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What is autonomy?
The obligation to respect patients as individuals and to honor their preferences in medical care
Which value might beneficence conflict with, and how is this conflict resolved?
Autonomy; if the patient can make an informed decision, ultimately the patient has the right to decide
What is nonmaleficence?
"Do no harm" However, if the benefits of an intervention outweigh the risks, a patient may make an informed decision to proceed (most surgeries fall into this category)
What three things are required for valid informed consent?
1. Discussion of pertinent information
2. Patient's agreement to the plan of care
3. Freedom from coercion
What three things must be explained to the patient in order for informed consent to be valid?
3. Alternatives (includes no intervention)
What are the four exceptions to informed consent?
1. Patient lacks decision making capacity or is legally incompetent
2. Implied consent in an emergency
3. Therapeutic privilege-withholding information when disclosure would severely harm the patient or undermine decision-making capacity
4. Waiver-patient waives the right of informed consent
What are four ways in which a minor can become emancipated?
3. Have children
4. In military
In which five situations is consent from parents NOT required to treat a minor?
1. Emergency situations
2. When prescribing contraceptives
3. Treatment involving STDs
4. Medical care during pregnancy
5. Management of drug addiction
What five things must occur for a patient to demonstrate "decision-making capacity"?
1. Patient makes and communicates a choice
2. Patient is informed
3. Decision remains stable over time
4. Decision is consistent with patient's values and goals
5. Decision is not a result of delusions or hallucinations
What are advance directives?
Instructions given by a patient in anticipation of the need for a medical decision
What four things make an oral directive more valid?
1. The patient was informed
2. The directive is specific
3. The patient made a choice
4. The decision was repeated over time
What is a living will?
A written description of treatments the patient wishes to receive or not receive if he/she becomes incapacitated and cannot communicate about treatment decisions.
What does a living will usually direct?
A physician to withhold or withdraw life-sustaining treatment if the patient develops a terminal disease or enters a persistent vegetative state
What is a durable power of attorney?
A surrogate designated by a patient to make medical decisions in the event that he/she loses decision-making capacity
Can a patient waive the right to confidentiality? What is an example of this?
Yes, e.g., insurance companies
What are four instances in which a physician is allowed to breach confidentiality?
1. Potential to harm others is serious
2. Likelihood of harm to self is great
3. No alternative means exist to warn or to protect those at risk
4. Physicians can take steps to prevent harm
What are 5 examples of steps physicians can take to prevent harm?
1. Infectious diseases--physicians may have a duty to warn public officials and identifiable people at risk
2. The Tarasoff decision--law requiring physician to directly inform and protect potential victim from harm; may involve breach of confidentiality
3. Child/elder abuse
4. Impaired automobile drivers
5. Suicidal/homicidal patients
What must be proved for a malpractice suit to be upheld?
1. Physician had a duty to the patient (Duty)
2. Physician breached that duty (Dereliction)
3. Patient suffers harm (Damage)
4. The breach of the duty was what caused the harm (Direct)
**The 4 D's**
What is the most common factor leading to litigation?
Poor communication between a physician and patient
What should a physician do if a patient is noncompliant?
1. Attempt to identify the patient's reason for non-compliance
2. Determine patient's willingness to change harmful behavior or undergo a necessary procedure
3. Do not attempt to coerce the patient into complying or refer the patient to another physician
What should a physician do if a patient continues smoking, believing that cigarettes are good for him?
1. Ask how the patient feels about his/her smoking
2. Offer advice on cessation if the patient seems willing to make an effort to quit
What should a physician do if a patient desires an unnecessary procedure?
1. Attempt to understand why the patient wants the procedure
2. Do not refuse to see the patient or refer him/her to another physician
3. Address the underlying concern
4. Avoid performing unnecessary procedures
What should a physician do if a patient has difficulty taking medications?
1. Provide written instructions
2. Attempt to simplify treatment regimens
What should a physician do if a patient's family members ask for information about patient's prognosis?
Avoid discussing issues with relatives without the permission of the patient
What should a physician do if a child wishes to know more about his illness?
1. Ask what the parents have told the child about his/her illness
2. Parents of a child decide what information can be relayed about the illness
What should a physician do if a 17-year-old patient is pregnant and requests an abortion?
1. Many states require parental notification or consent for minors for an abortion
2. Unless she is at medical risk, do not advise a patient to have an abortion regardless of her age or the condition of the fetus
What should a physician do if a 15-year-old patient is pregnant and wants to keep the child, but her parents want you to tell her to give the child up for adoption?
1. The patient retains the right to make decisions regarding her child, even if her parents disagree
2. Provide information to the teenager about the practical issues of caring for a baby
3. Discuss the options, if requested
4. Encourage discussion between the teenager and her parents to reach the best decision
What should a physician do if a terminally ill patient requests physician assistance to end his/her life?
1. In the overwhelming majority of states, refuse involvement in any form of physician assisted suicide
2. Physicians may, however, prescribe medically appropriate analgesics that coincidentally shorten the patient's life
What should a physician do if a patient is suicidal?
1. Assess the seriousness of the threat
2. If it is serious, suggest that the patient remain in the hospital voluntarily
3. Patient can be hospitalized involuntarily if he/she refuses
What should a physician do if a patient states that he finds you attractive?
1. Ask direct, closed ended questions, with a chaperone if necessary
2. Romantic relationships with a patient are NEVER appropriate
3. Never say, "there can be no relationship while you are a patient," because it implies that a relationship may be possible if the individual is no longer a patient
What should a physician do if a patient who had a mastectomy says she feels "ugly" when she undresses at night?
1. Find out why the patient feels this way
2. Do not offer falsely reassuring statements (e.g., "You still look good.").
What should a physician do if a patient is angry at the time spent in the waiting room?
1. Acknowledge the patient's anger, but do not take a patient's anger personally
2. Apologize for any inconvenience
3. Avoid efforts to explain the delay
What should a physician do if a patient is upset by the way he was treated by another doctor?
1. Suggest that the patient speak directly to that physician regarding his concerns
2. If the problem is with a member of the office staff, tell the patient you will speak to that individual
What should a physician do if a drug company offers a "referral fee" for every patient a doctor enrolls in a study?
Eligible patients who may benefit from the study may be enrolled, but it is NEVER acceptable for a physician to receive compensation from a drug company
APGAR scores of 1 are?
1. A = Trunk pink
2. P = <100/min
3. G = Grimace only
4. A = Some activity
5. R = Irregular
APGAR scores of 2 are?
1. A = All pink
2. P = >100/min
3. G = Grimace + cough
4. A = Active
5. R = Regular
What are five common complications of low birth weight?
2. Respiratory distress syndrome
3. Necrotizing enterocolitis
4. Intraventricular hemorrhage
5. Persistent fetal circulation
What are two Motor milestones at 12-24 months?
1. Climbs stairs
2. Stacks 3 blocks at 1 year; 6 blocks at 2 years
What are two Cognitive/social milestones at 12-24 months?
1. Object permanence
2. 200 words and 2 word sentences at age 2
What are two Motor milestone at 3 years?
1. Rides tricycle
2. Copies line or circle drawing
**rides 3-cycle at age 3**
What are five Cognitive/social milestones at 4 years?
1. Cooperative play
2. Imaginary friends
3. Grooms self
4. Brushes teeth
5. Buttons and zips
What are the Tanner stages of development?
2. Pubic hair appears (adrenarche); breasts enlarge
3. Pubic hair darkens and becomes curly; penis size/length increase
4. Penis width increases, darker scrotal skin, development of glans, raised areolae
5. Adult; areolae no longer raised
What two sleep pattern changes are present in the elderly with age?
1. Decreased REM and slow wave sleep
2. Increased latency and awakenings
How does aging affect body systems?
1. Decreased vision
2. Decreased hearing
3. Decreased immune response
4. Decreased bladder control
5. Decreased renal, pulmonary, and GI function
6. Decreased muscle mass
7. Increased fat
What five things is normal grief characterized by?
4. Somatic symptoms
What four things might pathological grief include?
1. Excessively intense grief
2. Prolonged grief lasting > 2 months
3. Grief that is delayed, inhibited, or denied
4. Grief with depressive symptoms, delusions, and hallucinations
What are the Kubler-Ross grief stages of grief?
**Death Arrives Bringing Grave Adjustments**
Stages do not necessarily occur in this order, and more than one stage can be present at once
What five body substances does stress induces production of?
1. Free fatty acids
2. 17-OH corticosteroids (immunosuppression)
What are four effects stress has on body functions?
1. Water absorption
2. Muscular tonicity
3. Gastrocolic reflex
4. Mucosal circulation
What are four drug classes that can cause sexual dysfunction?
What are the categories and values defined by BMI?
1. <18.5 underweight
2. 18.5-25.9 normal
3. 25.0-29.9 overweight
4. >30.0 obese
5. >40.0 morbidly obese
What are the stages of sleep, the % time spent in each stage, and the EEG waveform associated with each stage?
Awake eyes open = Beta
Awake eyes closed = Alpha
Stage 1, light sleep, (5%) = Theta
Stage 2, deeper sleep, (45%) = Sleep spindles and K complexes
Stage 3-4, deepest, non-REM sleep, (25%) = Delta
REM, (25%) = Beta
**At night, BATS Drink Blood**
What are three sleep disorders tha t manifest in stage 4 sleep?
3. Night terrors
What kinds of things occur in REM sleep?
2. Loss of motor tone
3. Memory processing
5. Increased brain oxygen use
What are extraocular movements during REM sleep caused by?
Increased activity in the PPRF (paramedian pontine reticular formation/conjugate gaze center)
What is the preferred treatment for pathologic bedwetting? How does it work?
Imipramine; decreases stage 3-4 sleep
What is the preferred treatment for night terrors and sleepwalking? How does it work?
Benzodiazepines (decreased stage 3-4 sleep)
What are four physical changes that occur during REM sleep?
1. Increased and variable pulse
3. Increased and variable blood pressure
4. Penile/clitoral tumescence
**REM like sex: increased pulse, tumescence, decreases with age**
How does the duration of REM sleep change throughout the night?
REM duration increases as the night progresses
What are six ways depression affects sleep patterns?
1. Decreased slow wave sleep
2. Decreased REM latency
3. Increased REM early in sleep cycle
4. Increased total REM sleep
5. Repeated nighttime awakenings
6. Early-morning awakening (important screening question)
Narcolepsy: three symptoms?
1. Hypnogogic and hypnopompic hallucinations
2. Cataplexy (loss of all muscle tone following strong emotional stimulus)
3. Sleep episodes starting off with REM sleep
What is the circadian rhythm is driven by? What does this driver control, specifically?
Suprachiasmatic nucleus of hypothalamus; controls ACTH, prolactin, melatonin, and nocturnal NE release
Sleep terror disorder: definition and symptoms?
1. Periods of terror with screaming in the middle of the night
2. No memory of arousal
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