Anonymous
08-12-2004, 10:39 PM
Credit goes to my friend, Valium.
RULES OF ETHICS
HOW TO DEAL WITH A DYING PATIENT:
1) Tell the patient EVERYTHING. There is no excuse for not doing so. If you know, the patient knows.
2) DO NOT GIVE FALSE HOPE
3) Allow the person to talk about his feelings
4) Kept he patient involved in social activities
5) Avoid social isolation
GENERAL RULES:
1) “Substituted judgment”: when a patient cannot make a decision, the decision is made based on what is thought WOULD BE that person’s choice. The decision is finally made by who is most likely to represent the patient’s own wishes (not necessarily who is closest next of kin).
2) “Best interest standard”: trying to determine what a never-competent patient would have wanted is practically impossible.
When you are not clear about the patient’s wishes, you should make the decision as a dispassionate, rational observer: do what a rational person would do. It is not your personal preference is. DO WHAT MOST PEOPLE WOULD WANT in this circumstance. “What would a jury of 12 people do if they knew what I know?”
Who makes the decision is not really important: anybody using the best interest standard should arrive to the same decision.
You must set aside your personal preferences: like strong religious beliefs (that is considered irrelevant)
As a general rule, parents cannot withhold treatment from their children. Yet, in Infant Doe’s case, they did. In this case, the best interest standard rule was applied.
3) Patients decide over their own bodies: The patient ALWAYS MAKES THE DECISION.
This was decided over the ROE vs WADE case in 1973, the case that made abortion legal. The issue will never be over abortion in the USMLE, but it illustrates the principle that governs medicine in the US: the patient always decides, and the only thing a doctor can do is lay out the possibilities.
SPECIFIC RULES:
Rule #1: Competent patients have the right to refuse medical treatment, no matter what.
Rule #2: Assume that the patient is competent unless clear behavioral evidence indicates otherwise.
-Drunk, schizophrenia, Alzheimer’s: these are all medical dg. DIAGNOSIS SAYS NOTHING ABOUT THE LEGAL COMPETENCE OF A PERSON!!!
Competency can ONLY be decided by a COURT OF LAW: it is not a medical dg, it is not a blood alcohol level!
Clear behavioral evidence of incompetence:
Attempted suicide
Patient is grossly and evidently psychotic and dysfunctional
Patient’s physical or mental state prevents communication
However, when in doubt, assume competency!
Rule #3: Decision-making should occur in clinical setting if possible, without going to court. Normally, the USMLE will want YOU to make the decision: try to avoid the answer that says “go to court”, unless it is clearly stated that the guardian (ex: parent of a sick child) is NOT acting in the patient’s best interest. And that is only if the case is not an emergency: if it can wait going to court.
Rule #4: When surrogates make decisions for a patient, they should use the following criteria and in this order:
1) Patient expressing wishes in the past: what historically did the patient say in the past? (wish for organ donation expressed to relative, for example)
2) What would the patient want? : Substituted judgment
3) Best interest standard: what would most people want
Rule #5: If patient is incompetent, physician may rely on advance directives
Directives that a patient can leave for his doctor before becoming incompetent:
- Can be oral directive from patient to his doctor: does NOT necessarily have to be a written document.
- Can be living will: expression in writing, notarized, by the patient.
- Health powered attorney: person that was named by the patient to represent him. TREAT THIS PERSON AS THE PATIENT HIMSELF, IN TERMS OF DECISIONS: this person is the VOICE of the patient: a health powered attorney BEATS ALL OTHER CHOICES ON THE USMLE (it is the patient talking to you).
Rule #6: Feeding tube is a medical treatment and can be withdrawn at the patient's request. A competent patient has the right to refuse hydration and nutrition. Period.
In the case of anorexia nervosa: if the patient is a minor: not legally competent. If NOT a minor: go to court.
Refusing food and water: may seem close to euthanasia, but on the exam this is accepted.
Rule #7: Do nothing to actively assist the patient to die sooner. Do not ACTIVELY do anything (as opposed to number 6)
Rule #8: the physician decides when the patient is dead.
Futile treatment: means a treatment that is not AND WILL NOT improve anything. Still, if the patient or the family want the treatment to continue: it is not YOUR decision, it is the patient’s or the patient’s family.
In case of clear cortical death: even if the family is hoping for a special doctor to arrive, for a special treatment to come: CALL THE DEATH.
Rule #9: Never abandon a patient: even if they can’t pay you, even if you don’t like the patient. If you simply CANNOT continue to be the doctor to this patient: you need to arrange that he will have care and make sure that they are getting it.
Never, ever threat to abandon your patient (not even if you are doing it to make sure they follow treatment).
Rule #10: Always obtain informed consent: before you do ANYTHING!!!
Informed consent can be oral.
The patient can revoke written consent orally, at any moment
Of the patient signs “consent” without reading it: it is NOT INFORMED CONSENT
Informed consent: means that the patient understands:
1) Nature of the procedure
2) Purpose or rationale
3) Benefits of treatment or procedure
4) Risks
5) Availability of other alternatives
“GAG CLAUSES”: you work for an institution that tells you not to discuss certain procedures or possibilities. THEY ARE ILLEGAL.
Exceptions to informed consent:
1) Emergency situation
2) Waiver by the patient: the patient says it’s OK not to know what is going to happen (exploratory surgery, drug undergoing trial to know side effects)
DO NOT ASSUME YOU HAVE A WAIVER UNLESS THE USMLE TELLS YOU.
3) Patient is incompetent
4) Therapeutic privilege: doctors have the right and obligation to deprive the patient of their autonomy in the interest of the patient and other people. Ex: patient on PCP, violent and dangerous: put him on restraints!
Rule #11: Special rules apply with children
Rule #12: Parents cannot withhold life- or limb-saving treatment from their children
Rule #13: For the purposes of the USMLE, issues governed by laws that vary widely across states cannot be tested
Rule #14: Good Samaritan Laws limit liability when physicians help at accidents
Rule #15: Confidentiality is absolute
Rule #16: Patients should be given the chance to state DNR (Do Not Resuscitate) orders, and physicians should follow them
Rule #17: Committed mentally ill patients retain their rights
Rule #18: Detain patients to protect them or others.
Rule #19: Remove from patient contact health care professionals who pose risk to patients
Rule #20: Focus on what is the best ethical conduct, not simply the letter of the law
I looked it up:
rule # 8 says this:
- if there are no more treatment options (if the patient is cortically dead), and the family insists in treatment?: if there are no options and there is nothing the physician can do, it is his duty to stop the treatment. (The USMLE wants you to be able to make decisions when the patient is DEAD)
- if the physician thinks tratment is futile and the patient won't improve, but the patient (or surrogate) insists on continued treatment: then treatment must continue.
rule # 17:
Commited mentally ill adults legally are entitled to the following:
- they must have treatment available
- they can refuse treatment
- they can command a jury trial to determine sanity
They lose only the civil liberty to come and go
they retain their competence for everything UNLESS A COURT OF LAW DECIDES they are incompetent.
The underlying rule here is that no matter what the psychiatric diagnosis is, treat the patient as you would any other competent person (unless they show signs of clear incompetence, stated on #2)
rule #20: Focus on what is most ethical. USMLE wants you to pick the answer where there are no doubts that it is the most ethical thing to do. In other words, don't worry about being fired, sued or that your hospital may go to shreds if you do the "right thing". ACT NOT AS A LAWYER WOULD, BUT AS MOTHER THERESA WOULD.
There is also something interesting that they pointed out: what do you do if you find out a collegue or fellow resident is having a substance abuse problem? Who do you talk to?
RULES:
- talk to the collegue and REMOVE him from patient care
- if there is a direct employer or supervisor (like your residency program director) : TELL THE SUPERVISOR. Failure to do so will endanger patients, and will ALWAYS be the worong answer on the USMLE.
What they meant was: the best way to get someone to treatment is if their employer forces them to: if they are afraid to lose their job. So don;t waste time talking to the person or the family or anyone: go to the supervisor.
RULES OF ETHICS
HOW TO DEAL WITH A DYING PATIENT:
1) Tell the patient EVERYTHING. There is no excuse for not doing so. If you know, the patient knows.
2) DO NOT GIVE FALSE HOPE
3) Allow the person to talk about his feelings
4) Kept he patient involved in social activities
5) Avoid social isolation
GENERAL RULES:
1) “Substituted judgment”: when a patient cannot make a decision, the decision is made based on what is thought WOULD BE that person’s choice. The decision is finally made by who is most likely to represent the patient’s own wishes (not necessarily who is closest next of kin).
2) “Best interest standard”: trying to determine what a never-competent patient would have wanted is practically impossible.
When you are not clear about the patient’s wishes, you should make the decision as a dispassionate, rational observer: do what a rational person would do. It is not your personal preference is. DO WHAT MOST PEOPLE WOULD WANT in this circumstance. “What would a jury of 12 people do if they knew what I know?”
Who makes the decision is not really important: anybody using the best interest standard should arrive to the same decision.
You must set aside your personal preferences: like strong religious beliefs (that is considered irrelevant)
As a general rule, parents cannot withhold treatment from their children. Yet, in Infant Doe’s case, they did. In this case, the best interest standard rule was applied.
3) Patients decide over their own bodies: The patient ALWAYS MAKES THE DECISION.
This was decided over the ROE vs WADE case in 1973, the case that made abortion legal. The issue will never be over abortion in the USMLE, but it illustrates the principle that governs medicine in the US: the patient always decides, and the only thing a doctor can do is lay out the possibilities.
SPECIFIC RULES:
Rule #1: Competent patients have the right to refuse medical treatment, no matter what.
Rule #2: Assume that the patient is competent unless clear behavioral evidence indicates otherwise.
-Drunk, schizophrenia, Alzheimer’s: these are all medical dg. DIAGNOSIS SAYS NOTHING ABOUT THE LEGAL COMPETENCE OF A PERSON!!!
Competency can ONLY be decided by a COURT OF LAW: it is not a medical dg, it is not a blood alcohol level!
Clear behavioral evidence of incompetence:
Attempted suicide
Patient is grossly and evidently psychotic and dysfunctional
Patient’s physical or mental state prevents communication
However, when in doubt, assume competency!
Rule #3: Decision-making should occur in clinical setting if possible, without going to court. Normally, the USMLE will want YOU to make the decision: try to avoid the answer that says “go to court”, unless it is clearly stated that the guardian (ex: parent of a sick child) is NOT acting in the patient’s best interest. And that is only if the case is not an emergency: if it can wait going to court.
Rule #4: When surrogates make decisions for a patient, they should use the following criteria and in this order:
1) Patient expressing wishes in the past: what historically did the patient say in the past? (wish for organ donation expressed to relative, for example)
2) What would the patient want? : Substituted judgment
3) Best interest standard: what would most people want
Rule #5: If patient is incompetent, physician may rely on advance directives
Directives that a patient can leave for his doctor before becoming incompetent:
- Can be oral directive from patient to his doctor: does NOT necessarily have to be a written document.
- Can be living will: expression in writing, notarized, by the patient.
- Health powered attorney: person that was named by the patient to represent him. TREAT THIS PERSON AS THE PATIENT HIMSELF, IN TERMS OF DECISIONS: this person is the VOICE of the patient: a health powered attorney BEATS ALL OTHER CHOICES ON THE USMLE (it is the patient talking to you).
Rule #6: Feeding tube is a medical treatment and can be withdrawn at the patient's request. A competent patient has the right to refuse hydration and nutrition. Period.
In the case of anorexia nervosa: if the patient is a minor: not legally competent. If NOT a minor: go to court.
Refusing food and water: may seem close to euthanasia, but on the exam this is accepted.
Rule #7: Do nothing to actively assist the patient to die sooner. Do not ACTIVELY do anything (as opposed to number 6)
Rule #8: the physician decides when the patient is dead.
Futile treatment: means a treatment that is not AND WILL NOT improve anything. Still, if the patient or the family want the treatment to continue: it is not YOUR decision, it is the patient’s or the patient’s family.
In case of clear cortical death: even if the family is hoping for a special doctor to arrive, for a special treatment to come: CALL THE DEATH.
Rule #9: Never abandon a patient: even if they can’t pay you, even if you don’t like the patient. If you simply CANNOT continue to be the doctor to this patient: you need to arrange that he will have care and make sure that they are getting it.
Never, ever threat to abandon your patient (not even if you are doing it to make sure they follow treatment).
Rule #10: Always obtain informed consent: before you do ANYTHING!!!
Informed consent can be oral.
The patient can revoke written consent orally, at any moment
Of the patient signs “consent” without reading it: it is NOT INFORMED CONSENT
Informed consent: means that the patient understands:
1) Nature of the procedure
2) Purpose or rationale
3) Benefits of treatment or procedure
4) Risks
5) Availability of other alternatives
“GAG CLAUSES”: you work for an institution that tells you not to discuss certain procedures or possibilities. THEY ARE ILLEGAL.
Exceptions to informed consent:
1) Emergency situation
2) Waiver by the patient: the patient says it’s OK not to know what is going to happen (exploratory surgery, drug undergoing trial to know side effects)
DO NOT ASSUME YOU HAVE A WAIVER UNLESS THE USMLE TELLS YOU.
3) Patient is incompetent
4) Therapeutic privilege: doctors have the right and obligation to deprive the patient of their autonomy in the interest of the patient and other people. Ex: patient on PCP, violent and dangerous: put him on restraints!
Rule #11: Special rules apply with children
Rule #12: Parents cannot withhold life- or limb-saving treatment from their children
Rule #13: For the purposes of the USMLE, issues governed by laws that vary widely across states cannot be tested
Rule #14: Good Samaritan Laws limit liability when physicians help at accidents
Rule #15: Confidentiality is absolute
Rule #16: Patients should be given the chance to state DNR (Do Not Resuscitate) orders, and physicians should follow them
Rule #17: Committed mentally ill patients retain their rights
Rule #18: Detain patients to protect them or others.
Rule #19: Remove from patient contact health care professionals who pose risk to patients
Rule #20: Focus on what is the best ethical conduct, not simply the letter of the law
I looked it up:
rule # 8 says this:
- if there are no more treatment options (if the patient is cortically dead), and the family insists in treatment?: if there are no options and there is nothing the physician can do, it is his duty to stop the treatment. (The USMLE wants you to be able to make decisions when the patient is DEAD)
- if the physician thinks tratment is futile and the patient won't improve, but the patient (or surrogate) insists on continued treatment: then treatment must continue.
rule # 17:
Commited mentally ill adults legally are entitled to the following:
- they must have treatment available
- they can refuse treatment
- they can command a jury trial to determine sanity
They lose only the civil liberty to come and go
they retain their competence for everything UNLESS A COURT OF LAW DECIDES they are incompetent.
The underlying rule here is that no matter what the psychiatric diagnosis is, treat the patient as you would any other competent person (unless they show signs of clear incompetence, stated on #2)
rule #20: Focus on what is most ethical. USMLE wants you to pick the answer where there are no doubts that it is the most ethical thing to do. In other words, don't worry about being fired, sued or that your hospital may go to shreds if you do the "right thing". ACT NOT AS A LAWYER WOULD, BUT AS MOTHER THERESA WOULD.
There is also something interesting that they pointed out: what do you do if you find out a collegue or fellow resident is having a substance abuse problem? Who do you talk to?
RULES:
- talk to the collegue and REMOVE him from patient care
- if there is a direct employer or supervisor (like your residency program director) : TELL THE SUPERVISOR. Failure to do so will endanger patients, and will ALWAYS be the worong answer on the USMLE.
What they meant was: the best way to get someone to treatment is if their employer forces them to: if they are afraid to lose their job. So don;t waste time talking to the person or the family or anyone: go to the supervisor.