Advice on Approaching this MMI Scenario/Situation Q

[LelouchLamperouge]

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Hello all! Hope you are doing well. Happy Sept.

I'm preparing for an MMI, and I came across this part of a question that I got stuck on a little bit while practicing out loud: "Is there any instance that a physician should perform a procedure without consent?"

From my understanding, if the patient is unconscious and unable to provide consent, and it's likely that they will sustain significant bodily harm (i.e., death/loss of limb/function), then a physician does not need to obtain consent. This is my interpretation after reading an article from the AMA's journal of ethics, where the first part states, "(1) the patient is unconscious or otherwise incapable of consenting." The second part states, "...and (2) the benefit of treating the patient outweighs any potential harm of the treatment."

I suppose my questions are: Are there any other circumstances where a physician should perform a procedure without consent? And what are some examples where the benefit of treating the patient outweighs any potential harm of the treatment? From my clinical experiences in the ER, I have seen patients sign out AMA and refuse to go up to the cath lab for a stent. I thought that that would be a situation where the benefit would outweigh the harm of treatment; however, (in my experience) if they want to sign out AMA and understand the risks, then we can't keep them there.

 

[Euxox]

From my clinical experiences in the ER, I have seen patients sign out AMA and refuse to go up to the cath lab for a stent. I thought that that would be a situation where the benefit would outweigh the harm of treatment; however, (in my experience) if they want to sign out AMA and understand the risks, then we can't keep them there.

The criteria are (1) the patient is unconscious or otherwise incapable of consenting AND (2) the benefit of treating the patient outweighs any potential harm of the treatment. And, not or. In your example, we meet criteria (2) but not criteria (1).

• If the risks of the treatment are worse than the benefits, you don't even offer the treatment. This is the principle of nonmaleficence ("first do no harm"), and it holds irrespective of the consent question.
• If the patient is in a state where they can provide consent, you MUST get their consent before proceeding with a major procedure. This is the principle of autonomy. It doesn't matter if they are declining a lifesaving procedure.
• Determining if a patient is able provide consent is tricky. If they are unconscious, the answer is obviously no. But what if they are delirious or have dementia? In these cases you need to establish capacity for consent. That's a complicated topic that's better discussed elsewhere.

Are there any other circumstances where a physician should perform a procedure without consent?

Yes, these are situations of implied consent. For example, let's say that a patient consented for a surgery, but during the surgery the surgeon accidentally ruptures an artery and the bleeding is likely to be fatal in a matter of minutes. Waking the patient up, explaining the situation, and asking for consent doesn't work because they will be dead by then. In this scenario the surgeon has implied consent to ligate the artery without asking the patient.

Implied consent also holds for very minor procedures with near zero risk. For example, getting your blood pressure checked at your primary care doctor's office. You have the right to say no, but the nurse or patient care tech doesn't have to explicitly get a 'yes' before putting the cuff on your arm.