FDN2_Ethics

Question 1

What 4 pieces of information are necessary for a patient to make an informed decision?

Answer 1

1. Diagnosis and prognosis
2. Recommended treatment*
3. Alternative treatments*
4. Consequences of no intervention*

*And associated risks, benefits, and consequences

Question 2

What case resulted in the “duty to inform” ruling?

Answer 2

Martin Salgo

Question 3

Describe the Martin Salgo case

Answer 3

• Martin Salgo was permanently paralyzed following translumbar aortography.
• The physician did not infrom him of the possible risk of paralysis
• Martin Salgo sued
• The court ruled that physicians had a duty to inform patients of “any facts which are necessary to form the basis of an intelligent consent by the patient to the proposed treatment”

Question 4

What information should be provided to the patient under the “duty to inform” ruling?

Answer 4

• Any facts necessary to provide informed consent
• Basically, any side effects/consequences that are common or serious

Question 5

Name 3 informed refusal cases

Answer 5

• Dax Coward (Texas, 1972)
• Elizabeth Bouvia (California, 1983)
• William Bartling (California, 1984)

Question 6

Describe the Dax Coward case

Answer 6

Dax Coward suffered severe burns all over his body and continually requested that treatmetn be stopped. Physicians refused, and Coward was treated against his will

Question 7

Describe the Elizabeth Bouvia case

Answer 7

• Elizabeth Bouvia had cerebral palsy
• She admitted herself to the hospital, requesting that she be allowed to starve herself to death
• Eventually, the hospital force fed Bouvia
• The court determined that Bouvia (like any competent patient) had the right to refuse any medical treatment

Question 8

Describe the William Bartling case

Answer 8

• William Bartling was a patient with several medical conditions, but was not terminally ill
• Bartling requested to be removed from the respirator, but the hospital refused
• The supreme court of California sided with Bartling

Question 9

Describe the idea of consent

Answer 9

Patients who have decision making capacity have the ability to agree to or refuse any medical treatment proposed by a physician

Question 10

What is assent? How is it different from consent?

Answer 10

Patients who lack decision making capacity cannot consent to or refuse a treatment

Assent = these patients agreeing to/accepting the treatment for which their surrogate has given consent

Health care professionals have a moral oblication to ask for assent

Question 11

Describe a patient who can give assent, but not consent, for a proposed treatment

Answer 11

• A minor
• A patient who lacks decision-making capacity

Question 12

What are the 4 types of advance directives?

Which are written and which are oral?

Answer 12

1. Living wills (written)
2. Health care proxy (written)
3. Oral statements to family members or friends
4. Oral statements to physicians

Question 13

What are the 3 criteria for evaluating the trustworthiness of an advance directive?

Answer 13

Advance directives are more trustworthy if they are…

1. _S_pecific - The directive should indicate what specific treatments the patient would want in various clinical situations
2. _I_nformed - The patient’s preferences must be informed
3. _R_epeated - The directive is repeated over time, in different situations, to varous individuals

Question 14

If a patient lacks decision making capacity and an advance directive is unavailable, how are decisions made about treatment?

Answer 14

A surrogate decision maker

Question 15

What are the two standards for surrogate decision making for adults?

Answer 15

1. Substituted Judgement: Surrogate attempts to make decisions based upon the known values of the patient
2. Best Interest: Descisions are bade based upon what a “reasonable person” would wish done in the given case. One should consider reduced suffering, quality of life, and risks and benefits of proposed intervention

Question 16

A surrogate decision maker who is using best interest standards should take into accout…

Answer 16

• Reduced potential suffering
• Quality of life
• Risks and benefits of proposed treatment

Question 17

If a surrogate is using the patient’s values to make a decision about their treatment, they are using…

Answer 17

Substituted judgement

Question 18

If a surrogate is basing treatment desisions upon what a reasonable person would wish for, they are using…

Answer 18

Best interest standards

Question 19

Name 3 surrogate desision court cases

Answer 19

1. Karen Anne Quinlan
2. Nancy Cruzan
3. Terri Schiavo

Question 20

Describe the Karen Anne Quinlan case

Answer 20

The first “right to die” case

• Karen Anne Quinlan was a 22 year old woman in a persistent vegetative state
• Physicians refused the family’s request to remove her ventilator
• The court decided that family members can act as guardians and patients can be removed from ventilators

Question 21

Describe the Nancy Cruzan case

Answer 21

• Nancy Cruzan was a 33 year old woman in a persistent vegetative state
• Her family requested that her feeding tube be removed, but physicians refused
• The court decided that states have the right to determine the level of evidence necessary for substituted judgement

Question 22

Describe the Terri Shiavo case

Answer 22

• Terri Shaivo was a 27 year old woman in a persistent vegetative state
• Terri’s husband requested that her feeding tube be removed
• Terri’s parents challenged the decision
• Extended/multiple court cases (lasting 15+ years!); Pro-life groups and governors (Jeb bush) got involved to affect the outcome (significant because of how much it blew up)

Question 23

How is a living will different from an advance directive?

Answer 23

A living will is a type of advance directive that is written down

Question 24

What is the difference between a healthcare proxy and a surrogate decision maker?

Answer 24

A healthcare proxy is a type of surrogate decision maker appointed by the patient while they still have decision-making capacity

Question 25

What is the order for determining a surrogate decision maker?

Answer 25

Highest to lowest priority: 1. Court appointed 2. Proxy appointed by the patient 3. Family 1. Spouse 2. Adult children 3. Adult siblings 4. Friend 5. Physician consulting with hospital ethics committee

Question 26

How shoudl physicians assist surrogates in making decisions for the patient?

Answer 26

* Discuss the process * Give a recommendation (especially if the surrogate wants one) * Get help from other healthcare workers (ethics committee)

Question 27

When should "best interest" standards be used in surrogate decision making?

Answer 27

* When it is unclear what decision the patient would have made * When a reliable surrogate is unavailable or doesn't know what to do