KC Ethics

Question 1

*What are 3 elements of capacity?

Answer 1

• Nature of the proposed investigation or treatment
• Anticipated effect of the proposed treatment and alternatives
• Consequences of refusing treatment

Question 2

*What are 5 clinical situations or patient characteristics apart from intoxication, when you can deem someone without capacity?

Answer 2

Unconscious patient
Under public/private curator
Minor below provincial threshold
Advanced dementia
Severe psychiatric disease

Question 3

*What are 2 instances where a physician can circumvent asking for consent and treat anyway?

Answer 3

Life threatening situations
If life or limb are in danger and the patient is unable to consent and the substitute decision maker is not immediately available, a doctor has a duty to:
Do what is immediately necessary.
Respect any known previous wishes of the patient.
Obtain consent as soon as reasonably possible.

Question 4

*What are the elements of informed consent?

Answer 4

Patient is:
Informed
Not-coerced
Capable

Informed
Free of coercion
Understand risk and benefit
Capacity (communicate)
Specific

Question 5

*CAEP 2018 Resident Wellness statement. What are the three elements that comprise burnout?

Answer 5

Emotional exhaustion
Reduced sense of personal accomplishment
Depersonalization

DEESPerAte

Question 6

*What are 8 psychological, professional, or physical consequences of burnout?

Answer 6

Suboptimal patient care
Greater self reported clinical errors
Difficulty focusing
Suicidal ideation
Depression
Substance abuse
Headaches
GI upset
Insomnia
Metabolic syndrome
Systemic inflammation and sympathetic system activation
Poor health behaviors

Question 7

*What 2 psych conditions are reduced in family members of patients who are allowed to
witness the resuscitation in cardiac arrest

Answer 7

PTSD
Depression
Anxiety

Question 8

*What are the 8 steps to break bad news in an empathetic manner

Answer 8

Introduce self and role.
Sit down.
Assume comfortable communication distance.
Use acceptable tone and rate of speech.
Make eye contact.
Maintain open posture.
Give advance warning of bad news.
Deliver news of death clearly (use dead or died).
Tolerate survivor’s reaction.
Explain medical attempts to “save” patient.
Use no medical jargon; use language that is clear and easily understood.
Offer viewing of deceased.
Offer to be available to survivor.
Conclude appropriately.

Question 9

*4 components of ethical decision making:

Answer 9

Justice
Autonomy,
Beneficence,
Nonmaleficience,
Confidentiality,
Personal integrity

Question 10

*3 situations of medical futility

Answer 10

1. Clinicians can identify in only a limited set of circumstances - in which the intervention is effective in less than 1% of identical cases, based on the medical literature. ED thoracotomy for blunt trauma is a well-documented example
2. Physiologic futility is when known anatomic or biochemical abnormalities will not permit succesful medical interventions. Example: EMS will not trasnport rigor mortis.
3. When the proposed intervention will not achieve the patient’s goals for medical therapy in accordance with the patient’s values

Question 11

*3 ‘tests’ that can be applied in ethics when there is no precedent

Answer 11

impartiality test (whether the practitioner would accept this action if he or she were in the patient’s place)
universalizability test (whether the practitioner would be comfortable having all practitioners perform this action in all relevantly similar circumstances)
interpersonal justifiability test (whether the practitioner can supply good reasons to others for the action)

Question 12

*What is the order to determine an SDM?

Answer 12

SDM is the spouse first, then adult children, then parents

Question 13

*In general, when do you need to ask an SDM for treatment?

Answer 13

When the patient lacks capacity and there isn’t a clear pre-made statement of their wishes (eg, there’s no level of care or clear advance directive)

Question 14

*How would you frame a conversation with the SDM if they want to act contrary to the DNR?

Answer 14

I would remind them that the role of an SDM is not to make decisions that they want, but rather to make decisions that reflect what the wishes of the incapacitated patient would be if they were able to make a decision for themselves (ie, what the patient would want).

Question 15

*Three symptoms that would happen once extubated and evidence-based treatments to relieve them (end of life)

Answer 15

1. Drooling / secretions – treat with glycopyrrolate 0.1mg IV/SC q4h prn for secretions
2. Agitation – treat with Ativan lorazepam 1mg IV/SL q2h prn for anxiety
3. Respiratory distress – treat with morphine
   morphine 0-10mg /hr for reduction of dyspnea (D/C if RR<8)

Question 16

*Shift work is bad for you. What part of the brain controls circadian rhythms?

Answer 16

Hypothalamus (wiki)

Question 17

*List 4 potential adverse effects of shift work on physical health

Answer 17

• Myocardial infarction
• Ischemic stroke
• Obesity
• Diabetes
• Breast cancer

Question 18

*List 4 external factors that affect the circadian rhythm

Answer 18

Ambient factors:
- Shift length
- Workload
- Stress
- Light
- Noise
- Temperature
Personal factors:
- Physical health
- Affective state
- Alcohol, drugs
- Age
- Commitments outside ED

Question 19

*List 4 ways that scheduling can help to reduce the adverse effects of shift work

Answer 19

Forward rotating (clockwise with circadian rhythms)
Minimize consecutive nights (1 or 2)
24 to 48 hours off after nights
8-hour shifts (absolute maximum 12 hours)
Institute regular, predictable template

Question 20

*List 4 ways to improve quantity and quality of sleep

Answer 20

Avoid caffeine, alcohol, and drugs
Prophylactic naps
Avoid caffeine, alcohol, and drugs
Prophylactic naps
Use caffeine in moderation, prn
Do not use sedatives or stimulants
Avoid alcohol before sleep

Question 21

Who determines capacity

Answer 21

the practitioner proposing treatment

Question 22

What are pre-requisites to being an SDM

Answer 22

Must be 1) at least 16 2) not prohibited by court order from access to the incapable patient 3) must be available and willing to assume responsibility of giving or refusing consent

Question 23

When can a physician iniate treatment without medical consent

Answer 23

Life or limb threatening condition for which there is a time limited condition. A delay in treatment would result in undue morbidity or mortality to the patient

Question 24

List the order for SDMs

Answer 24

see photo

Question 25

As of 2021, what is the new MAID eligibility criteria

Answer 25

1. Be 18 years or older 2. Be eligible for publicaly funded health care service 3. give informed consent to receive MAID 4. Have a grievous and irremediable medical condition. This currently excludes persons suffering solely from mental illness until further expert review 5. Be in an advanced state of irreversible decline in capability 6. Hvae enduring and intolerable physicial or psychological suffering that cannot be alleviated under conditions that the person finds acceptable **"Reasonable foreseeability of natural death" criteria repealed, however additional safeguard have been added

Question 26

What is the process for requesting MAID

Answer 26

If death is reasonably froseeable: - Request for MAID is made in writing, signed by an independent witness - Two independent doctors or nurse practitioners must provide an assessment and confirm that all eligibility criteria are met - The person must be informed that they can withdraw consent at any time - The person must be given an opportunity to withdraw consent and must confirm their consident before receiving maid (this "final consent" can be waived in certain circumstances If death is not reasonably forseeable - The two independent doctors or practitioners must be experts in the medical condition that is causing the patient suffering - The patient must be informed of any available means to relieve their suffering including counselling, community services - The person and practitioners must have assessed that the person have considered these alternative means to alleviate suffering **The 10 day reflection period is now removed

Question 27

For MAID, what is considered to be a grievous and irremediable medical condition

Answer 27

1. Have a serious illness, disease or disability (excluding a mental illness until March 17, 2023) 2. Be in an advanced state of decline that cannot be reversed 3. Experience unbearable physical or mental suffering from an illness, disease, disability or state of decline that cannot be relieved under conditions that the person considers acceptable.

Question 28

Who can provide MAID

Answer 28

Both physicians and nurse practioniers

Question 29

List 5 cases where mandatory reporting is required

Answer 29

Abuse - Child abuse or neglect - Abuse or harm in a long term care and retirement home - Sexual abuse of a patient by a physician Motor Vehicles - Impaired driving (that is not transient or non-recurring) ex. Seizures - Impaired pilots or air traffic controllers - Impaired ralroad operators Communicable diseases Gunshot wounds Life and death - Deaths - Live births - Still births

Question 30

What are the 4 D's required to be sued?

Answer 30

Duty Diligence Direct Causation Damages