeks. He is not depressed and not encephalopathic.
What should you tell him?
a. "I need a court order first."
b. "I am sorry; I don't feel comfortable doing that."
c. "I can't do that. Physician-assisted suicide is not ethical."
d. "I will stop when we get you a kidney transplant."
e. "You will feel better if I sedate you so that you stop disagreeing with me."
f. "Although I disagree with your decision, I will stop the dialysis."
g. "I cannot do that. We already started dialysis. Now we have to continue."
h. "Not until you pay your bill."

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Problem 99

A 92-year-old man with Alzheimer's disease has been admitted to the hospital with aspiration pneumonia. He is on a ventilator and has a nasogastric tube in place. He does not have the capacity to understand his medial condition. You find a living will in an old chart that says "No heroic measures," "I want to be DNR," and "I wish to be kept comfortable." There is no proxy and there is no family available with whom you can discuss the matter. He has no private physician with whom you can discuss the case.
What should you do regarding the ventilator and tube feeding?
a. Continue both for now.
b. Remove the ventilator and the tube feeding.
c. Remove the nasogastric tube but continue the ventilator.
d. Seek a court-appointed guardian.
e. Decide what you think is best for the patient.

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Problem 100

Which of the following best approximates the role of the health-care proxy?
a. To explain the physician's plan to the family
b. To convey the wishes of the family to the medical team
c. To communicate and carry out the wishes of the patient
d. To make decisions based on what he or she genuinely believes is the best interests of the patient
e. To carry out the financial decisions of the patient when he or she loses the capacity to speak

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02:29

Problem 101

A 34-year-old woman with three children presents pregnant at 20 weeks of gestational age with anemia and severe gastrointestinal bleeding requiring transfusion to save her life. She is a Jehovah's Witness and she is refusing blood transfusion.
What should you do?
a. Honor her wishes; no transfusion.
b. No transfusion now, but the transfusion is mandatory after the second trimester when the fetus is a potentially viable baby.
c. Transfuse the patient.
d. Seek a court order mandating the transfusion.
e. Get consent of the father of the baby.

Bryan Valdivia
Bryan Valdivia
Numerade Educator

Problem 102

Mr. Barber is a 58 -year old man who has a cardiac arrest after surgery. He suffers permanent brain damage from anoxic encephalopathy. He is in a permanent vegetative state and ventilator dependent. His wife and eight children are present in the hospital and request in writing for the ventilator to be stopped. After its removal he continues to breath. They are asking for the intravenous lines to be removed and all blood testing to be stopped. They agree that this was his wish for himself. He did not leave a written advance directive such as a living will but he clearly told his family, "I don't want to be a vegetable." He never designated a health-care proxy.
What should you do?
a. Refer the case to the ethics committee.
b. Obtain a court order.
c. Refuse; you cannot ethically do this.
d. Transfer the care of the patient to another physician.
e. Remove the IV lines and stop blood draws as they wish.
f. You can withhold additional new treatments and tests, but you cannot stop those already started.

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