USMLE Forum Archives - USMLE Step 2 CK - Psychaitry & Ethics 9
Psychaitry & Ethics 9
TheOne - 06-11-07 19:31
A hospitalist on duty for the weekend is called to consult on a case involving a 53-year-old woman in the medical intensive care unit. The patient has been hospitalized for 5 weeks. Her initial injury was a massive subarachnoid bleed complicated by an ischemic infarct of her brain 3 days later. Since that time, she has been persistently vegetative. She requires mechanical ventilation and external feeding to maintain her vital functions. It is discovered that, during a previous admission to the hospital, the patient clearly stated that she would want to be maintained on life support only if she were likely to regain a meaningful quality of life. The medical team believes that she does not have a significant chance of regaining an acceptable level of function. The children maintain that the situation is reversible and want to continue care, whereas the husband wants to withdraw care in fulfillment of his wife's wishes. Which of the following is the most appropriate next step?
A. Arrange a family meeting, hoping to resolve the patient's previously expressed wishes with those of the children and husband
B. Begin the withdrawal of care, despite the reservations of the children, after discussion with the hospital lawyer
C. Consult a psychiatrist to speak to the children
D. Notify the department of social services for the question of elder abuse
E. Refer the case to the ethics committee for review
TheOne - 06-11-07 19:31
A hospitalist on duty for the weekend is called to consult on a case involving a 53-year-old woman in the medical intensive care unit. The patient has been hospitalized for 5 weeks. Her initial injury was a massive subarachnoid bleed complicated by an ischemic infarct of her brain 3 days later. Since that time, she has been persistently vegetative. She requires mechanical ventilation and external feeding to maintain her vital functions. It is discovered that, during a previous admission to the hospital, the patient clearly stated that she would want to be maintained on life support only if she were likely to regain a meaningful quality of life. The medical team believes that she does not have a significant chance of regaining an acceptable level of function. The children maintain that the situation is reversible and want to continue care, whereas the husband wants to withdraw care in fulfillment of his wife's wishes. Which of the following is the most appropriate next step?
A. Arrange a family meeting, hoping to resolve the patient's previously expressed wishes with those of the children and husband
B. Begin the withdrawal of care, despite the reservations of the children, after discussion with the hospital lawyer
C. Consult a psychiatrist to speak to the children
D. Notify the department of social services for the question of elder abuse
E. Refer the case to the ethics committee for review
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#1
Re: Psychaitry & Ethics 9 Sarahhh - 06-12-07 00:59 i would go with fullfillin the wishes of the lady ... but i dont know if id involve a lawyer in it.. maybe have a family meeting would be a wise option...
A...
and in the USMLE exams NEVER go to court!
#2
Re: Psychaitry & Ethics 9 jwang - 06-13-07 12:00 I think the answer is A. However I do believe the legal choice is up to the husband unless she designated a specific power of attorney (I know there is another term) for her end of life desires. But it is always best to have everyone meet and see if you can come to a friendly resolution rather than dragging in lawyers, etc. If the family meeting does not result in a resolution, then perhaps you would then hand the case over to the ethics committee?
#3
Re: Psychaitry & Ethics 9 mosaabma - 06-13-07 17:02 I believe the answer is
B. Begin the withdrawal of care, despite the reservations of the children, after discussion with the hospital lawye.
The the patient clearly stated that she would want to be maintained on life support only if she were likely to regain a meaningful quality of life. She has brain death and now in persistently vegetative state. You can not resolve the patient's previously expressed wishes with those of the children and husband because the children now refuse that their mother is dead (denial). Discussing this with the hospital laywer is considered to be in the hospital setting yet, and the case have not gone to court.....
#4
Re: Psychaitry & Ethics 9
TheOne - 06-19-07 15:23 The correct answer is A. Although it is clear that the physician is ethically bound to follow the patient's wishes, which in this case appears to be the withdrawal of care, it is always better to do so with the resolve of the family. Oftentimes, feelings such as guilt will drive family members to insist on seemingly unreasonable or inappropriate action. A thoughtful discussion, whereby the family members are allowed to express their reservations in a supportive setting, often will produce a resolution among previous disparate views.
Although withdrawing care (choice B) appears to be what ultimately is the most appropriate action, it is worth trying first to have all of the interested parties "on the same page" before preceding if this resolution can be achieved in a timely manner without causing suffering on the patient's part. Whereas consult services such as psychiatry (choice C) may be helpful on selected occasions, the first attempts to resolve conflict should fall on the primary medical team and primary care physicians. Although physicians have the positive duty to report suspected elder abuse, there is no indication from the information present that the children have abused their mother (choice D).
#6
Re: Psychaitry & Ethics 9 babbu5508 - 07-07-10 00:26 A. Arrange a family meeting, hoping to resolve the patient's previously expressed wishes with those of the children and husband
#7
Re: Psychaitry & Ethics 9 bingousmle - 07-07-10 01:07 A. Arrange a family meeting, hoping to resolve the patient's previously expressed wishes with those of the children and husband
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