Withholding-Withdrawal of Treatment
All adults with the capacity to understand their own medical conditions have the right to decide what treatments they wish to receive. There is no ethical or legal distinction between withholding and withdrawal of medical treatment.
There may be an emotional distinction between withholding respiratory assistance and stopping it after it has started, but there is no ethical distinction between the two.
When a treating physician suspects anxiety or depression, or any other mental health issue that may interfere with a patient’s decision-making process, a psychiatric consult is prudent.
Withdrawing Treatment from Patients Without Decisional Capacity
It is important to note an important distinction between competence and decisional capacity.
Decisional capacity is a clinical determination that a patient’s physician is medically qualified and legally authorized to make. Moreover, while many physicians seek a psychiatric consult (when readily available) prior to making such determinations, one is not required by law. Clinical literature also suggests, however, that the assessment of decisional capacity is not a skill that many physicians possess.
Diagnosis of depression does not preclude decisional capacity. When making such determinations, physicians should also be aware of a fundamental principle of American jurisprudence that every adult is presumed to possess decisional capacity, and the burden of persuasion falls upon anyone who asserts the contrary.
Q19 An 82-year-old white female is admitted with shortness of breath, hyperkalemia and metabolic acidosis. She has end-stage renal disease and based on the volume overload and emergency hemodialysis is indicated. Risks, benefits, and likelihood of death are discussed with the patient and she verbalizes understanding. She refuses dialysis and states, “I have had a good life and I am at peace with my lord.” Her medical chart contains an advanced directive and appoints her son as the surrogate decision-maker. What should be your next step?
A-withhold hemodialysis B- order hemodialysis C- discuss hemodialysis with patient’s son
D-assess the patient’s decision-making capacity
Q20 A 28-year-old male sustains a large subdural hematoma post motor vehicle accident. His oxygen saturation is dropping, and intubation is imminent. The patient’s mother insists on all measures to be taken to save his life. However, the male partner is the healthcare agent. He reports that the patient had repeatedly stated that he would never want to be on a ventilator for any reason. What is the best next step?
A- Obtain a full neurological evaluation B- Consult the ethics committee C- Honor the mother’s wishes and intubate D- Honor the agent of proxy and do not intubate
A method by which a patient communicates his wishes for his/her healthcare in advance of becoming unable to make decisions for him/herself. The advance directive is part of the concept of autonomy. Thus, last-minute decision-making processes, emotionally driven by family members, can be avoided.
Living Will, Health-Care Proxy
A living will is a written form of advance directive that outlines the care that a patient would want for him/herself if he/she were to lose the ability to communicate, or the capacity to understand his/her medical problems.
The living will is be usable when specific tests and treatments are outlined. A living will would overrule the wishes of the family, because the living will communicates the patient’s own wishes. Unfortunately, living wills often lack specificity, and furthermore, most patients do not have an advance directive order. A united family often makes the decisions for the patient.
In absence of clear advance directive, and a family disagreement on what the patient wanted for himself or herself, the recourse is to refer to the ethics committee and the courts.
“Do Not Resuscitate” (DNR) Orders
A “Do Not Resuscitate” (DNR) order means, if the patient dies, not to perform CPR, cardioversion, or antiarrhythmics. “DNR” is not a declaration of pending death.
A patient should receive all necessary medical procedures, and DNR should be viewed purely as the endpoint of therapies. A DNR patient should receive all medical attention, all but CPR, etc.
Q21 A 68-year-old female presents to the emergency department with shortness of breath. Past medical history is significant for diabetes, coronary artery disease, and hypertension. She has a DNR/DNI status. Lab results reveal severe hyperkalemia and the patient is in renal failure.
What should be the next step? A-Admit to the general medical floor with medications. B-Dialyze the patient and admit to ICU, avoid intubation. C-Inform the patient that the DNR/DNI does not allow him to be admitted to hospital.
D-Inform the patient that she needs to revoke her DNR/DNI status for treatment.
Q22 A 70-year-old man is admitted for acute appendicitis. This patient has a DNR status since his previous admission. He needs an urgent appendectomy. He still wishes to maintain the DNR. How should you explain the scenario to the patient?
A -Reverse the DNR order to attempt the surgery. B -DNR is acceptable if there is no intubation. C -DNR does not preclude surgery, proceed with anticipated surgery. E -No surgery can be performed patient due to the patient’s DNR status.
Q23 A 72-year-old patient advises his family that he would never want to be a vegetable attached to a breathing machine. What is the most likely perception of the treating physician?
A -The patient does not want any heroics measures. B- Disconnect the respirator if the patient is ever in terminal state. C- Allow the patient to die in a comatose state. D-The physician should request more clarification for advanced care planning.
Q24- An elderly man with congestive heart failure presents to the emergency room alert and oriented complaining of shortness of breath. Chest X-Ray reveals that he has pneumonia. He starts desaturating in the emergency room and he has an impending respiratory failure, though still awake and alert. A copy of living will is in his chart clearly states that he wants
no “invasive” medical procedures that may only prolong his death. Should mechanical ventilation be instituted?
A-A living will, or other advance directive obviates the responsibility to involve a competent patient in medical decision making.
B-An awake and alert patient overrides all advance directives, his living will is therefore irrelevant to medical decision making.
C-Risks and benefits of mechanical ventilation need not be presented to the patient because of the presence of a valid living will.
D-If the patient refuses mechanical ventilation therapy, his wishes should not be honored because he is in the emergency room.
The artificial administration of fluids and nutrition is a medical procedure and treatment that can be accepted or refused by a competent adult. “Artificial administration” basically refers to any form of nutrition other than eating through the mouth. “Artificial” specifically means feedings or fluids administered by nasogastric, gastric, or jejunostomy tube placement. “Artificial nutrition” and intravenously administered nutrition such as total parenteral nutrition is also referred to as hyperalimentation.
Patients who cannot speak are a challenge in medical decision making. Nutrition is the single most difficult issue in terms of treatment cessation. Physicians can never withhold simple nutrition like food to eat and water to drink. Hence, clear evidence of a patient’s wishes regarding artificial nutrition is clearly important. Again, a lack of clarity in a patient’s wishes mandates a referral to the Ethics Committee.
Treatments, investigations, and tests must ultimately benefit the patient, and should not be administered to satisfy the curiosity of family members. Certainty in withholding or withdrawing therapy based on futility is paramount.
Q25 An elderly man residing in a nursing home is admitted to the medical floor with pneumonia. He is awake but grossly demented. He can only utter sound yet interacts and acknowledges family members. The admitting resident states that treating his pneumonia with antibiotics would be “futile” and suggests informing the family.
What is the proper approach?
A-Treating the patient’s pneumonia with antibiotics stands a reasonable chance of success. B-Patient is severely demented, treating his pneumonia with antibiotics would be “futile”.
C-The treatment of pneumonia in this severely demented patient is futile because antibiotics may be ineffective.
D-None of the above.
Physician Assisted Suicide
In physician-assisted suicide, the physician provides the patient with the means of ending his/her own life. The physician does not actually administer the substance that ends the patient’s life. Despite much controversy around the topic, physician-assisted suicide is considered unethical.
Euthanasia means that the healthcare worker is prescribing and administering the method of death. In the United States, euthanasia is illegal.
Intentional high-dose opiates in order to end a patient’s life is wrong, but it is acceptable to give pain medications even if they might decrease a patient’s respiratory drive, in order to ultimately decrease pain and suffering. A physician cannot leave a patient to simply suffer, as the ethical duty is to relieve pain. The key, of course, is the intention behind the chosen course of action.
Organ donation is a voluntary act. No one, and no court of law, has jurisdiction to mandate organ donation.
The organ donor network should obtain consent for an organ donation, not the medical team, as the priority of the medical team is not to obtain organs.
Organ donor cards provide the healthcare team with an indication of a patient’s wishes for donation. Family members’ objections can overrule the organ donor card.
Q26 A 44-year-old male responds to an ad, where he is offered a large sum for his kidney. This will help him with his desperate financial dilemma. He is requesting a full medical evaluation to be approved for the procedure.
What should be your response?
A-It is unacceptable to receive any money for solid organs donation.
B-It is acceptable if the recipient is in true need for the organ. C-It is okay if the donor’s remaining kidney is healthy. D-Profiting from the donation is unacceptable.
Q27 A man arrives at the hospital post a crushing MVA; he meets all criteria as brain-dead. He has an organ donor card indicating his wishes to donate. The organ donor team contacts the family. The family refuses to sign a consent for donation.
What should be immediate considerations?A-Seek a court order to overrule family.B-Honor family’s wishes against donation.C-Remove the organs, regardless of family’s wishes.
D-Wait for complete cardiac arrest, then remove the organs.