Ethics

Question 1

T or F: Withdrawal of care must always be proven brain death.

Answer 1

False

• i.e. 7 y.o. CP with MVA presents GCS 4. ICU x 1 week with no change. if parents certain to withdraw they can.

Question 2

Jehovah’s witness need emergent blood. What do you do?

Answer 2

Transfuse now without parental consent.

Question 3

What are exceptions to general duty to provide life-sustaining tx?

Answer 3

• No Tx.
• Tx harmful.
• Going to die fast.
• Withdrawal better palliation.

Details:

• distress or suffering cannot be prevented or alleviated
• tx clearly ineffective or harmful
• irreversible progression to imminent death
• life to be severely shortened regardless of tx; withdrawal or limited care provide better palliation

Question 4

T or F: withhold or withdraw life-sustaining tx ethically appropriate if tx will not benefit child or adolescent.

Answer 4

True

Question 5

Tips with withdrawal or withholding care:

Answer 5

• interdisciplinary team involved +/- ethics committee or consultant
• recognize cultural, religious, spiritual, moral bkgrd of families
• document + review well decision well

Question 6

Management decisions should ALWAYS be based on:

Answer 6

best interest of child

NOT:

• cost to society
• burden to fam

Question 7

T or F: Autonomy may be superseded with CAS if child apprehended.

Answer 7

True.

• CAS authority can supersede wishes of parent + child if apprehended.

Question 8

T or F: tx decision from proxy decision makers cannot change once made.

Answer 8

False.

Question 9

What is a substitute decision maker?

Answer 9

• guardian respect child’s previously expressed wishes

Question 10

What is a proxy decision maker?

Answer 10

= decision makers if pt incapable

• two types:
  > substitute= know well and already discussed what they want done
  >surrogate= don’t know but decide in best interest

Question 11

List 3 Hallmarks of Informed Choice

Answer 11

“VIC”

1. VOLUNTARIness (no manipulation or coercion)
2. Appropriate INFO
3. CAPACITY

Question 12

What is assent?

Answer 12

Info they can understand and appropriate choice of tx.

• i.e. which arm to poke for BW
• best for kids w/ partial skills to make decision

Question 13

What’s the difference between emancipated versus mature minors?

Answer 13

Emancipated: no longer dependent on parent.

Mature= irregardless of age can understand health condition and tx

Question 14

If you think parental decision not in best interest of child- what do you do?

Answer 14

• explore decision w/ multi-D
• 2nd opinion.
• ethics committee or consultant
• or if all consultants agree contrary then legal opinion

Question 15

T or F: there is minimum age for decision making?

Answer 15

False.

Question 16

Brain death =

Answer 16

irreversible cessation of entire brain (inclding brainstem)

AKA determination of death using neuro criteria

Question 17

Brain death is most commonly after:

Answer 17

1. TBI

2. Asphyxia injury

Question 18

What are the 3 clinical components of brain death:

Answer 18

1. Irreversible coma with known cause
   - not metabolic, toxin, drugs, T, lytes etc.
2. Absence of brainstem reflexes
   - pupillary light, oculocephalic, corneal, oculovestibular, gag + cough
3. Apnea
   - no resp effort after adequate stimulus

+ observation period x 2 examinations (12-24h)

Question 19

T or F: spinal reflexes may occur in brain death

Answer 19

True.

• subtle, semi-rhythmic movement of facial nerve, finger flexion, tonic neck etc.

Question 20

What is the apnea test in brain death?

Answer 20

Goal: assess function of medulla in driving vent

1- ensure no other reason for apnea (i.e. sedative drugs, metabolic)
2- pre-O2 100%
3- vent adjusted to get PCO2 40
4- baseline gas
5- repeated blood gas till target PCO2 suppressed (60) or unstable

Question 21

Are EEG and Cerebral blood flow required for brain death dx?

Answer 21

No.

Ancillary test.
- may do if can’t do apnea test well
+ help shorten observation period

Question 22

Most kids on peds organ donation waiting for:

Answer 22

liver
kidney
small bowel

Question 23

T or F: anyone can approach families about organ donation

Answer 23

False.

• AAP: approach in systematic person trained in psych, social, medial part of dx

Question 24

Who can be considered for organ donation?

Answer 24

• declared brain death

- cardiocirculatory death

Question 25

T or F: consent is all or nothin (no organ specific)

Answer 25

False. Organ specific

Question 26

Contraindicatons to Organ Donation:

Answer 26

"PIMM" Prematurity Infection (septicemia, TB, Creutzfeldt-Jakob dx, HIV, west nile, Hep B, Hep C) Malignancy Mets (disseminated)

Question 27

Child with severe head injury. Father suspected of abuse. What do you do about withdrawal of care? Court, Parents both decide, Police need to be aware?

Answer 27

Parents both decide AAP: decision re: life-sustaining tx for kids injured by suspected abuse should be determined by same send as other kids.

Question 28

T or F: patient does not need to be brain dead to consent to be obtained for organ donation?

Answer 28

True. - pt suffered devastating or irreversible brain injury - near death but does not meet formal criteria - fam may withdraw and when heart stops organs recovered in OR - can recover up to 1hr after withdrawal of support

Question 29

T or F: parent's wishes are more imp than MD fiduciary obligation to act in best interest?

Answer 29

False.

Question 30

What is reasonableness when someone makes SDM decision?

Answer 30

Best option= one most rational people would choose after all factors considered?

Question 31

Define autonomy

Answer 31

Right of individual to make decision and act freely without interference.

Question 32

Define beneficence

Answer 32

Responsibility of physician to act in patient's best interest

Question 33

Old theory of parental authority=

Answer 33

right of parent to make decision for child because considered property of parent= BAD

Question 34

Define non-maleficence

Answer 34

Do not harm

Question 35

Clinical tip: what guideline can you refer to if ensure if parental decision oppose best interest for child?

Answer 35

Does it fit.... "All children are entitled to medical tx that is likely to 1. prevent serious harm 2. prevent suffering 3. prevent death"

Question 36

What are high risk sexual assaults traits for transmission of STI?

Answer 36

- pt has STI signs - suspected perpetrator has known STI - genital, oral, anal penetration or ejaculation - someone living in household has STI - pt or parent requesting test

Question 37

What do you disclose to police re: a pt?

Answer 37

- refrain from patient info unless patient consent or warrant/ court order/ subpoena

Question 38

Is it appropriate to donate organs from anencephalic baby?

Answer 38

No. - do not usually satisfy brain death b/c adequate brainstem f'n - once death occur usually organ have irreparable ischemic damage (which occurs due to gradual brainstem deterioration even on life support)

Question 39

What special consideration may you keep in mind for teenager who hung herself?

Answer 39

- high cervical spine injury= confounding factor to clinical assessment for neurologic brain death - R/O cervical spine injury before full assessment for brain death - if can't do clinical test due to injury= ancillary tests!

Question 40

Which withdrawal consideration must you make for child submersed in cold water?

Answer 40

- rewarm to min. 34C before resus stopped - if survive + CVS stable serial neuro exam x 48-72h (as can see significant gains) - consider withdrawal if no neurologic recovery after this.

Question 41

Which is true for kids in foster care: a. in older kids occasional visit warranted if pvx strong attachment b. disruption in continuity of care potentially harmful c. if loving in foster home in 1st year of life- will do well. d. child should be placed with grandparents for best long term oucome

Answer 41

B. Disruption of continuity of care may be potentially detrimental to all kids.

Question 42

List common medical issues that arise with foster care admission?

Answer 42

- poor hygiene - under immunization - dental neglect - contraception

Question 43

T or F: mental health problems + behavioural found in 1/2 of foster care kids

Answer 43

True