Ethics Public Health PDF

USMLE ENDPOINT ETHICS & Public health
 Most important 4 major principles that guide medical ethics are:

 Autonomy.
 Beneficence.
 Non-maleficence.
 Justice.
AUTONOMY
 Most important US ethical principle. Absolute right of all competent adult
patients to make decisions about their own healthcare.
 Patient has “autonomy” over their own body
 Autonomy is the most frequently tested subject on USMLE.
 The following is the most fundamental ethical concept:
 An adult with the capacity to understand his or her medical problems
can refuse any therapy or test.
 It does not matter if the treatment or test is simple, safe, and risk-free. It
does not matter if the person will die without the treatment or test. The
patient can refuse the treatment or test.
 Respecting autonomy is more important than trying to do the right thing for a
patient. Trying to do the right thing for a patient is called beneficence.
 When patients decline medical care:
 Okay to ask why they are declining.
 Avoid judging, threatening, or scolding:
 “You may die if you make this choice…”
 “This choice is a mistake…”
 “You should not do this…”
A 35-year-old mentally intact patient is refusing radiation for a stage I lymphoma. The treatment
has a 95 percent chance of cure and virtually no adverse effects. What do you do?
A. Try to discuss it with him.

B. Honor his wishes.
C. Order a psychiatric consultation.
D. Arrange an ethics committee consultation.
E. Get a court order.
Answer: A. Even though an adult patient with capacity can refuse anything, USMLE wants you
to discuss things first. Even though you may eventually honor his wishes, if an answer says
“meet,” “confer,” or “discuss,” then do that first.
Dr Ahmed Shebl Page 1

Discharge against medical advice (AMA)

 Every effort should be made to prevent patients with high-risk medical conditions from
refusing treatment.
 This includes fully explaining the patient's medical condition, proposed treatments, and
the disease-specific risks of refusing treatment and leaving the hospital, including the
risk of death. The physician should ask the patient to explain the reason for refusing
treatment and address any modifiable external influences (eg, financial concerns, social
or work responsibilities).
 If the patient continues to insist on discharge, the physician must assess the patient's
decision-making capacity to refuse care. Decision-making capacity requires that the
patient demonstrate an understanding of the proposed treatment, can state the risks and
benefits of refusing treatment, and can communicate a clear rationale for the decision.
Patients determined to have decision-making capacity should be discharged against
medical advice. If a patient lacks decision-making capacity, the patient cannot be
discharged.
Adult patient refuses care because it is against their religious

beliefs
 Work with patient by either explaining treatment or pursuing alternative treatment.
 However physician should never force a competent adult to receive care contrary to their
religious beliefs.
Knowledge of an incurable disease may result in significant

psychological distress.
 Including depression, anxiety, and suicide.
 If the patient is not psychologically ready to receive the information, the physician
should respect his decision but leave an opening for the patient to change his
mind. Additional counseling to support and help the patient come to a decision
should be offered.
Psychotic patient is experiencing command auditory

hallucinations telling him to hurt himself or others:
 Efforts should be made to hospitalize the patient voluntarily, but involuntary
commitment should be implemented if he refuses.

A patient refuses knowledge of his diagnosis

 Just as competent patients have the right to refuse medical care and interventions
if they wish, competent patients also have the right to refuse knowledge of their
diagnosis or other facts of their medical condition if they wish.
 Efforts should be made to clarify potential diagnoses and be sure that the patient who is
refusing knowledge of their medical information knows the facts about issues that are
presently pending and knows possible risks of refusing this knowledge.
 Effort should also be made to identify a surrogate decision maker for the patient so
medical care can proceed.
A patient with mental illness refusing treatment

 Patients, who are confined to mental health facilities, whether voluntarily or
involuntarily, have the right to receive treatment and to refuse treatment (e.g.,
medication, electroconvulsive therapy).
 Patients who are actively psychotic or suicidal, however, generally cannot refuse
treatment aimed at stabilizing their condition.
30 year-old patient wants to undergo bilateral tubal ligation

 Consent of a married or unmarried significant other is not required for a patient to
undergo any type of procedure, including sterilization.
 Physicians should counsel the patient regarding the risks and benefits of and alternatives
to, any procedure or treatment.
 Spousal consent is not required for the patient to undergo tubal ligation.
BENEFICENCE
 Providers must act in best interests of patients.
 Usually superseded by autonomy:
 Patients may choose to act against their interests.
 Example: Patient may decline life-saving medical care.

NON-MALEFICENCE
 Do no harm.
 Always balanced against beneficence:
 Risk versus benefits.
 Some harmful actions (surgery) are beneficial.
Patient desires unnecessary procedure:

 Attempt to understand why patient wants procedure
 Address underlying concerns.
 Do not refuse to see patient or refer them.
 Avoid performing unnecessary procedures, for patients with Illness Anxiety
Disorder, schedule routine short visits.
Patient desires antibiotics for viral illness:
1) Do not prescribe antibiotics either immediately or with instructions for patient
to fill prescription if they get worse/don’t get better.
2) Explain to them the potential harms of taking antibiotics unnecessarily.
When an ill patient requests your prayers in an acute setting:
 It is appropriate to offer your personal support without interjecting your personal beliefs
into the interaction.
 The overriding goal in these situations is to do no harm. This can be achieved by not
disagreeing with the patient, not entering into a religious debate with them, and not
displacing responsibility for the care of the patient onto others.
A patient is asking the doctor for herbal medicine which is banned by

FDA.
 The best approach in this situation is to explain the safety risks and then document
counseling the patient to avoid this medication and her refusal to do so.
 It is also important to maintain the doctor-patient relationship and follow the patient
closely to monitor for adverse effects due to this medication.
A patient is using a weight loss drugs from internet that contains

caffeine.
 Physicians should routinely ask their patients about the use of herbal preparations
and nutritional supplements and advise them on the quality, safety and efficacy of
these products.

JUSTICE
 Treat patients fairly and equally.
 Also use health resources equitably.
 EXAMPLE in Triage:
 Form of “distributive justice”
 Care delivered fairly to all.
DECISION MAKING CAPACITY

 Ability to comprehend information about illness and treatment options and make
choices in keeping with personal values.
 Usually used regarding a specific choice.
 Example: Patient has capacity to consent to surgery.
 Required for informed consent.
 Key component of ethical principle of autonomy.
Competency
 Legal judgment; different from decision-making capacity.
 Determined by a court/judge.
 Clinicians can determine decision-making capacity.
 An adult who is alert and not mentally handicapped is deemed to have capacity to
understand her own medical procedures and treatments.
 Mini-Mental State Examination (MMSE) correlates to some extent with clinicians’
evaluation of capacity. While scores below 20 on the MiniMental State Examination indicate
significant cognitive impairment, the test score alone cannot be used to declare a patient
incompetent.
Requirements for decision making capacity:

 Patient is ≥ 18 years old or legally emancipated.
 Decision not clouded by a mood disorder.
 No altered mental status: • Intoxication • Delirium • Psychosis.

Intellectual Disability
 Patients with Down syndrome, Fragile X.
 Does not automatically preclude decision making.
 Disabled patient must meet usual requirements: • Understanding • Expression of a
choice • Appreciation of facts • Reasoning.
Legal guardian:
 If the patient has already been evaluated for general competency and has a legal
guardian. Parents and legal guardians may request sterilization of an
intellectually disabled person in their care due to reasonable concerns about
these individuals' ability to raise a child.
 However, even when incompetency is legally determined, as a case (mother is
legal guardian), forced sterilization is considered unethical.
 Involuntary sterilization violates a woman's right to privacy, her reproductive
rights, and her bodily integrity.
 Women with intellectual disabilities must freely consent to their own
sterilization.
 Non-permanent and less invasive methods of contraception should be discussed
instead.

PSYCHIATRY CONSULTATION
 “Psychiatry consultation” is the answer when a patient‟s capacity to understand
is not clear.
 A psychiatry consultation is not necessary in the following situations:
 The patient is clearly competent.
 The patient is in a coma and clearly does not have the capacity to
understand.
MINORS
 Minors, by definition, are not determined to have the capacity to understand
their medical problems until the age of 18.
 Emancipation means that although the patient is under 18, he can make his own
decisions.
 Emancipated minors are living independently and self-supporting, married, or
in the military.
 Partial emancipation is considered to be present for the following issues:
 Sex
 Reproductive health
 Substance abuse
 If the patient is a minor and seeks treatment for contraception, sexually transmitted
diseases, HIV, or prenatal care, she is partially emancipated. In other words, she
can make these decisions on her own, and her privacy is to be respected like that
of an adult. An exception is abortion: 36 states have parental notification laws for
abortion.
 How does USMLE get around issues that are not universal across the United
States? For such questions, the answer is a safe, universally correct answer, such
as “Recommend that the patient inform the parents.”
 UW: Stable minor but life-threatening condition and parents not agreeing to
treatment  hospital ethics committee, social services, and hospital risk
management can also assist  in some cases parents may agree but if they
continue to refuse treatment  obtain court orders to give treatment.
 BRS: A minor can be compelled to donate tissue (e.g. bone marrow, skin) to a
close relative if he or she:
1. Is the only appropriate source AND
2. Will not be harmed seriously by the donation.

 BRS: Genetic testing for carrier status should be deferred until either the child
reaches maturity, or the child needs to make reproductive decisions.
LIMITATIONS ON THE ABILITY OF PARENTS TO

REFUSE TREATMENT FOR A MINOR
 Parents cannot refuse lifesaving therapy for minors.
 For example, if a blood transfusion would be lifesaving, the parents cannot refuse.
Doing so would be considered child abuse. Jehovah’s Witnesses may refuse
therapy for themselves but not for a child.
 UW: The wish of individuals and family not to know genetic information,
including test results, should be respected, except in testing of newborn babies or
children for treatable conditions.

INFORMED CONSENT
 Informed consent is based on autonomy. Only a fully informed patient with the
capacity to understand the issues can grant “informed consent.” For the consent to
be informed, the patient must be informed as follows:
 The patient is informed of the benefits of the procedure (how will it help).
 The patient is informed of the risks of the procedure.
 Alternatives to the procedure are given.
 The information is in a language the patient can understand.
 Physicians are obligated to provide a trained medical interpreter when the
patient speaks a different language.
 The informed consent must be given for each procedure (specificity).
 Patients may withdraw consent at any time.
Exceptions of informed consent:

 Emergencies:
 Consent is implied in an emergency.
 Classic example: Unconscious trauma patient.
 Therapeutic Privilege:
 May withhold information when disclosing it would cause dangerous
psychological threat.
 Often invoked for psychiatric patients at risk of harm.
 Information often temporarily withheld until plan put in place with family, other
providers.
 Does not apply to distressing test results:
 Cancer diagnosis would upset patient.
 Family cannot request information be withheld.
 Cannot trick patient into treatment.
 Cannot lie to patient to get them to agree to therapy.
 Patient autonomy most important guiding principle.
 Waiver:
 Patient may ask provider not to disclose risks.
 Waives the right to informed consent.
 Provider not required to state risks over objection.
 Try to understand why patient requests waiver.

 Minors:
 Usually defined as person < 18 years of age.
 Only parent or legal guardian may give consent.
 Exceptions:
 Emergency:
 Care administered even if parent not present.
 Care can be administered against parents’ wishes.
 Classic example: Parents are Jehovah's Witnesses. Physician may administer
blood products to child.
 Do not need court order.
 Emancipated minors:
 Minors can attain “legal adulthood” before 18.
 Common criteria: • Marriage • Military service • Living separately from parents,
managing own affairs.
 Emancipated minors may give consent
 Special situations: (certain interventions without parental consent)
 Contraceptives.
 Prenatal Care.
 Treatment for STDs
 Treatment for substance abuse
 UW: If the parents remain steadfast about not wanting their child to be vaccinate, their
wishes should be honored and the discussion should be documented in the chart.
 UW: bacterial meningitis is a medical emergency and requires immediate treatment; in
such circumstances, there is not even enough time to contact the courts directly for
permission to proceed in case parents refusal to treat.
Documentation
 Person performing procedure should obtain and document patient’s consent.
 Often patient asked to sign form.
 Act of signing not sufficient for informed consent.
 Patient must be fully informed by provider.
 Patient must have understanding.
 Legal cases have been won despite signed form.
 Telephone consent is valid
 Usually requires a “witness”.
 Provider and witness document phone consent.

CONFIDENTIALITY
 The patient has an absolute right to privacy concerning his own medical
information.
 The following persons do not have a right to any of the medical information of the
patient:
 Relatives, employers, friends, and spouses.
 Other physicians:
 If a physician seeks medical information about a patient, you cannot
release it without the express consent of the patient.
 If a colleague initiates a discussion about private patient information in a
public place, do not scold them; offer to step aside to a more private place
before discussing anything about the patient.
 Members of law enforcement: You cannot release medical information to courts
or police without a court order or subpoena.
 Hence, only a patient can obtain or ask for his or her medical information to be
released. A current physician cannot obtain a patient’s previous medical records
without her direct consent.
 Exceptions to break Confidentiality:
BREAKING CONFIDENTIALITY
 May tell family a patient’s location in ER/hospital.
 Protecting other people:
 Sexually Transmitted Diseases:
 Duty to protect/warn partners of patients.
 Partners of HIV+ patients, Partners of patients with other STDs
 Only applies to sexual partners.
 Does not apply to other individuals: • Co-workers • Students of a
teacher • Patients of a physician.
 Physician may disclose STD status to partners.
 May do so without consent in special cases:
 Reasonable effort to encourage patient to voluntarily disclose.
 Reasonable belief patient will not disclose information.
 Disclosure is necessary to protect health of partner.
 Always encourage patient to disclose first.
 Some states have partner referral services.

 Reportable Illnesses:
 US states mandate certain “reportable diseases”
 Prevent infectious disease outbreaks.
 Most micro labs have protocols to automatically report:
 Tuberculosis, • Syphilis, • Gonorrhea, • Childhood diseases
(measles, mumps).
 Dangerous communicable diseases, such as TB or Ebola, require
involuntary treatment.
 Psychiatric illness who may be planning to harm others:
 They physician has the right to break your confidentiality to alert the
person at risk to prevent harm.
 Suicidal patients (i.e. family notification).
 Homicidal patients (i.e. police notification).
 Genetic diseases:
 Disclosure of genetic information to relatives is permissible only if
such a disclosure would serve to ameliorate or prevent a highly
likely and foreseeable harm to the identified individual.
 In Huntington disease situation, informing the patient's family
members about Huntington disease would not be expected to
prevent or ameliorate harm. However, it could aid future planning
and possibly assist with genetic screening in future pregnancies if
the patient and his wife so desired.
 If a health care provider is exposed to the body fluids of a patient who may
potentially be infected with HIV (e.g., a nurse is stuck with a needle while
obtaining blood from a patient whose HIV status is unknown), it is acceptable
to test the patient for HIV infection even if the patient refuses to consent to
the test.
 This issue comes down entirely to whether another person may be harmed by the
patient’s illness or actions. If you have a dangerous disease and your doctor does
not inform the innocent third party at risk, then that physician is liable for harm
that befalls the innocent person.

Special situations:
 Patient’s family members ask for information about patient’s
prognosis
 Avoid discussing issues with relatives without the patient’s permission.
 Patient’s family member asks if patient is ok following emergency

situation
 It is acceptable to inform the family member that the patient is stable
to prevent presumed harm to the patient due to likely family members
worrying unnecessarily.
 However specific medical details should not be shared without the patient’s
explicit consent (or lack of objection given a reasonable opportunity).
 Patient’s family member calls office wanting medical information

about spouse or relative
 You must say that if that person is one of your patients, they must provide
verbal or written release of their medical information.
 Obtained in a no pressure situation (i.e. not on the phone), written consent is
greatly preferred over oral.
 Patient’s family members ask you not to disclose test results if

prognosis is poor because patient “unable to handle it”
 Attempt to identify why family members believe such information would be
detrimental to patient’s condition.
 Explain that as long as patient has decision-making capacity and does not
indicate otherwise, communication of information concerning their care will
not be withheld.
 However if you believe patient might seriously harm himself or others if
informed, then you may invoke therapeutic privilege and withhold the
information.
 Note: if patient himself (not his family members) requests not to be informed,
then do not inform him.
 Female patient asks doctor not to inform husband child is not his:
 Don’t tell him.
 Patient is Suicidal
 Assess seriousness of threat, if serious, suggest patient remain in hospital
voluntarily, patient may be involuntarily hospitalized if they refuse.

 A football player with infectious mononucleosis and splenomegaly

that requires him to avoid playing but he refuses and beg you not
to tell his coach.
 Inform the coach of the medical recommendation that the patient be
restricted from playing.
 The primary responsibility of a team physician is to protect the health and
safety of the athlete. The physician's judgment should be guided only by
medical considerations and not influenced by the desires of the athlete coaches,
or spectators.
END-OF-LIFE ISSUES
 Autonomy as applied to end-of-life issues is the most important subject for the
test and for patient autonomy.
WITHHOLDING AND WITHDRAWING OF CARE

 Withholding of care and withdrawing of care are considered indistinguishable
from the point of view of the test and of proper ethical behavior. An adult with
capacity can withhold or withdraw any form of therapy. If the patient begins
therapy, he or she has the right to withdraw that care. The reasons for the
withdrawal or withholding of care are not important.
ADVANCE DIRECTIVES
 Instructions by patient in case of loss of capacity.
 Ideally done as outpatient with primary care MD.
 Often done at admission to hospital.
 Very important in patients with chronic illness:
 Cancer, Heart Failure, COPD.
 Components:
1) Living will. 2) Health care proxy. 3) DNR/DNI status (“code status”).
1- Living Will
 A living will is a written document outlining end-of-life wishes, desired by the
patient.
 Often includes specific directives regarding intubation, CPR, enteral feeding, and
other life-prolonging interventions.
 If the patient writes out, “I never want to be intubated,” this is valid.
 If he writes, “No heroic measures,” this is not valid. To be useful, a living will
must be clear and precise.

2- Health Care Proxy

 Allows patient to designate specific individual to make health care decisions.
 When patient become incapacitated, proxy decision maker must make decisions in
accordance with patient‟s wishes, as outlined in living will.
 The agent as a decision maker does not take hold until the patient loses the
capacity to make a decision.
 If I appoint a proxy but I am still here, alert, and communicative, you cannot ask
the agent for consent for my procedures.
Patient incapacitated, legally designated proxy (friend) refuses

procedure, husband wants procedure
Listen to proxy, not husband
Types of advance directives:

1. Oral:
a. Incapacitated patient’s prior oral statements commonly used as guide.
b. Problems arise from variation in interpretation, oral directive more valid if
patient was informed, directive was specific, patient made a choice, and
decision was repeated over time to multiple people.
2. Written:
a. Specifies specific healthcare interventions that a patient anticipates he or
she would accept or reject during treatment or a critical or life-threatening
illness.
b. Living will is an example.
3. Medical Power of Attorney:
a. Patient designates agent to make medical decisions in the event that
he/she loses decision-making capacity.
b. Patient may also specify decisions in clinical situations, can be
revoked by patient if decision-making capacity intact.
c. More flexible than a living will.
4. Do Not Resuscitate (DNR):
a. Includes basic life support (mouth-to mouth, chest compressions) and
advanced cardiac life support (intubation, mechanical ventilation,
defibrillation, pressors).
b. Pain meds and comfort care can still be given.
c. The family can be with the patient when they die.
d. A DNR order does not mean the elimination of testing or medical therapy.

Patient with no capacity and no advance directive

(proxy or living will):
 Surrogate Decision-Maker – if patient loses decision-making capacity and has
not prepared an advance directive, individuals (surrogates) who know the
patient must determine what the patient would have done, priority: spouse >
adult children > parents > siblings > other relatives.
 In this case, the care is based on the best understanding of the patient’s wishes for
himself.
 Family and friends attempt to outline what they heard the patient say he wanted.
 This is not the same as saying “This is what is best for the patient.”
 Decisions are based on the best possible understanding of clearly expressed
wishes. If there is no clear expression of wishes, then the weakest basis on which
to act is the “best interests of the patient.”
ETHICS COMMITTEE
 The ethics committee is used for cases in which the following are true:
 The patient is not an adult with capacity.
 There are no clearly stated wishes on the part of the patient.
 Also, the ethics committee is the answer if:
 The caregivers, such as the family, are split or in disagreement about
the nature of the care. If some family members say, “He never wanted to
be on a ventilator, ever,” and some family members say, “He might have
wanted a ventilator sometime,” then this is a case for an ethics committee.
COURT ORDER
 This option comes into play only when all the other options have not given
clarity. If there is disagreement after all the other steps, including an ethics
committee, which cannot reach a clear determination of care, then a court order is
the answer.
 You do not need a court order if the proxy clearly states wishes or the family is in
agreement.
 A court order can be obtained from a judge (within hours if necessary) if a child
has a life threatening illness or accident and the parent or guardian refuses to
consent to an established (but not an experimental) medical procedure for
religious or other reasons.

FLUID AND NUTRITION ISSUES

 An adult patient with capacity may refuse all forms of nutrition. There is no
ethical basis for forcing fluids or nutrition upon a patient. If the patient is not an
adult with the capacity to understand, the proxy or living will can direct the
removal of fluid and nutrition, provided the patient’s clearly expressed wishes
while competent stated that no artificial nutrition be started. In the absence of
clearly stated wishes on the issue of fluids and nutrition, they should be given.
PHYSICIAN-ASSISTED SUICIDE AND EUTHANASIA

 Physician-assisted suicide means providing the patient with the means to end her
own life. This is always wrong.
 Euthanasia means the physician directly administers the means of ending the
patient’s life. This is always wrong.
 If a competent patient requests cessation of artificial life support, it is both legal
and ethical for a physician to comply with this request. Such action by the physician is
not considered euthanasia.
 These are not the same as providing pain medications that may end the patient’s
life. It is ethical to give pain medication, even if the only way to relieve pain may
result in the inadvertent shortening of life. The primary difference is intent:
 In physician-assisted suicide, the primary intent is to end life.
 With a life shortened by pain medication, the primary intent is to relieve
suffering.
FUTILE CARE
 There is no obligation on the part of the physician to provide care that will not
work. There is no obligation to provide treatments without possible benefit.
A patient with widely metastatic cervical cancer develops renal failure. The family insists
that dialysis be started. What do you tell them?
Answer: You do not have to provide dialysis to a person who will certainly die and not
benefit from the treatment.

BRAIN DEATH
 You are not obliged to provide care for a brain-dead patient.
 Brain death = dead.
 Life support may be withdrawn even over surrogate/family objections.

 Patient officially determined brain dead, family insists on

maintaining life support indefinitely because patient moves when
touched:
 Gently explain to family that there is no chance of recovery, that brain death is
equivalent to death, and that movement is due to spinal arc reflex and is not
voluntary, bring case to appropriate ethics board regulating futility of care and
withdrawal of life support.
 Patient with persistent vegetative state:

 A condition arising from severe brain damage that results in a state of wakefulness
without awareness (Vs. coma which is a state that lacks both awareness and
wakefulness.)
 Cerebral cortical function (e.g. communication, thinking, purposeful movement, etc) is
lost while brainstem functions (e.g. breathing, maintaining circulation and
hemodynamic stability, etc) are preserved. Non-cognitive upper brainstem functions
such as eye-opening, occasional vocalizations (e.g. crying, laughing), maintaining
normal sleep patterns, and spontaneous non-purposeful movements often remain
intact.
 Patients may regain consciousness within 6 months in approximately 50% of
cases, but rarely without severe subsequent disability.

REPRODUCTIVE ISSUES
ABORTION
 A woman’s right to an abortion varies by trimester of pregnancy:
 First trimester: A woman has an unrestricted right to an abortion.
 Second trimester: A woman has access, but her rights are less clear.
 Third trimester: There is no clear access to abortion in the third trimester.
In the third trimester, the fetus is potentially viable.
 You do not need the consent of the father for the abortion.
 Providers not compelled to perform a procedure. If patient insists, refer to
another provider.
Pregnancy
 Pregnant women may refuse treatment.
 Even if baby’s health is impacted.
 Until the fetus comes out of the body, it is considered part of the woman’s body.
 For example:
 A woman can refuse a blood transfusion while pregnant. She can also refuse
antiretroviral therapy during pregnancy, even if the life of the fetus is at risk.
Once the baby comes out, however, she cannot refuse treatment for the baby.
 Although medical or surgical intervention may be necessary to protect the health
or life of the fetus, a competent pregnant woman has the right to refuse such
intervention (e.g., cesarean section) even if the fetus will die or be seriously
injured without the intervention.
15 year old patient is pregnant and wants to keep child, parents want
you to tell her to give it up for adoption
 Patient retains right to make decisions regarding her child, even if parents
disagree, provide information to teenager about practical issues of caring for a
baby, discuss options, if requested, encourage discussion between teenager and
parents to reach best decision.
17 year old patient is pregnant and requests abortion

 Many states require parental notification for minors for an abortion, unless there
are specific medical risks associated with pregnancy.
 A physician should not attempt to sway patient’s decision for an elective abortion
(regardless of maternal age or fetal condition).

DONATION OF GAMETES
 Patients have an unrestricted right to donate sperm and eggs. There is no ethical
problem with being a paid donor for sperm and eggs. Note that one cannot be a
paid donor for organs, such as the kidney or corneas.
ORGAN DONATION
 Brain dead patients are possible organ donors.
 In US, organ donation must be discussed only by individuals with specialized
training:
 Conflict of interest for caregiver to request organ donation.
 Family may believe physician giving up obtaining organs.
 “Organ procurement organizations”
 Often donation coordinator and attending physician.
 Organ donation cards:
 Indicate a preference not final choice.
 Usually not a reason to override family refusal to donate.
Transplant issues:
 Mood disorders and a troubled home life in possible transplant recipients are major issues
that may predispose patients to poor outcomes after surgery.
 Mood disorders, however, are potentially treatable psychiatric conditions, and their mere
presence does not prevent a potential candidate from heart transplantation.
 Psychiatrists are unable to predict future behavior with much accuracy, and data about
patients not able to receive transplantation is limited because they generally expire before
such long term data is collected. At best, physicians and organ transplant teams can
merely consider these findings in the same way they consider all other findings when
assessing a patient for transplantation.
 This patient should be fully evaluated and treated by a psychiatrist before he
receives the heart transplant.

HIV ISSUES
 A patient has a right to confidentiality of his HIV status.
 However, this confidentiality can be broken to protect the uninfected, such
as sexual and needle-sharing partners.
 There is no obligation for HIV-positive health care workers to disclose their
HIV status. This includes surgeons. A surgeon does not have to disclose her HIV
status to patient.
 Physicians have the legal right to refuse to treat any patient:
 It is not illegal to refuse to take care of HIV-positive persons.
 It is unethical to refuse care to HIV-positive patients simply because they are
HIV-positive, but it is legal to do so.
 UW: sexually active pregnant woman with multiple partners “high-risk HIV”
refuses to be tested for HIV:
 Physicians are no longer required to obtain written consent for HIV testing unless
required by law.
 However, physicians should document the conversation about HIV testing in
the chart.
 This patient is certainly at high risk for HIV infection. While it is recommended
that all pregnant women be screened for HIV, this patient does retain the right to
refuse this test.
 A pregnant patient at high risk for HIV infection cannot be tested for the virus or
treated (e.g., with zidovudine [AZT] and/or nevirapine [Viramine]) against her
will, even if the fetus could be adversely affected by such refusal. After the child
is born, however, the mother cannot refuse to allow the child to be tested for the
virus or treated.

DOCTOR-DOCTOR
 UW: When treating patients who have been referred for specialty care or a second
opinion, it is imperative to not undermine the patient's relationship with the primary
physician.
 A physician should avoid making negative comments about the quality of care
rendered by that practitioner unless practices are imminently dangerous or far outside
acceptable standards of care.
DOCTOR-PATIENT RELATIONSHIP
ACCEPTING A PATIENT
 A physician does not have an obligation to accept a patient. The need of a person does
not compel the physician to accept that person as a patient. For example, if there is only 1
neurosurgeon at a hospital and a patient needs neurosurgery, this situation does not
compel the physician to accept the patient.
 Once having accepted a patient, however, the physician cannot simply abandon the
patient. The physician has an obligation to inform the patient that he must find another
physician, and the physician must render care until a substitute caregiver can be
identified.

GIFTS
 As a rule, physicians should maintain a general policy of not accepting gifts of

significant monetary value from patients or their families.
 One-time gifts of token monetary value (eg, cards, photographs, cookies) are an
exception to this rule if given altruistically.
 The proper amount of respect and gratitude should always be expressed when declining
a gift.
 Some general recommendations regarding the acceptance of gifts include the

following:
 Cash gifts (including gift certificates or vouchers) should never be accepted.
 Gifts should never influence patient treatment or even give the impression that
they could influence quality of treatment.
 Gifts should not make a significant impact on either the patient's or physician
financial status and should not exceed what would be considered to be modest by
community standards.
 The patient's motivation and underlying psychological needs must always be
carefully evaluated when deciding to accept a gift. This is especially true when
dealing with psychiatric patients, even when accepting small gifts (eg. holiday
cookies).
 It is important to maintain consistency among all patients. For example, if the
office has a no-gift policy, then no gifts should be accepted from any patient
regardless of the value.
 If the physician would feel embarrassed or uncomfortable if colleagues or
patients knew about the gift, then it should not be accepted.
 Rejection of a valuable gift should be done with care, as a tactless approach to refusal
can have a negative impact on the physician-patient relationship. For example, in some
cultures it is customary to express gratitude by giving a gift, and denying patients the
right to express their gratitude could be deemed insulting and harm the physician-patient
relationship. Other patients may see the rejection of a gift as a personal rejection and feel
shunned by the physician. Therefore, the physician should always express an appropriate
amount of gratitude toward the gesture and explain why the gift cannot be accepted.

SEXUAL CONTACT
 Psychiatrists: Sexual contact between a patient and a psychiatrist is never acceptable.
 Other physicians: They must end the doctor-patient relationship first.
 Patient states they find you attractive:
 Ask direct, closed-ended questions and use a chaperone if necessary.
 Romantic relationships with patients are never appropriate.
 Patient who had mastectomy feels “ugly”
 Find out why patient feels this way.
 Do not offer falsely-reassuring statements (e.g. “You still look good”).
 Patient interested in relationship with doctor, doctor also interested
 Don‟t date a patient, some ethicists are OK with you dating a person once they are no
longer your patient, but for exams, don’t date a patient.
 Under no circumstances can you date a psychiatric patient, even if they are no longer
your patient – this is always unethical.
Patient angry about long wait time at office

 Acknowledge patient’s anger, but do not take it personally, apologize for any
inconvenience, avoid efforts to explain delay.
 When confronting angry patients, physicians should use a non-defensive, empathic
approach that acknowledges their anger and attempts to build a collaborative
physician-patient relationship.
Patient upset by way they were treated by another doctor

 Suggest patient speak directly to that physician regarding their concerns.
 If problem is with another member of office staff, tell patient you will speak to that
person.
Help rejecters
 Example: If a patient remains symptomatic despite the best efforts of the physician to
treat her with multiple medication trials and rejects all recommended non
pharmacological approaches.
 Such patients are "help rejecters"; they believe that no treatment will help and appear not
to want to improve. These patients are frustrating and can leave the physician feeling
angry and manipulated.
 The understandable tendency to want to refer this patient to another provider or specialist
should be avoided.
 Often, these patients have underlying depression but will refuse referral to a psychiatrist.
 They are needy for attention and unconsciously wish to remain symptomatic so that
they can continue to see a physician.

 The best approach is to empathize with these patients and attempt to engage them in a
collaborative plan in which there is mutual agreement about realistic treatment
approaches and limited expectations. Sharing frustration over disappointing outcomes
and focusing on alleviation of symptoms rather than a cure is often helpful.
Patient is upset by her back pain that is not responding to treatment

 The best initial approach is to build the physician-patient relationship by
empathizing with the patient's frustration and disappointment with past
treatment failures.
 In this way, the patient feels understood and will be more willing to work with the
physician to develop a collaborative plan focused on realistic goals.

GIFTS FROM COMPANIES

 Can influence physician behavior.
 Generally acceptable if educational and low value:
 Educational dinner or textbook.
 Value usually should be < $100.
 Cash, tickets, vacations, other gifts NOT acceptable.
 Special funding for medical education of students, residents, fellows.
 Grants whose recipients are chosen by independent institutional criteria, and
funds distributed without attribution of sponsors.
Honoraria
 Fees to physicians paid by industry.
 Goal usually to promote research about a new product:
 Example: Drug company pays MD to speak.
 Acceptable but must be disclosed to audience.
 Fee must be fair and reasonable.
 Fee cannot be in exchange for MD using product.
 UW: Physicians attending conferences cannot accept subsidies from industry
for travel costs, lodging, or other personal expenses. However, it is permissible
for faculty physician lecturers to accept reasonable honoraria and/or
reimbursement for reasonable travel expenses. Prior to delivering a
presentation, a physician receiving industry payment or support for a conference
must fully disclose the name of the company, his/her participation in company-
funded research projects, and the nature of financial ties to the company.
Likewise, an explanatory statement disclosing conflicts of interest should
accompany all published research.
Pharmaceutical company offers sponsorship in exchange for

advertising new drug:
 Reject offer, generally decline gifts and sponsorships to avoid any appearance of
conflict of interest.

ABUSE
 Child and elder abuse must be reported:
 Child abuse: Reporting mandatory in all US states.
 Elder abuse: Reporting mandatory in most US states.
 Child protective services & Adult protective services.
 First step: child/adult interviewed alone.
 Physician protected if reporting proves incorrect.
Child abuse

Elder abuse
 Elder abuse can be reported even against the will of the patient.
 Elder abuse does not imply a specific age; it has to do with the fragility of the
patient. If the patient is frail and vulnerable, the abuse can be reported even against
the patient’s will.
 Risk factors associated with the abused:
 Female gender. Old age (especially 80 and above).
 Physical and mental impairment from chronic medical conditions.
 Risk factors identified in abusers:
 Young age.
 Relationship with the victim (spouse or children).
 Substance abuse, mental illness.
 Dependence on the victim, and previous history of violence in the abuser.
Spousal Abuse
 “Intimate Partner Violence”. Suggested by multiple, recurrent injuries/accidents.
 Primary concern is safety of victim.
 Provider should be supportive.
 Ask if patient feels safe at home.
 Ensure patient has a safe place in emergency.
 Do not
 Pressure patient to leave their partner.
 Disclose incident to authorities (unless required by state law).

IMPAIRED DRIVERS
 Often elderly patients with vision, mobility disorders, seizure disorder.
 No uniform standard for reporting.
 Widely varying rules by US state.
 Best answer often to discuss with patient/family.
 Exception: Seizures:
 Most states requires a seizure-free interval: i.e. 6 months, 1 year.
 Often involves consulting with state DMV.
TORTURE
 Physician participation in torture, on any level, is always wrong. You cannot
even agree to certify the patient dead.
IMPAIRED PHYSICIANS
 Impaired physicians must be reported to an authority figure:
 For physicians in training, the reporting should be to the program director
or department chair.
 For faculty, reporting is to the department chair or the dean of the medical
school.
 For those in practice, reporting is to the state medical board of the office
of profession medical conduct.
 The impairment must involve potential danger to medical care. If you see a
physician stealing a car, his behavior is not reportable to the department chair. If
you see a physician at a bar dancing naked on the table top, but her medical
performance is not impaired, this is not reportable.

MEDICAL ERRORS
 Regardless of outcome, physician ethically obligated to inform patient a mistake has
been made, he should apologize as well, and do both as soon as possible.
Types of medical errors:

 Active Error: occurs at level of frontline operator (e.g. wrong IV pump dose
programmed), immediate impact.
 Latent Error: occurs in processes not directly linked to frontline operator, but
impacts patient care (e.g. different types of IV pumps used within same hospital),
accident waiting to happen.
Analysis of medical errors:

Failure mode and effects analysis Root cause analysis
Uses inductive reasoning to identify all the Uses records and participant interviews to
ways a process might fail and prioritize identify all the underlying problems that
these by their probability of occurrence and led to an error.
impact on patients.
Forward-looking approach applied Retrospective approach applied after
before process implementation to prevent failure of event to prevent recurrence.
failure occurrence (“Failure Mode and “Root Cause Analysis is Retrospective”
Effects Analysis looks Forward”)
Root cause analysis:

 A quality improvement tool used to identify what, how, and why an undesirable
outcome occurred.
 Involves 5 steps:
1. Collect data
2. Create causal factor flow chart
3. Identify root causes
4. Generate recommendations & implementation
5. Measure success of changes implemented
 For example, the pharmacist may have accidentally dispensed the wrong amount of insulin
(causal factor), citing that the pharmacy has been understaffed due to budget cuts (root cause).
This would have required the pharmacist to fulfill orders in a more hurried manner, increasing
vulnerability to mistakes. The fourth step involves generating recommendations and implementing
them. An example is having a pharmacist present on the medical floor to double-check orders. The
fifth step requires assessing the success of implemented changes.

Near-miss event
 Medical error that is recognized before any harm is done to the patient.
 Example: a patient is prescribed a lethal dose of medication, but the error is
caught by the pharmacist.
 For approximately every 300 near misses, 1 adverse outcome occurs, indicating
that analysis of near-miss events can be helpful in improving overall patient
safety. For this reason, near-miss events should be reported to administration to
ensure that adequate measures are taken to prevent other practitioners from
making the same error.
 Disclosure to the patient should be determined on a case-by-case basis by the
individual practitioner. In general, disclosure is recommended if there is a related,
ongoing safety threat to the patient (potential for harm) or if the patient is aware
of the near miss and disclosure will decrease anxiety and improve trust.
Wrong-Site Surgery
 Most frequently reported serious adverse event.
 Risk factors include emergency procedures, failure to mark surgical site, poor
communication, surgeon fatigue, multiple procedures on the same patient, and
multiple surgeons on the same procedure.
 Preoperative verification process important to decrease risk.
 Surgical site marking.
 Independent verification of patient, procedure, and site by 2 health care
workers (e.g. nurse and physician, “dual identifiers”) should be
performed.
 Verification should be done independently because 2 clinicians verifying
identifiers together can replicate an error.
 “Surgical timeout” immediately prior to procedure recommended
conducting final verification of patient, procedure, and site.
Non-Preventable Adverse Event

 A complication that cannot be prevented given the current state of medical
knowledge.
 Example: a patient with no known history of drug allergies has an allergic
reaction to a medication.

Preventable Medical Error

 Harm to the patient via an act of either
 Omission (not doing something you should have done) or
 Commission (doing something you should not have done) rather than
from the patient’s underlying disease.
 These errors are the result of failure to follow evidence-based best practice
guidelines or delayed diagnosis.
 Examples:
 Delayed diagnosis due to failure to perform a recommended test based on the
patient’s presentation.
 The wrong patient is prescribed a colon cleanse (commission), a patient is not
screened for hypothyroidism and endures their condition a month longer than
they should have had to (omission).
Sentinel Event
 Unexpected occurrence involving death or serious physical or psychological
injury that requires immediate investigation.
 Example:
 Inpatient suicide.
 Death of a full-term infant.
 Retained object after surgery.
Technology and Medical Errors

 Technological solutions (dose alerts, expiration alerts, etc.) to medication errors
are essentially never preferred over human solutions (e.g. proper use of
abbreviations, interviewing staff to determine causes, etc.)

 UW: Sleep deprivation is common among physicians and can have a profound effect
on patient safety.
 Sleep science has demonstrated "dose-dependent" effects of sleep deprivation on
physician cognitive performance and risk of medical errors.
 Impairments in cognitive performance and motor skills typically manifest after 17 hours
of wakefulness and are comparable to those seen in an alcohol-intoxicated individual.
 Although the Accreditation Council for Graduate Medical Education has
mandated limitations on resident work hours in response to patient safety concerns,
extended work hours of attending physicians are unregulated.
 Physicians typically do a poor job of self-regulating their workload, often underestimate
their cumulative sleep debt, and minimize its impact on their clinical skills.
 In this scenario, the physician has been working continuously for more than 24 hours;
fatigue is the most likely contributor to medical errors.

 UW: Physician burnout:

 “An erosion of the soul caused by a deterioration of one's values, dignity, spirit, and
will”
 A state of emotional exhaustion, cynicism, depersonalization, and decreased sense of
personal accomplishment that can result in suboptimal patient care and medical errors.
 The 3 cardinal symptoms:
1. Exhaustion: The physician's physical and emotional energy levels are
extremely low and in a downward spiral. A common thought process at this
point is, “I'm not sure how much longer I can keep going like this.”
2. Depersonalization: This is signaled by cynicism, sarcasm, and the need to vent
about your patients or your job. This is also known as “compassion fatigue.” At
this stage, you are not emotionally available for your patients, or anyone else for
that matter. Your emotional energy is tapped dry.
3. Lack of efficacy: You begin to doubt the meaning and quality of your work and
think, “What's the use? My work doesn't really serve a purpose anyway.” You
may worry that you will make a mistake if things don't get better soon.
 Although sleep deprivation may contribute to burnout, there is no evidence that this
physician's error was secondary to burnout, which often involves errors resulting from
lack of concern or callousness toward patients rather than forgetfulness.
 UW: Handoffs:
 The process of transferring responsibility for medical care is
referred to as a patient handoff. with "sign-out referring to the process of
transmitting information about the patient and needed follow-up care
 Communication failures between physicians during patient handoffs are a major cause
of medical errors and can be reduced by use of a structured process.
 Structured handoffs that include specified key elements (eg, a systematic procedure for
sign-out. checklists of tasks that need to be completed a standardized approach for each
patient) have been shown to significantly reduce preventable adverse events.
FAMILY AND FRIENDS

 Most medical societies recommend against giving nonemergent medical care to
family and friends.
 Emergencies are an exception.
FAMILY OF PATIENTS
 May be present during patient encounters. May answer for patients, disrupt
interview.
 Don‟t ask patient if they want family present !
 Patient may be afraid to say no.
 Politely ask family for time alone with patient.

NONCOMPLIANT PATIENTS
 The best initial approach is to build a therapeutic alliance with the patient by
acknowledging “eg, it is difficult to take medication daily for a silent illness”
 Always try to understand WHY
 Why doesn’t patient want to take medications?
 Why doesn’t patient want to go for tests?
 Determine patient willingness to change.
 Try to help  provide more information.
 Avoid scolding or threats  “You will get sick if you don’t…”
 Avoid referring them.
 Avoid judgment.
 Adolescents more likely to adhere to treatment plans if they have close peers with
similar conditions who are adherent (positive peer pressure).
Patient has difficulty taking medications:

 Provide written instructions.
 Attempt to simplify treatment regimens.
 Use teach-back method (ask patient to repeat regimen back to
physician) to ensure comprehension.
 If patient seems unable to follow regimen (e.g. due to dementia) and
there is inadequate family support, get Social Services involved to help
patient adhere to treatment regimen.
 UW: A social worker can be instrumental in assessing whether the
patient has adequate family or caregiver support at home.
UW: A discharge checklist detailing medication changes and follow-up

appointments can significantly facilitate a patient's transition from the hospital and
improve adherence to outpatient treatment. Individuals who experience a smooth
transition from the inpatient to the outpatient setting are at lower risk for early
rehospitalization.

EMOTIONAL PATIENTS
 Acknowledge the patient’s feelings:
 “I understand you are upset because…”
 Always try to understand WHY:
 Why is the patient upset?
 Check for understanding of issues.
 Avoid telling patients to calm down.
 Don’t ignore emotions.
Dependent patient behavior:

 Example: female patient with frequent appointments and after-hours phone calls
for non-urgent matters.
 The best approach is to be empathic and nonjudgmental.
 But establish clear boundaries:
 The physician should explain what degree of distress warrants an "urgent"
call.
 Direct the patient to other resources for guidance on routine questions.
 Making sure that all members of a treatment team are in agreement on
maintaining clear boundaries with the patient can also be helpful.
RESEARCH
 Research requires consent.
 All clinical research studies require informed consent.
 Even if drug/therapy is FDA approved.
 Even if drug/therapy has no known risks.
 Institutional Review Board (IRB):
 Hospital/Institutional committee that reviews and approves all research studies.
 Ensures protection of human subjects.
 Balances risks/benefits.
 Ensures adequate informed consent.
 Prisoners:
 Informed consent required as for non-prisoners.
 Financial disclosures:
 Many companies sponsor research.
 Must inform patients of industry sponsorship.

CLINICAL TRIALS ETHICS:

 Guidelines typically emphasize the importance of avoiding coercion while still including
these (low socio-economic status) individuals in research.
 Methods for achieving this include avoiding excessive financial compensation and
ensuring that patients receive compensation in a stepwise manner rather than only upon
completion of the trial.
 Any discussion of clinical trial participation should involve an upfront discussion of risks
and benefits.
 Participation in clinical trial research is entirely voluntary, and subjects have the right to
discontinue study participation at any point and for any reason.
 Participant should know everything about the clinical trial (benefits, risks,
compensation,..) at one time before taking the decision regardless his socioeconomic
status.
Underaged patient (<15) a candidate for research study

 Get parental consent and assent from the underage patient after discussing the study
with them (they are too young to give informed consent).

Ethical Situations
 Patient requires treatment not covered by insurance:
 Never limit or deny care because of expense in time or money.
 Discuss all treatment options with patients, even those not covered by their
insurance companies.
 7 year old loses sibling to cancer and feels responsible:

 At age 5-7, children begin to understand that death is permanent, that all life
functions end completely at death, and that everything that is alive eventually dies.
 Physician should provide direct, concrete description of sister’s death, avoiding
clichés and euphemisms, reassure child that they are not responsible, identify and
normalize fears and feelings, encourage play and healthy coping behaviors (e.g.
remembering sibling in their own way).
 Patient wants to try alternative/holistic medicine:

 Find out why and allow patient to do so as long as there are no contraindications,
medication interactions, or adverse effects to the new treatment.
 Physician colleague presents to work impaired:

 If impaired or incompetent, colleague a threat to patient safety, report situation to
local supervisory personnel.
 Should organization fail to take action, alert state licensing board.
 Mother and 15-year-old child unresponsive and need blood

transfusion, father says „do not transfuse‟ because they are
Jehovah‟s Witnesses
 Transfuse daughter, but not mother.
 Emergent care can be refused by healthcare proxy for an adult, particularly when
patient preferences are known or can be reasonably inferred, but not for a minor.
 Intern has concerns with medication ordered by attending

physician:
 Do not blindly follow orders that could potentially harm a patient.
 Instead respectfully discuss the issue directly with the attending physician to
understand their clinical reasoning.

 Obtaining sexual history

 In taking a sexual history, physicians should use a neutral, open, and
nonjudgmental approach.
o Have your sexual partners been women, men, or both?
 Physicians should never make assumptions about patients' sexual orientation and
should inquire about all sexual partners.
 Patient with low levels of literacy (can‟t read instructions well):

 Use a visual aide to educate the patient about the procedure.
o Visual resources such as videos or drawings can help convey information.
 Patients with low literacy experience difficulties in forming a therapeutic alliance,
poor understanding of written or spoken medical advice and adverse health
outcomes.
 Physicians should remain alert to patients with a low level of literacy as this can
often impair communication and result in low-quality medical care and poor
adherence Alternate learning methods (eg, visual resources) should be used to
address this challenge.
 Addressing patient name during conversations:

 First impressions are important and initial encounters with new patients should
ideally include asking them their preferred names.
 Any uncertainties about pronunciation or titles should be clarified as well.
 Although younger adults often prefer being called by their first name, older
patients may take offense at undue familiarity.
 When in doubt, older patients should initially be addressed as Ms, Mrs, or Mr to
show proper respect and then asked their preferred form of address.
 As familiarity develops between the physician and patient over time, many patients
will prefer to be addressed by their first name. However, it is always the patient,
not the physician, who must take the lead in lowering the level of formality.
 It is better to default to the more formal approach initially and ask the patient's
preference in an open-ended manner than to make assumptions.

MISCELLANEOUS UW TOPICS
FEMALE CIRCUMCISION:
 Woman who is inquiring about female circumcision should be advised that the
procedure can have an adverse effect on her health and that it is a painful and
irreversible procedure.
 Medically unnecessary surgery on the genitalia of girls younger than 18 years was
banned by the United States Congress in 1997.
 While the requested procedure is technically legal for adult women, few physicians
in the United States are comfortable performing it. Ultimately, educating the woman
about the health risks associated with the procedure is more likely to be effective in
discouraging her than is informing her of its unavailability.
 Referrals to the gynecology or surgery departments would not be appropriate as this
procedure is generally not performed in the United States.
ELDERLY FALLS:
 Falls in the elderly population occur as a result of a mixture of intrinsic and extrinsic
factors. The intrinsic factors include any acute illness or an age-related decline in
balance, vision, ambulation, proprioception, cognitive impairment, musculoskeletal or
cardiovascular function. Some of the extrinsic stressors that can lead to an
increased risk of falls include the use of multiple medications, psychotropic
medications, and an unsafe home environment.
 Prevention of recurrent falls and the associated complications is important in patients
with a history of prior falls. Some interventions that have been proven to be useful in
the prevention of falls include muscle strength and balance training, withdrawal of
psychotropic medications, and home hazard evaluation and modification
by a trained professional.
NARCOTICS PRESCRIPTION:
 The patients most likely to arouse suspicion are those who insist upon narcotics
during their first encounter with a physician.
o Nevertheless, if there is clinical evidence that the patient's symptoms are
genuine, it is appropriate to provide a 2-week refill of a narcotic
prescription in an effort to provide continuity of care.
o Many organizations recommend that the patient sign a pain contract so that
there is an agreement between the physician and patient that the patient will
obtain the medication from one doctor and one pharmacy during regular
hours and may have the medication discontinued if he/she violates the
agreement.

Public health
DISEASE PREVENTION
Primary Prevention
 Prevents disease from occurring.
 Examples: Immunizations, Folate supplementation in pregnancy.
Secondary Prevention
 Prevent disability.
 Detect and treat early, ideally when asymptomatic.
 Examples: Most screening programs, Mammograms, Pap smears, Colonoscopy.
Tertiary Prevention
 Prevents long-term disease complications.
 Maximize remaining function.
 Examples: Cardiac rehabilitation programs.

Quaternary Prevention
 Prevents overtreatment or harm from treatment.
 Many examples of overuse in US medicine: • Blood tests • Radiology tests • Coronary
procedures.
 Ensure appropriate use.
US HEALTHCARE
 Healthcare is expensive ($$$), few patients pay out of pocket.
 Major insurance options:
 Medicare
 Medicaid
 Private insurance
 Emergency Care:
 Must always be provided regardless of insurance.
 After patient stable, insurance can be discussed.
Medicare
 Federal program administered by US government.
 Paid for by Federal US taxes.
 Provides health insurance for:
 Patients over 65 years of age:
 Who have worked and paid into the system (ie, have paid taxes).
 Individuals must also hold residence and citizenship in the United States.
 Disabled.
 Patients on dialysis.
 Certain neurodegenerative disorders (eg, amyotrophic lateral sclerosis).
 The program is subdivided into parts A, B, C, and D, and enrollees may choose which
parts they wish to participate in:

Medicaid
 Administered by states.
 A state-run medical insurance program that covers “low income patients/families” such
as homeless, undocumented immigrants pregnant women.
 NB: “Care for the elderly, Aid the poor”

Private Insurance
 Often provided by patient‟s employer.
 Employer pays fee to insurance company.
 Insurance company pays costs of medical care.
 Expensive for employer.
 Helps to attract skilled workers.
 Several types of plans that vary in features/cost.
Health Maintenance Organization (HMO)
 Reduce utilization by confining patients to a limited panel of providers,

requiring referral from a primary care provider prior to specialist
consultations, and
denying payment for services that do not meet established guidelines.
 Less expensive  an insurance plan with low monthly premiums, low
copayments and deductibles, and low total cost for the patient.
Preferred Provider Organization (PPO)
 See any MD you want.

 “In network” MDs have a lower co-pay.
 Most expensive plan.
 Most flexible plan.
Point of Service plan (POS)
 Middle option between HMO and PPO.

 Must use specific primary care doctor.
 Can go “out of network” with a higher co-pay.

COBRA (Consolidated Omnibus Budget Reconciliation Act)

A legal framework in which patients who have left their employer may continue to
receive benefits on their previous employer's group health insurance. The benefits are
provided for a limited period under certain circumstances (eg, transition between jobs,
death, or divorce)
 Dual eligible enrollees (also known as Medicare-Medicaid or "Medi-Medi") are

very low income seniors or disabled individuals who qualify for both standard
Medicare and Medicaid benefits.
 Medigap (Medicare supplement insurance) plans are optional supplemental plans
that cover copays, deductibles, and other services not covered by parts A and B;
they do not cover medications.

 Certification of Disability:
o Provides financial assistance to workers who are unable to continue working due
to medical or psychiatric condition.
o Certification of disability by a physician usually required before benefits granted,.
o Patient seeking disability due to pain requires doctor to assess symptoms and
conduct physical exam, considering the possibilities of malingering, inadequately
treated pain, or chronic pain resulting in legitimate disability, physician should
neither assume legitimate disability based on past assessments by other doctors,
nor should they necessarily assume malingering because a patient appears
frustrated of demanding.
 UW: Patient with pain asks the physician to sign a disability form with a hostile
threatening manner:
o Calm the patient, as the patient may have been rejected or mistreated by
practitioners in the past.
o Inquire more about what troubles them by using open-ended questions.

PAYMENT TYPES
1. Discounted Fee for service:
a. Payment arrangement in which an insurer pays a provider for each individual
service provided at a pre-arranged, discounted rate.
b. $100 per clinic visit.
2. Salary:
a. $100,000 per year  doctor must see all patients.
3. Capitation:
a. Physician receives set amount per patient assigned to them per period of time,
regardless of how much the patient uses healthcare system.
b. An arrangement in which a payor (individual, employer or government entity) pays
a fixed, predetermined fee to cover all the medical services required by a patient.
c. Capitation is the payment structure underlying health maintenance organization (HMO)
provider networks.
d. Under capitation there is an incentive for the provider and patient to reduce expenses,
usually by
1.) Restricting patients to a limited panel of providers within the plan.
2.) Requiring referrals from a primary care provider prior to specialist
consultations.
3.) Denying payment for services that do not meet established evidence-based
guidelines.
e. Spends LESS than fee  make money.
f. Spends MORE than  loses money.
g. Payors may negotiate a capitated contract with an insurance company that then pays the
providers, or a large medical group may negotiate directly with the payor.
h. Financial risk transferred to physician/hospital.
4. Global payment
a. Insurer pays a provider a single payment to cover all the expenses associated with an
incident of care.
b. This is most commonly done for elective surgeries, in which the global payment covers
the surgery as well as any pre- and post-operative visits needed.
5. Affordable Care Act
a. Enacted in 2010. Expands Medicaid coverage.
b. Establishes exchanges.
c. Uninsured patients may purchase private healthcare.

HOSPICE
 End of life care.
 UW: Patients are permitted to leave hospice to receive life-prolonging treatments and are
free to return as long as they continue to meet these criteria.
 Although patients on hospice can receive palliative medical therapies (eg, chemotherapy,
radiation, tumor debulking) to improve comfort, life-prolonging medical therapies while
on hospice are not permitted.
 It is the role of the oncologist, not the hospice physician, to discuss with the patient the
prognosis and expectations for the new chemotherapy regimen that he wishes to pursue.
 For patients (and families) who decide to pursue hospice care, there are no
contraindications provided the patient has an estimated prognosis of < 6 months and has
decided to forego life-prolonging treatments. This decision should be made when curative
treatments are no longer beneficial or when the suffering associated with medical
treatment outweighs the benefits.

DELIVERING BAD NEWS

BLAST INJURY
 Injuries compounded when explosion occurs in confined space.
 Types:
 Primary Injuries:
 Caused by blast overpressure/shock waves.
 Pressure and time-dependent (the more of each, the worse the injury).
 Ears most affected, then lungs, then hollow organs of GI tract (GI
injuries may present after delay of hours-days).
 Secondary Injuries:
 Caused by fragmentation and other objects propelled by explosion.
 May affect any part of the body and sometimes result in penetrating
trauma with visible bleeding.
 Tertiary Injuries:
 Displacement of air by explosion which can throw person against solid
objects.
 Characterized by combination of blunt and penetrating trauma.
 Including bone fractures and coup-contrecoup injuries.
 Children especially at risk due to their small size.
 Quaternary Injuries:
 All injuries not included in the first 3 categories.
 Including flash burns, crush, respiratory, eye, and neurologic/psychiatric
injuries (e.g. PTSD).

CHANGES IN NORMAL AGING

System Physiologic Changes Medical Complications
↓ Maximum HR ↓ Exercise capacity
Cardiovascular
Thickening and calcification of the aorta Systolic hypertension
Unchanged Total Lung Capacity (TLC)
↑ Residual Volume (RV)
↓ FEV1, FVC,
Respiratory
normal/↑ FEV1/FVC ratio
↓ PaO2, ↑ A-a gradient (O2 diffusion more
difficult)
↑ Gastric acid reflux GERD
Gastrointestinal
↓ Colonic motility Chronic constipation
↓ Ability to concentrate urine. Dehydration
Urinary
Impaired emptying of the bladder. UTIs and urinary incontinence
↑ Respiratory and nosocomial
Immune ↓ Number of B-cells and T-cells infection, malignancies, and
autoimmune conditions
↓ Muscle mass ↑ Risk of falls
Musculoskeletal
↑ Bone mineral loss ↑ Risk of fractures
Skin atrophy ↑ Skin fragility
Integumentary
↓ Subdermal fat Skin wrinkling
Presbyopia (patients with mild
myopia often note vision
Hardening of the ocular lens
Sensory improvement with age as
Deterioration of auditory pathway
presbyopia develops)
Presbycusis
M: slower erections/ejaculations, longer
Reproductive refractory period
F: vaginal shortening, thinning, and dryness
↓ REM and slow-wave sleep
Sleep ↑ Sleep onset latency,
↑ Early awakenings
↑ Suicide rate
Psychological
Unchanged intelligence (does not decrease)

FISH CONSUMPTION GUIDELINES FOR PREGNANT

WOMEN
 Issued by the FDA, places fish into 3 categories:
1.“Best Choices”: eat 2-3 servings/week, ~90% of fish eaten in the US.
2.“Good Choices”: 1 serving/week.
3.“Fish to Avoid”: usually due to high mercury content.

INTERVIEWING PATIENTS

Public health first aid 2021 updates
 Observational studies “Extra”
 Statistical hypothesis testing “Extra”

p-value The probability of obtaining test results at least as extreme as those observed during the test,assuming that
H0 is correct.
 Types of medical errors P. 31

Near miss Unplanned event that does not result in harm but has the potential to do so (eg, pharmacist recognizes a
medication interaction and cancels the order).
 Patient-centered interviewing techniques “Extra”
1. Introduction Introduce yourself and address the patient by preferred name. Sit at eye-level near the patient.
2. Agenda setting Identify concerns and set goals by developing joint agenda between the physician and the
patient.
3. Reflection Actively listen and synthesize information offered by the patient, particularly with respect to primary
concern(s).
4. Validation Legitimize or affirm the patient’s perspectives.
5. Recapitulation Summarize what the patient has said so far to ensure correct interpretation.
6. Facilitation Encourage the patient to speak freely without guiding responses or leading questions. Allow the
patient to ask questions throughout the encounter.
 Expressing empathy PEARLS “Extra”

1. Partnership Reassure the patient that you will work together through difficult times, and offer appropriate
resources.
2. Empathy Acknowledge the emotions displayed and demonstrate understanding of why the patient is feeling
that way.
3. Apology Take personal responsibility when appropriate, or offer condolences for the patient’s situation.
4. Respect Commend the patient for coming in to discuss a problem, pushing through challenging circumstances,
keeping a positive attitude, or other constructive behaviors.
5. Legitimization Assure the patient that emotional responses are understandable or common.
6. Support Offer to help the patient through difficult times.
 Delivering bad news SPIKES P. 50

1. Setting Offer in advance for the patient to bring support. Eliminate distractions, ensure privacy, and sitdown
with the patient to talk.
2. Perception Determine the patient’s understanding and expectations of the situation.
3. Invitation obtain the patient’s permission to disclose the news and what level of detail is desired.
4. Knowledge Share the information in small pieces without medical jargon, allowing time to process. Assess the
patient’s understanding.
5. Emotions Acknowledge the patient’s emotions, and provide opportunity to express them. Listen and offer
empathetic responses.
6. Strategy If the patient feels ready, discuss treatment options and goals of care. Offer an agenda for the next
appointment.
 Gender- and sexuality inclusive history taking “Extra”

1. Avoid making assumptions about sexual orientation, gender identity, gender expression, and behavior (eg, a
patient who identifies as heterosexual may engage in same-sex sexual activity).
2. Use gender-neutral terms (eg, refer to a patient’s “partner” rather than assuming a spouse’s gender). A
patient’s sex assigned at birth and gender identity may differ.
3. Consider stating what pronouns you use when you introduce yourself (eg, “I’m Dr. Smith, and I use she/her
pronouns”) and asking patients how they would like to be addressed.
4. Reassure them about the confidentiality of their appointments and be sensitive to the fact that patients may
not be open about their sexual orientation or gender identity to others in their life.
5. Do not bring up gender or sexuality if it is not relevant to the visit (eg, a gender nonconforming patient seeking
care for a hand laceration).
 Motivational interviewing “Extra”
Counseling technique to facilitate behavior modification by helping patients resolve ambivalence about change.
Useful for many conditions (eg, nicotine dependence, obesity). Helpful when patient has some desire to change, but
it does not require that the patient be committed to making the change. May involve asking patients to examine
how their behavior interferes with their life or why they might want to change it.
Assess barriers (eg, food access, untreated trauma) that may make behavior change difficult. Assessing a patient’s
readiness for change is also important for guiding physician-suggested goals.
These goals should be Specific, Measurable, Achievable, Relevant, and Time bound (SMART).
 Communicating with patients with disabilities “Extra”

Use “person-first” language, which refers to “a person with a disability” rather than “a disabled person.” Consider
asking patients what terms they use to describe themselves.
Under most circumstances, talk directly to the patient. Do not assume that nonverbal patients do not understand.
Accompanying caregivers can add information to any discussion as needed.
Ask if assistance is desired rather than assuming the patient cannot do something alone. Most people, including
people with disabilities, value their independence. For patients with speech difficulties, provide extra time for the
interview. If their speech is difficult to understand, consider asking them to write down a few words or ask them to
rephrase their sentence. Repeat what they said to ensure you understood it correctly.
For patients with a cognitive impairment, use concrete, specific language. Ask simple, direct questions. Eliminate
background noise and distractions. Do not assume the patient can read. Adjust to how the patient understands best
(eg, use hand gestures or ask them to demonstrate a task).
Ask patients who are deaf or hard of hearing their preferred mode of communication. Use light touch or waving to
get their attention. For patients who prefer to speak and lipread, eliminate background noise, face the patient, and
do not change your mode of speaking. As with other parts of a medical history, do not bring up a disability if it is not
relevant to a visit (eg, a patient in a wheelchair with an ear infection). Do not skip relevant parts of the physical
exam even if the disability makes the exam challenging.
 Challenging patient and ethical scenarios “Extra”

The most appropriate response is usually one that is open ended, empathetic, and patient centered. It often honors
one or more of the principles of autonomy, beneficence, nonmaleficence, and justice. Appropriate responses are
respectful of patients and other members of the healthcare team.
A dependent patient presents with injuries inconsistent with caretaker’s story.

Document detailed history and physical. If possible and appropriate, interview the
patient alone. Provide any necessary medical care. If suspicion remains, contact
the appropriate agencies or authorities (eg, child or adult protective services) for an
evaluation. Inform the caretaker of your obligation to report. Physicians are required
by law to report any reasonable suspicion of abuse, neglect, or endangerment.
A pediatrician recommends standard vaccinations for a patient, but the child’s parent refuses.
Address any concerns the parent has. Explain the risks and benefits of vaccinations
and why they are recommended. Do not administer routine vaccinations without the
parent’s consent.
 Use of interpreters “Extra”
Visits with a patient who speaks little English should utilize a professionally trained medical interpreter
unless the physician is also fluent in the patient’s preferred language. Interpretation services may be
provided in person, by telephone, or by video call. If the patient prefers to utilize a family member, this
should be recorded in the chart.
Do not assume that a patient is a poor English speaker because of name, skin tone, or accent. Ask the
patient what language is preferred. The physician should make eye contact with the patient and speak to
them normally, without use of third-person statements such as “tell him.” Allow extra time for the
interview, and ask one question at a time.
For in-person spoken language interpretation, the interpreter should ideally be next to or slightly behind
the patient. For sign language interpretation, the interpreter should be next to or slightly behind the
physician.
Ethics and public health UW updates
 Skewed distribution:
Always the median is in the middle
- positive skewed: mode < median < mean
- negative skewed: mode > median > mean
 Ecological study: when the frequency of a given character and outcome are studied using population data
not individual data, these studies geerate hypothesis and associations but unable to make conclusions
regarding individuals (ecological fallacy)
 Sentinel event : unexpected occurrence involving death or serious physical or psychological injury (e.g.
inpatient suicide) … require immediate investigation
 Accumulation effect: it means that effect of exposure to risk factors or risk reductions depend on the
duration, intensity of the exposure so long term exposure may be necessary before effect appear, this is
relevant with antioxidant use, smoking in lung cancer
 To reduce the “wrong site surgery” error:
- Causes by failure to mark the site, emergency operations, poor communication, surgeon fatigue
- To reduce this most frequent error → marking the operative site, independent verification Independent
verification of the patient, site, procedure mustbe done independely by 2 HCW, also use of surgical
timeout is important
 The proper managemt of an emergency case with NO money:

- According to Law EMTALA, three primary requirements in hospitals that provide emergency services.
1) Provide appropriate screening medical exam to anyone who comes to ED seeking medical care
2) Stabilize & treat the emergency situation
3) Not transfer an individual with emergency medical condition that has not been stabilized
 the leading causes of death in adolescents:

1) accidents
2) homicides
3) suicide
 Calling the patient by his first / surname:

- to build good relationships with the patients → first impressions are important
- initially, asking the patients for their preferred names at the initial encounters
- especially in older patients, call them y their surnae & addressed by Ms. / Mr. to show respect
- by time, after building strong relationship; many patients will prefer to be addressed by their frst name.
however it is always the patient who must take the lead to lower level of formality.
 Types of health insurance plans
 What is the proper response in the following situation:
1. “if one’s physician disagree with another’s practices & physicians”
- If the practice within the standard of care → never criticize the physician in front of the patient
- If the practice is grossly negligent or treatment far outside the standard of care (dangerous)→ the doctor
should be criticized
- Privately discuss the patient with the referring physician to understand the reason for his medications
and explain the change
2. “non adherent to anti diabetic management as she feels good”
1. Always begin by acknowledging that it is difficult to take medications daily for a silent disease
(normalizing her difficutly of non-adherence)
2. Then, start open ended exploration about the reasons of her non-adherence
3. Then followed by non-judgmental exploration of the patient’s understanding of illness
4. Never criticize the patient behavior or knowledge
3. “please, don’t tell my father about his cancer diagnosis”
- Every patient have the right to refuse receival of medical information as well as he is intact
- Certain cultures view that withholding medical information is appropriate (with beneficence >
autonomy)
- The physician rule is to respect these cultural beliefs about the patient, but emphasis is paced on family
making health care decisions for the patient alone as well as he is competent
4. “adolescent don’t take his insulin regularly”
- Adolescence involve developmental separation form parental figures to find one’s society and taking
responsibilities for ones health
- Factors associated with better treatment adherence → close peers with complementary behavioral
practices, positive family functioning, physician empathy
- These changes occur in adolescence may be due to immaturation of prefrontal cortex which is completely
developed at 3rd decade of life, so they less able to weigh risks & benefits of their decisions
5. “ senior attending order a wrong drug to the patient”
- As art of education process it is essential to understand the clinical reasoning behind the team member
decisions, as it is the best interest for both junior & senior staff
- So respectfully discuss the issue directly and ask why the decision was made, don’t order the medication
until you ask him
6. “I need more pain medication”
- First, revise his previous prescriptions using state based online prescription drug monitoring programs
, it will clarify which drugs, by whom and any suspected abuse will appear
- The most appropriate actions are to validate the patient’s concern about pain control, engage in non-
judgmental & collaborative discussion of how he is using medication
7. “non-English speaking patient and need informed consent”
- The best is providing medically trained interpreters, they are trained and know medical terms and can
easily explain the procedure to the patients.
- Begin by screening test to assess language proficiency; “how well do you spek English∷ not at all, not
well, well, very well” → language interprter is needed when the answer is not well or no answer
- Using bilingual friend or family member is inappropriate as it will break the confidentiality and they are
generally not trained and not knowing the medical terms
8. “The patient is deaf”
- Just like limited English proficiency, deaf patients require either American sign language fluent provider
or qualified sign language interpreter, if not available, remote video interpreting services should be
offered
- If urgent situation need communication, use any communication available including family, drawing
and writing
9. “the intern should take informed consent about procedure he didn’t know about”
- Informed consent is not a paper needed to be signed, it is a dialogue between the provider and patient
about the procedure
- The doctor must inform the patient about risk, benefits, alternative treatment
- The ideal physician who take informed consent is the one who will do the procedure
10. “you are an attractive doctor, I wish to go for date with you”
- Romantic and sexual relationships with current patients are always unethical due to potential
interference with the physician role as a doctor
- Romantic relationships between doctors (non-psychiatrists)– patients (after termination the doctor
patient relationship) may be acceptable, but it is not the role
11. “I use weight loss herbal preparations, they are good”
- Although FDA regulate the use of herbal medications, they contain toxic ingredients that may cause
adverse effects and dangerous drug interactions
- The patient should be counseled regarding the risks of using unregulated supplements and by the help
of physician they should prepare plan for safer behavior to lose weight
12. “different religion, but pray for me in the OR”
- You as a doctor should respect the beliefs of your patient even it is totally different from yours
- In the interests of doing no harm, the physician should agree at least in a generic sense, to keep the
patient in their thoughts / prayers
- In non-emergency cases, chaplain is a very crucial person for religious patients especially in advnce
directive & DNR orders
13. “I always skip the dose of cortisol, double the dose as needed”
- Patient misunderstanding of medication use can resut in medication error and in serious cases can lead
to toxicity
- The physician should educate this patient about the risk associated with irregular dosing (not only write
the dose)
14. “terminate the pregnancy as soon as possible”
- Physicians are not required to provide medical services that are against their personal / moral beliefs
- First, establish patient-physician relationship, start neutral non judgmental discussion with the patients
and alternatives.
- Second, if the patient insists, the physician should respect patient autonomy and he is obligated to refer
the patient to another service provider.
15. “write an antibiotic to me, i am your friend”
- Treatment of friends and family should be limited to emergency situations when no other physician is
available
- Before helping your friend, consider ethical issues. There are potential problems that results from
inadequate assessment.
10. “you are an attractive doctor, I wish to go for date with you”
- Romantic and sexual relationships with current patients are always unethical due to potential
interference with the physician role as a doctor
- Romantic relationships between doctors (non-psychiatrists)– patients (after termination the doctor
patient relationship) may be acceptable, but it is not the role
11. “I use weight loss herbal preparations, they are good”
- Although FDA regulate the use of herbal medications, they contain toxic ingredients that may cause
adverse effects and dangerous drug interactions
- The patient should be counseled regarding the risks of using unregulated supplements and by the help
of physician they should prepare plan for safer behavior to lose weight
12. “different religion, but pray for me in the OR”
- You as a doctor should respect the beliefs of your patient even it is totally different from yours
- In the interests of doing no harm, the physician should agree at least in a generic sense, to keep the
patient in their thoughts / prayers
- In non-emergency cases, chaplain is a very crucial person for religious patients especially in advnce
directive & DNR orders
13. “I always skip the dose of cortisol, double the dose as needed”
- Patient misunderstanding of medication use can resut in medication error and in serious cases can lead
to toxicity
- The physician should educate this patient about the risk associated with irregular dosing (not only write
the dose)
14. “terminate the pregnancy as soon as possible”
- Physicians are not required to provide medical services that are against their personal / moral beliefs
- First, establish patient-physician relationship, start neutral non judgmental discussion with the patients
and alternatives.
- Second, if the patient insists, the physician should respect patient autonomy and he is obligated to refer
the patient to another service provider.
15. “write an antibiotic to me, i am your friend”
- Treatment of friends and family should be limited to emergency situations when no other physician is
available
- Before helping your friend, consider ethical issues. There are potential problems that results from
inadequate assessment.
16. “I need antibiotic for my common cold”
- This problem of prescribing un-necessary antibiotic is common
- The best approach is (patient centered approach) → educate the patient about the adverse effects of
antibiotics and lack of efficacy and provide another options for treating the conditions, this should be
done with empathic, non-judgmental fashion
17. “I want my fallopian tubes get ligated”

- Every individual has autonomy over his body including reproductive organs
- Although, the physician should encourage the patient to discuss the decision with her husband, his
consent is useless.
- So consent must be taken from the patient alone after discussing with her the different options

Ethics Public Health PDF

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ethics Public Health PDF

Uploaded by

Copyright:

Available Formats

USMLE ENDPOINT ETHICS & Public health

 Most important 4 major principles that guide medical ethics are:

A. Try to discuss it with him.

Dr Ahmed Shebl Page 1

Discharge against medical advice (AMA)

Adult patient refuses care because it is against their religious

Knowledge of an incurable disease may result in significant

Psychotic patient is experiencing command auditory

Dr Ahmed Shebl Page 2

A patient refuses knowledge of his diagnosis

A patient with mental illness refusing treatment

30 year-old patient wants to undergo bilateral tubal ligation

Dr Ahmed Shebl Page 3

Patient desires unnecessary procedure:

A patient is asking the doctor for herbal medicine which is banned by

A patient is using a weight loss drugs from internet that contains

Dr Ahmed Shebl Page 4

DECISION MAKING CAPACITY

Requirements for decision making capacity:

Dr Ahmed Shebl Page 5

Dr Ahmed Shebl Page 6

Dr Ahmed Shebl Page 7

LIMITATIONS ON THE ABILITY OF PARENTS TO

Dr Ahmed Shebl Page 8

Exceptions of informed consent:

Dr Ahmed Shebl Page 9

Dr Ahmed Shebl Page 10

Dr Ahmed Shebl Page 11

Dr Ahmed Shebl Page 12

 Patient’s family member asks if patient is ok following emergency

 Patient’s family member calls office wanting medical information

 Patient’s family members ask you not to disclose test results if

Dr Ahmed Shebl Page 13

 A football player with infectious mononucleosis and splenomegaly

WITHHOLDING AND WITHDRAWING OF CARE

Dr Ahmed Shebl Page 14

2- Health Care Proxy

Patient incapacitated, legally designated proxy (friend) refuses

Types of advance directives:

Dr Ahmed Shebl Page 15

Patient with no capacity and no advance directive

Dr Ahmed Shebl Page 16

FLUID AND NUTRITION ISSUES

PHYSICIAN-ASSISTED SUICIDE AND EUTHANASIA

Dr Ahmed Shebl Page 17

Dr Ahmed Shebl Page 18

 Patient officially determined brain dead, family insists on

 Patient with persistent vegetative state:

Dr Ahmed Shebl Page 19

17 year old patient is pregnant and requests abortion

Dr Ahmed Shebl Page 20

Dr Ahmed Shebl Page 21

Dr Ahmed Shebl Page 22

Dr Ahmed Shebl Page 23

 As a rule, physicians should maintain a general policy of not accepting gifts of

 Some general recommendations regarding the acceptance of gifts include the

Dr Ahmed Shebl Page 24

Patient angry about long wait time at office

Patient upset by way they were treated by another doctor

Dr Ahmed Shebl Page 25

Patient is upset by her back pain that is not responding to treatment

Dr Ahmed Shebl Page 26