ABSITE - Ethics
A 39-year-old female with melanoma metastatic to the brain is admitted to the intensive care
unit with new hemiplegia and obtundation. She has previously had an aggressive approach to
her disease, undergoing surgical removal of a lesion in her occipital lobe, gamma knife
treatment of other lesions, and total brain radiation. She has a five-year-old daughter. She also
has an advance directive stating that if the lesions cause her to lose her personality and ability
to perform daily tasks, she would like to receive supportive care only. Her family has
unanimously decided to continue with aggressive treatment so that she can see her daughter
turn six in a couple of months. Who has the ultimate decision-making authority?
A. The patient's family
B. The patient's advance directive
C. The patient's physicians
D. The hospital ethics committee
E. A judge in the local court system - ANS-The patient's advance directive
Correct.
The patient has the ultimate authority to determine the type of care he/she would like to receive.
An advance directive is a formalized document that informs providers about the patient's wishes
should they become incapacitated. In all states, the advance directive is the ultimate authority
as a direct expression of a patient's wishes. Family members may think they know the patient's
wishes based on knowledge of their values, but may not know the contents of a patient's
advance directive. Providers may become decision makers if a substitute decision maker
abdicates the authority to them. If that is the case, the provider should involve all stakeholders in
an in-depth discussion about the condition and use negotiation and consensus building to come
to an acceptable plan for all, keeping the patient's best interests at the forefront. The hospital
ethics committee and a judge may ultimately become involved, but these are not the first steps.
A 57-year-old female is transferred to your facility after spending a prolonged amount of time at
another hospital where she had a partial colectomy complicated by unrecognized bowel injury,
fascial dehiscence, and enterocutaneous fistula. When you arrive to the patient's room to admit
her, you see the patient sitting in bed, typing on a laptop. Before you can introduce yourself, she
interrupts you and demands to know what the treatment plan is and how you will help her so
she can return to running her business. You try your best to explain that not all the medical
records came over from the outside hospital and that you need to review her entire situation
before you can come up with a plan. She insists that the whole record was transferred and you
should have all the information you need. She then gets even angrier, insisting that it was a
mistake to have been transferred and that you are refusing to help her becaus - ANS-Offer an
apology for the perceived offense.
Correct.
If this scenario is to have any hope of a positive outcome, an apology should be offered for any
perceived offense, even if none was intended. The patient is likely well-educated and has
researched her condition, as evidenced by her possession of a computer and the fact that she
, owns her own business. She is frustrated with the care she has received so far with the
complications that have occurred and are likely displacing onto you. Learning to recognize this
and attempt to diffuse these situations is a key skill needed in building trust. Showing your
practice's patient demographics is unprofessional and likely to lead to further mistrust as you try
to prove her wrong.
A 62-year-old male with a history of known abdominal aortic aneurysm comes to the office for
evaluation. He was diagnosed with a 5.5-cm suprarenal aneurysm extending from 2 cm above
the diaphragm to 1 cm inferior to the renal arteries and it has grown in the past year to 6.2 cm in
diameter. He also has a history of moderate COPD. He is interested in a surgical opinion. The
only vascular surgeon who is a provider on his health plan does not do interventional radiologic
vascular procedures. Which of the following should be discussed with the patient?
A. He may want to see a surgeon who can do both interventional and open vascular repairs
even if the provider is not on his insurance.
B. Continued observation until he turns 65 when he will receive Medicare and have more
options
C. Referral to the insurance-approved surgeon for consideration of open repair
D. Admission of the patient to the hospital for evaluation since i - ANS-He may want to see a
surgeon who can do both interventional and open vascular repairs even if the provider is not on
his insurance.
Correct.
BIOETHICS BOTTOM LINE
In situations involving choices between provision of suboptimal care that is readily available and
covered by insurance versus optimal care that may be more difficult to access and/or pay for,
physicians should discuss services that are available outside the system. Doing so will allow the
patient to make an informed decision about his care, as well as indicate to the patient the
recommendation that he try to obtain these services, either by paying out of pocket for care or
trying to convince his plan to pay for care outside the system. Physicians should honor their
fiduciary duty to patients, which requires physicians to disclose medically feasible and desirable
alternatives, including alternatives that may not be covered by an insurance plan.
Continued observation and no repair would not be in this patient's best interest since his risk of
rupture is increased. Admission to the hospital solely for the reason of obtaining insurance
coverage for his consultation is ethically not appropriate and misuses resources.
A 74-year-old male with hypertension, chronic obstructive pulmonary disease, and pancreatic
cancer is admitted to the hospital with hypoxia and community-acquired pneumonia. He was
diagnosed with pancreatic cancer 1 year ago and had a pancreaticoduodenectomy (Whipple
procedure), from which he recovered well.
During this admission, his pulmonary status declines rapidly and he is intubated. Pulmonary
emboli and diffuse pulmonary metastases are seen on computed tomography (CT) scan. He
A 39-year-old female with melanoma metastatic to the brain is admitted to the intensive care
unit with new hemiplegia and obtundation. She has previously had an aggressive approach to
her disease, undergoing surgical removal of a lesion in her occipital lobe, gamma knife
treatment of other lesions, and total brain radiation. She has a five-year-old daughter. She also
has an advance directive stating that if the lesions cause her to lose her personality and ability
to perform daily tasks, she would like to receive supportive care only. Her family has
unanimously decided to continue with aggressive treatment so that she can see her daughter
turn six in a couple of months. Who has the ultimate decision-making authority?
A. The patient's family
B. The patient's advance directive
C. The patient's physicians
D. The hospital ethics committee
E. A judge in the local court system - ANS-The patient's advance directive
Correct.
The patient has the ultimate authority to determine the type of care he/she would like to receive.
An advance directive is a formalized document that informs providers about the patient's wishes
should they become incapacitated. In all states, the advance directive is the ultimate authority
as a direct expression of a patient's wishes. Family members may think they know the patient's
wishes based on knowledge of their values, but may not know the contents of a patient's
advance directive. Providers may become decision makers if a substitute decision maker
abdicates the authority to them. If that is the case, the provider should involve all stakeholders in
an in-depth discussion about the condition and use negotiation and consensus building to come
to an acceptable plan for all, keeping the patient's best interests at the forefront. The hospital
ethics committee and a judge may ultimately become involved, but these are not the first steps.
A 57-year-old female is transferred to your facility after spending a prolonged amount of time at
another hospital where she had a partial colectomy complicated by unrecognized bowel injury,
fascial dehiscence, and enterocutaneous fistula. When you arrive to the patient's room to admit
her, you see the patient sitting in bed, typing on a laptop. Before you can introduce yourself, she
interrupts you and demands to know what the treatment plan is and how you will help her so
she can return to running her business. You try your best to explain that not all the medical
records came over from the outside hospital and that you need to review her entire situation
before you can come up with a plan. She insists that the whole record was transferred and you
should have all the information you need. She then gets even angrier, insisting that it was a
mistake to have been transferred and that you are refusing to help her becaus - ANS-Offer an
apology for the perceived offense.
Correct.
If this scenario is to have any hope of a positive outcome, an apology should be offered for any
perceived offense, even if none was intended. The patient is likely well-educated and has
researched her condition, as evidenced by her possession of a computer and the fact that she
, owns her own business. She is frustrated with the care she has received so far with the
complications that have occurred and are likely displacing onto you. Learning to recognize this
and attempt to diffuse these situations is a key skill needed in building trust. Showing your
practice's patient demographics is unprofessional and likely to lead to further mistrust as you try
to prove her wrong.
A 62-year-old male with a history of known abdominal aortic aneurysm comes to the office for
evaluation. He was diagnosed with a 5.5-cm suprarenal aneurysm extending from 2 cm above
the diaphragm to 1 cm inferior to the renal arteries and it has grown in the past year to 6.2 cm in
diameter. He also has a history of moderate COPD. He is interested in a surgical opinion. The
only vascular surgeon who is a provider on his health plan does not do interventional radiologic
vascular procedures. Which of the following should be discussed with the patient?
A. He may want to see a surgeon who can do both interventional and open vascular repairs
even if the provider is not on his insurance.
B. Continued observation until he turns 65 when he will receive Medicare and have more
options
C. Referral to the insurance-approved surgeon for consideration of open repair
D. Admission of the patient to the hospital for evaluation since i - ANS-He may want to see a
surgeon who can do both interventional and open vascular repairs even if the provider is not on
his insurance.
Correct.
BIOETHICS BOTTOM LINE
In situations involving choices between provision of suboptimal care that is readily available and
covered by insurance versus optimal care that may be more difficult to access and/or pay for,
physicians should discuss services that are available outside the system. Doing so will allow the
patient to make an informed decision about his care, as well as indicate to the patient the
recommendation that he try to obtain these services, either by paying out of pocket for care or
trying to convince his plan to pay for care outside the system. Physicians should honor their
fiduciary duty to patients, which requires physicians to disclose medically feasible and desirable
alternatives, including alternatives that may not be covered by an insurance plan.
Continued observation and no repair would not be in this patient's best interest since his risk of
rupture is increased. Admission to the hospital solely for the reason of obtaining insurance
coverage for his consultation is ethically not appropriate and misuses resources.
A 74-year-old male with hypertension, chronic obstructive pulmonary disease, and pancreatic
cancer is admitted to the hospital with hypoxia and community-acquired pneumonia. He was
diagnosed with pancreatic cancer 1 year ago and had a pancreaticoduodenectomy (Whipple
procedure), from which he recovered well.
During this admission, his pulmonary status declines rapidly and he is intubated. Pulmonary
emboli and diffuse pulmonary metastases are seen on computed tomography (CT) scan. He
