Behavioral Science experts

[caffeine52]

For those who are performing well on the behavioral science questions, can you give some tips as to how to approach these questions (especially the "quote" questions). I feel like I can always narrow it down to two or three and then I always seem to pick the wrong one.

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[popbirch]

I feel good about most of the behavioral stuff, I'm not like a superstar or anything but here's my advice anyway.

1. never refer to anyone, you should almost always be able to take an appropriate action without referring.
2. do the most politically correct thing that you can think of. Don't necessarily do what you would do in the situation as much as what would the perfect doctor with perfect manners would do.
3. always obey the rules, even if it seems silly. never tell other people about the patient even their family without asking first. always ask the patient what they want first. always do what the patient wants, not necessarily what you think is best (unless its kids then you make the choices for them regardless of what the parents want)
4. ask open ended questions. for example, if the question is what should ask the patient next, the answer shouldn't be something that the patient can answer yes/no to.

if you have access to the kaplan material (they are online some places) the behavioral section has a list of rules that are really good too.

good luck.

 

[lilnoelle]

if you have access to the kaplan material (they are online some places) the behavioral section has a list of rules that are really good too.

good luck.

I agree with this.

Physician/patient relationships
I'll paraphrase to make it easy.
1. Always put the patients interests first.
2. Answer all questions, address emotion and facts involved in questions.
3. Tell the patient everything.
4. Work on long term relationships with patients.
5. Listening is better than talking.
6. Negotiate rather than make commands.
7. Everything is your responsibility, solve the problem presented - don't leave the room.
8. Admit mistakes to patients.
9. In general, never refer. If the situation is WAY beyong your expertise (eye surgery), then it is appropriate to refer, but otherwise, don't refer.
10. Express empathy - then empower. "I'm so sorry, what do you want to do next?"
11. First agree on the problem - then move to a solution.
12. Understand what patient is trying to say before offering a solution. (open ended questions first)
13. Patients do not get to select inappropriate treatments. Patients select the treatment, but from a group of appropriate choices given to them by you.
14. Be sure who your patient is. (child is patient, not mom that brought her in, individual in coma is patient, not spouse)
15. Never lie.
16. Accept patient's health beliefs. Expect benign folk medicine practices. Be careful of who explains treatment options (young family members may not understand how treatment options appear to elderly patient)
17. Accept patient's religious beliefs and participate. (Ask about religious belief's, pray with patient if they ask)
18. Anything that increases communication with patient is benefitial.
19. Advocate for your patient. (Never refuse treatment when a patient can't pay)
20. The key is not what you do, but how you do it. Focus on process, not goals, means, not ends. Do the right thing, the right way. Humane-sensitive choices are the right choices. Treat family members politely, but patient comes first.

 

[lilnoelle]

Legal issues in medicine
1. Competent patients can refuse medical treatment.
2. Assume patient is competent unless clear evidence indicates otherwise. (Competence is a legal, not medical issues - only courts can say a person is incompetent). Clear indications of incompetence - suicide attempt, patient is GROSSLY psychotic and dysfunctional, simple communication with patient is impossible. If unsure, assume competence.
3. Avoid going to court.
4. Surrogate decisions should be made with this criteria a. what did patient say in the past? b. What would patient do if they could? c. What is in patient's best interest? (In above order)
5. If patient is incompetent, use advanced directives if available. Health power of attorney rules out everything else, "speaks with patient's voice".
6. Feeding tube can be withdrawn at patients request.
7. Do nothing to actively assist patient in death.
8. Physician decides when patient is dead. (If patient is dead and family insists on treatment - no more treatment. If doctor thinks treatment is futile, but patient is still alive and family wants treatment, then continue treatment)
9. "Till death do we part" Never abandon patient.
10. Always obtain informed consent - requires patient to understand nature of procedure, its purpose, its benefits, its risks, and the alternative treatments available. Exceptions include emergency, waiver by patient (surgery, research - don't assume waiver is present unless told so), patient is incompetent, therapeutic privilege (unconcious, confused).
A signed paper the patient has not read or does not understand is NOT informed consent. Written consent can be revoked orally at any time.
11. Children have different rules. Child under 18 is incompetent unless emancipated (>13 years and taking care of self, marriage, military service). Partial emancipation - with substance abuse treatment, prenatal care, STD treatment, and birth control.
12. Patient cannot withhold life or limb saving treatment from their children. If emergency - treat. If not emergency, generally patient will be declared ward of the court if the condition is serious. If not life or limb threatening - do what patients wish. A child's refusal of treatment is irrelevant. (unless emancipated)
13. Issues governed by laws that vary widely by states (abortion rights with minors) will not be tested on USMLE.
14. Good samaritan Laws limit liability to physician, but only if actions are within physician's competence, only accepted procedures are preformed, and no form of payment is recieved, physician remains at scene until relieved by competent personnel.
You are NOT required to stop and help.
15. Confidentiality is ABSOLUTE. Even if you get a court subpeona. Show up in court - don't even admit person is your patient.
Only if patient is a threat to self or another then confidentiality can AND MUST be broken.
16. Patients should be given chance to state DNR and physician should follow order. (DNR is only cardiopulmonary resuscitation.) When talking to your patient about DNR status, make sure you explain what that means.
17. Committed mentally ill patients retain rights to treatment, to refuse treatment, and can command a jury trial to determine "sanity". They ONLY lose the civil liberty to come and go.
18. Detain patients to protect themself or others. - 48 hours max, pending a hearing. Children can be committed only if they are imminent danger to self or others, unable to care for their own daily needs, or parents have absolutely no control over child and child is a danger to self or others. (Fire setter).
19. Remove from patient contact health providers who pose a risk to patients. (infectious disease, substance abuse, depression, incompetence.)
20. Focus on what is the best ethical conduct - not just what the law says.

 

[tfom08]

Legal issues in medicine
1. Competent patients can refuse medical treatment.
2. Assume patient is competent unless clear evidence indicates otherwise. (Competence is a legal, not medical issues - only courts can say a person is incompetent). Clear indications of incompetence - suicide attempt, patient is GROSSLY psychotic and dysfunctional, simple communication with patient is impossible. If unsure, assume competence.
3. Avoid going to court.
4. Surrogate decisions should be made with this criteria a. what did patient say in the past? b. What would patient do if they could? c. What is in patient's best interest? (In above order)
5. If patient is incompetent, use advanced directives if available. Health power of attorney rules out everything else, "speaks with patient's voice".
6. Feeding tube can be withdrawn at patients request.
7. Do nothing to actively assist patient in death.
8. Physician decides when patient is dead. (If patient is dead and family insists on treatment - no more treatment. If doctor thinks treatment is futile, but patient is still alive and family wants treatment, then continue treatment)
9. "Till death do we part" Never abandon patient.
10. Always obtain informed consent - requires patient to understand nature of procedure, its purpose, its benefits, its risks, and the alternative treatments available. Exceptions include emergency, waiver by patient (surgery, research - don't assume waiver is present unless told so), patient is incompetent, therapeutic privilege (unconcious, confused).
A signed paper the patient has not read or does not understand is NOT informed consent. Written consent can be revoked orally at any time.
11. Children have different rules. Child under 18 is incompetent unless emancipated (>13 years and taking care of self, marriage, military service). Partial emancipation - with substance abuse treatment, prenatal care, STD treatment, and birth control.
12. Patient cannot withhold life or limb saving treatment from their children. If emergency - treat. If not emergency, generally patient will be declared ward of the court if the condition is serious. If not life or limb threatening - do what patients wish. A child's refusal of treatment is irrelevant. (unless emancipated)
13. Issues governed by laws that vary widely by states (abortion rights with minors) will not be tested on USMLE.
14. Good samaritan Laws limit liability to physician, but only if actions are within physician's competence, only accepted procedures are preformed, and no form of payment is recieved, physician remains at scene until relieved by competent personnel.
You are NOT required to stop and help.
15. Confidentiality is ABSOLUTE. Even if you get a court subpeona. Show up in court - don't even admit person is your patient.
Only if patient is a threat to self or another then confidentiality can AND MUST be broken.
16. Patients should be given chance to state DNR and physician should follow order. (DNR is only cardiopulmonary resuscitation.) When talking to your patient about DNR status, make sure you explain what that means.
17. Committed mentally ill patients retain rights to treatment, to refuse treatment, and can command a jury trial to determine "sanity". They ONLY lose the civil liberty to come and go.
18. Detain patients to protect themself or others. - 48 hours max, pending a hearing. Children can be committed only if they are imminent danger to self or others, unable to care for their own daily needs, or parents have absolutely no control over child and child is a danger to self or others. (Fire setter).
19. Remove from patient contact health providers who pose a risk to patients. (infectious disease, substance abuse, depression, incompetence.)
20. Focus on what is the best ethical conduct - not just what the law says.

Wow, did you do that off the top of your head? That seems very thorough from what I remember. I might actually come back and read this as a quick review later.

 

[lilnoelle]

Wow, did you do that off the top of your head? That seems very thorough from what I remember. I might actually come back and read this as a quick review later.

Nope. Lecture notes. I'm gonna have to go back through the behavioral science book sometime in the next week too. I'm pretty good with the psych/ethics stuff.... not so good with biostats.

I tried to change it a little so it wasn't me writing down what they had word for word, but what they have is just so good, its hard to change it and be effective.

 

[synapse lapse]

Nice synopsis lilnoelle! No matter how much you disagree with the "correct" answer, it is important to answer according to these rules, even though some of them are ridiculous, impractical, or unethical in and of themselves. I try and think about what they would want to know, not neccesarily what I personally do.

 

[45408]

Yeah, once I stopped picking the one that I thought I would do every time, I started getting them almost every time. For example - Jehovah's Witness family in a car accident. Mom and daughter are unconscious and need blood transfusions. Dad is alert and states that neither one of them would want it. Don't give the mom the transfusion, but go ahead and give the child one.

I think.

 

[synapse lapse]

Yeah, once I stopped picking the one that I thought I would do every time, I started getting them almost every time. For example - Jehovah's Witness family in a car accident. Mom and daughter are unconscious and need blood transfusions. Dad is alert and states that neither one of them would want it. Don't give the mom the transfusion, but go ahead and give the child one.

I think.

Yep, that's right (assuming the daughter is a legal minor). Interestingly there was a Babylon 5 episode where this exact issue came up (religious alien parents with some alien religion didn't want life saving procedure for kid), well the doctor did it, but on the show he broke the rules. I guess in the future on space stations we have no protection for minors...perhaps they didn't know what a "minor" was for the race, or the issue of sovereignty extended to other alien races Are you really supposed to pray with the patient if they ask on the test? I didn't know that one, I would think standing quietly, not arguing, etc. would be the correct answer. Also physician assisted suicide (which I strongly support) is legal in Oregon, but I think you put that it's wrong on the test (unless you live in Oregon? lol).

 

[lilnoelle]

Yep, that's right (assuming the daughter is a legal minor). Interestingly there was a Babylon 5 episode where this exact issue came up (religious alien parents with some alien religion didn't want life saving procedure for kid), well the doctor did it, but on the show he broke the rules. I guess in the future on space stations we have no protection for minors...perhaps they didn't know what a "minor" was for the race, or the issue of sovereignty extended to other alien races Are you really supposed to pray with the patient if they ask on the test? I didn't know that one, I would think standing quietly, not arguing, etc. would be the correct answer. Also physician assisted suicide (which I strongly support) is legal in Oregon, but I think you put that it's wrong on the test (unless you live in Oregon? lol).

I don't think they'll have "pray outloud for patient" It'll be more like "agreeing to pray with patient when they ask you" - whether you literally pray to yourself while the patient is praying is your own business.

The important thing is DON'T tell the patient no or get a chaplain.

 

[synapse lapse]

I don't think they'll have "pray outloud for patient" It'll be more like "agreeing to pray with patient when they ask you" - whether you literally pray to yourself while the patient is praying is your own business.

The important thing is DON'T tell the patient no or get a chaplain.

Yeah, agreed.

 

[jbuck824]

Yeah, agreed.

a world question explanation said to go along with the prayer to "avoid confrontation" or something like that during a stressful time...

 

[synapse lapse]

a world question explanation said to go along with the prayer to "avoid confrontation" or something like that during a stressful time...

Yes, obviously you should not enter in a debate with your patient, IRL or as an answer. Standing quietly is the appropriate action, agreed.

 

[lilnoelle]

the important thing is that your patient needs comforted - recieves strength from belief in God, and you need to be building your relationship with your patient. Theres actually quite a bit of proof to the power of prayer and religious belief. Most people attribute it to placebo effect (I don't, but thats another matter) - but even placebo effect is not something to be ignored. I think its rather amazing how the mind can heal the body.

Honestly - I think its the right thing to do in real life.

And maybe I'm alone in this, but I think that most of the above is the right thing to do in real life. Maybe thats why the ethical section seems easy for me....

not that I'm foolish enough to believe that the above HAPPENS in real life, but I think its ideal.

 

[synapse lapse]

the important thing is that your patient needs comforted - recieves strength from belief in God, and you need to be building your relationship with your patient. Theres actually quite a bit of proof to the power of prayer and religious belief. Most people attribute it to placebo effect (I don't, but thats another matter) - but even placebo effect is not something to be ignored. I think its rather amazing how the mind can heal the body.

Honestly - I think its the right thing to do in real life.

And maybe I'm alone in this, but I think that most of the above is the right thing to do in real life. Maybe thats why the ethical section seems easy for me....

not that I'm foolish enough to believe that the above HAPPENS in real life, but I think its ideal.

Well I don't want to turn this into an ethics debate thread, but plenty of things on the list are debatable. Would a Jehova's witness agree it is right to force life saving treatment on their children when it is against their beliefs? What if the child is a legal minor, but in reality old enough to make their own choice reasonably? Physician assisted suicide, in my opinion, is the humane thing to do, but is not to many others. Religious prayer is no different from positive thought, so of course placebo effect can be very powerful and heal the body, no debate there. I don't think anyone will disagree that the minds ability to affect bodily functions of all types, including healing, is amazing. I was a philosophy major in college, and have taken a number of ethics class, and what we are taught in medical school is not what I would call ethics. It is more what I would call sensitivity training...in any case, the list was a great synopsis of what needs to be answered.

 

[Noroozi]

Yeah, once I stopped picking the one that I thought I would do every time, I started getting them almost every time. For example - Jehovah's Witness family in a car accident. Mom and daughter are unconscious and need blood transfusions. Dad is alert and states that neither one of them would want it. Don't give the mom the transfusion, but go ahead and give the child one.

I think.

Humm I don't know about this one. On page 207 of the Kaplan Behavior Science book (8 book series) it states:

"Wife refuses to consent to emergency lifesaving treatment for unconscious husband citing religious grounds" - Answer is "Treat, no time to assess substituted judgement".

The next scenario is "Wife produces card stating unconcious husband's wish to not be treated on religious grounds" - Answer is "don't treat".

So if the blood transfusion is life saving, doesn't that mean the wife in the scenario above should be treated also along with the child, unless the husband can prove otherwise?

 

[synapse lapse]

Humm I don't know about this one. On page 207 of the Kaplan Behavior Science book (8 book series) it states:

"Wife refuses to consent to emergency lifesaving treatment for unconscious husband citing religious grounds" - Answer is "Treat, no time to assess substituted judgement".

The next scenario is "Wife produces card stating unconcious husband's wish to not be treated on religious grounds" - Answer is "don't treat".

So if the blood transfusion is life saving, doesn't that mean the wife in the scenario above should be treated also along with the child, unless the husband can prove otherwise?

I think Kaplan is wrong here. In an adult patient the power of attorney takes precedence, and in absence of that is the expressed wishes of the patient as given to a spouse, or what the spouse thinks the patient would want. This even takes precedence over a written living will (which I think is absurd personally, as a living will should take precedence over anything since it is your expressed, written wishes, but whatever.) I think you have to respect that wish for an adult patient.

 

[osli]

I know that DPoA takes precedent over a living will if you have designated one, but does the "next of kin" rule have equivalent standing in the pecking order as a power of attorney? i.e., if you haven't appointed a DPoA does the "next of kin" really overrule a living will/advanced directive?

This does seem like a gray area to me, and the answer seems to vary depending on whether you are looking at Kaplan, UW, Lippincott, FA, etc. And I guess when it really comes down to it, I'm not clear on the relationship between a DPoA and a spouse... are they always equivalent for legal purposes? If you are unmarried, does a parent/child/brother have the same legal status? If so, what is the purpose of a DPoA... only for those people that have no family? Anyone have a definitive answer and source?

 

[lilnoelle]

Well I don't want to turn this into an ethics debate thread, but plenty of things on the list are debatable. Would a Jehova's witness agree it is right to force life saving treatment on their children when it is against their beliefs? What if the child is a legal minor, but in reality old enough to make their own choice reasonably? Physician assisted suicide, in my opinion, is the humane thing to do, but is not to many others. Religious prayer is no different from positive thought, so of course placebo effect can be very powerful and heal the body, no debate there. I don't think anyone will disagree that the minds ability to affect bodily functions of all types, including healing, is amazing. I was a philosophy major in college, and have taken a number of ethics class, and what we are taught in medical school is not what I would call ethics. It is more what I would call sensitivity training...in any case, the list was a great synopsis of what needs to be answered.

Yeah.... I'm not going to disagree with you. I went back and read through the list after I said that I think they are "the right thing to do" and I should probably just delete that comment. Everything is subject to the situation in which it presents itself - and the only person who can make the call is the person who is involved.... its not an easy call to make, and honestly, mistakes are made, but no one can feel self righteous or blame the person who made the poor call because honestly, unless your the one making the call, you just can't understand the whole picture.

Anyway. Ethics is one of those things that is fun to debate - but clear cut black and white answers are hard to come by.

 

[lilnoelle]

Humm I don't know about this one. On page 207 of the Kaplan Behavior Science book (8 book series) it states:

"Wife refuses to consent to emergency lifesaving treatment for unconscious husband citing religious grounds" - Answer is "Treat, no time to assess substituted judgement".

The next scenario is "Wife produces card stating unconcious husband's wish to not be treated on religious grounds" - Answer is "don't treat".

So if the blood transfusion is life saving, doesn't that mean the wife in the scenario above should be treated also along with the child, unless the husband can prove otherwise?

I think Kaplan is stating what would probably happen in a real situation here.... but as to whether this is the answer they would want on the test - I don't know. UWorld definitely has a different approach to this same question.... so hopefully its not on the test.

 

[tfom08]

Yeah, once I stopped picking the one that I thought I would do every time, I started getting them almost every time. For example - Jehovah's Witness family in a car accident. Mom and daughter are unconscious and need blood transfusions. Dad is alert and states that neither one of them would want it. Don't give the mom the transfusion, but go ahead and give the child one.

I think.

Yeah I had this question and missed it because I thought you should just save them both. Who knows if the husband is trying to force his belief on his wife. But I guess since the question states, "it is what SHE would want" we should just take that at face value and not assume it is only what the husband would want. Sometimes I just miss obvious stuff because it seems strange. Like man has a heart attack, he is alert. Run into wife in the hallway outside and she asks you what happened to her husband, what do you do? Do not tell her anything about her husband, tell her to discuss it with him. Don't know why I thought you could tell her a little bit about it.

 

[MSKalltheway]

I don't think they'll have "pray outloud for patient" It'll be more like "agreeing to pray with patient when they ask you" - whether you literally pray to yourself while the patient is praying is your own business.

The important thing is DON'T tell the patient no or get a chaplain.

IRL this is definitely what you do, but I remember getting a question on this and two of the choices were "get the chaplain" or "agree to pray for the patient". I figured while respecting the religious/non-religious rights of the doc and complying with patient requests, getting the chaplain would be appropriate. Right?

Heh, turns out you were supposed to agree to pray for the pt while they were out getting surgery, but if you didnt want to, then dont but dont tell the patient. Im still wondering what is wrong with getting a chaplain

The logic was that it may hurt the patients feelings by getting someone else, because it silently shows your refusal. Refusing may "compromise the dr-pt relationship", so just agree to pray. I guess maybe the whole "referral" thing comes into play as well.

Thats the funny thing about behavioral...I completely agree with you lilnoelle, but some of this is so weird like that!

 

[tfom08]

Im still wondering what is wrong with getting a chaplain

Well the thing that is wrong with it from the USMLE standpoint is that it breaks rule #1 of USMLE Behavioral Science. DO NOT REFER, DO NOT EVER REFER. You can always take care of it. I don't care if a patient comes into your IM clinic and has a brain tumor. If you need to, go get a scalpel and cut it out right there in the office, but do not refer that patient or you will be wrong.

 

[synapse lapse]

Well the thing that is wrong with it from the USMLE standpoint is that it breaks rule #1 of USMLE Behavioral Science. DO NOT REFER, DO NOT EVER REFER. You can always take care of it. I don't care if a patient comes into your IM clinic and has a brain tumor. If you need to, go get a scalpel and cut it out right there in the office, but do not refer that patient or you will be wrong.

Correct, although there are a few situations where referal is appropriate I think. One I can think of is eye pain, but of course they would probably ask you which drug to give/not give or something like that, not an ethics questions, so probably a moot point.

 

[45408]

Yeah I had this question and missed it because I thought you should just save them both. Who knows if the husband is trying to force his belief on his wife. But I guess since the question states, "it is what SHE would want" we should just take that at face value and not assume it is only what the husband would want.

Again, not saying this is how I think it always should be in real life, but for the sake of a question, she wouldn't have married him if she didn't agree with his stance. He'd be a terrible husband to withhold a blood transfusion that she would want, so we're just supposed to assume that he is conveying her wishes. If the patient is conscious and competent, the spouse doesn't have any more power/sway than Joe off the street. If the patient is in a coma, the spouse is the final word.

 

[osli]

Any thoughts on whether a spouse is the legal equivalent of a DPoA, and if that extends to other family members as well?

 

[45408]

Any thoughts on whether a spouse is the legal equivalent of a DPoA, and if that extends to other family members as well?

patient > spouse > adult children > minor children

If the patient is incompetent/comatose, I think that's how the chain of command goes.

 

[lilnoelle]

patient > spouse > adult children > minor children

If the patient is incompetent/comatose, I think that's how the chain of command goes.

This is the case in emergency situations where the patient's wishes haven't been expressed to healthcare team... but in other situations, if the patient has declared their desires to the physician (doesn't have to be written down by patient, but should be indicated in medical records) and there isn't a legal power of attorney, then what the patient expressed trumps the "chain of command". (I think....)

If there is a legal power of attorney, what they say trumps all. (even if what they want is contrary to the patient's expressed wishes - which is one thing that I certainly don't agree with)

The problem is in an emergency situation, even if the patient has a living will, DNR orders, or the patient's physician knew the patient's wishes.... theres not time to figure all of that out. A decision has to be made, and chances are, it'll make someone mad.

 

[lilnoelle]

Here's a sad situation that one of our physician's dealt with a couple of years ago.

14 year old girl had been on renal dialysis for quite a long time when she finally recieved a kidney transplant. All was relatively well for two or three years and then the kidney went bad due to chronic rejection. She didn't want to go back on dialysis. Mom and Dad of course wanted her to. After a lot of discussion and heart wrenching thought, Mom and Dad believed that daughter REALLY knew what she wanted, it wasn't due to depression, and they decided to concede with her wishes. She was able to spend her last few weeks with a relatively normal teenage life, celebrate her 17th birthday, and attend prom and then she died.

Obviously the parents could have MADE child receive dialysis - but not really.... you can't really force a 16 year old to do something like that unless they sedated her every time. They chose instead to honor their daughters wishes, and she died.

 

[hardy]

Well the thing that is wrong with it from the USMLE standpoint is that it breaks rule #1 of USMLE Behavioral Science. DO NOT REFER, DO NOT EVER REFER. You can always take care of it. I don't care if a patient comes into your IM clinic and has a brain tumor. If you need to, go get a scalpel and cut it out right there in the office, but do not refer that patient or you will be wrong.

I think in cases of abuse (be it elderly or children) referral to social services can be the right answer. I remember two Qbank questions where that was the case.

 

[osli]

if the patient has declared their desires to the physician (doesn't have to be written down by patient, but should be indicated in medical records) and there isn't a legal power of attorney, then what the patient expressed trumps the "chain of command". (I think....)

This is the point I'm trying to understand better. We seem to have two different view here, supported by two different resources (UW and Kaplan). I can't seem to find any definitive answer myself... can the spouse trump living wills and expressed wishes just like a DPoA can or not? Is a spouse assumed to be "speaking for the patient" or not?

 

[lilnoelle]

This is the point I'm trying to understand better. We seem to have two different view here, supported by two different resources (UW and Kaplan). I can't seem to find any definitive answer myself... can the spouse trump living wills and expressed wishes just like a DPoA can or not? Is a spouse assumed to be "speaking for the patient" or not?

No, I don't think so. A DPoA is a legal assignment. It would have to go to court to determine if the spouse could act as such. If patients wishes are known, spouse's opinion means nothing.

However, if patients wishes are not known - spouse acts as a surrogate.

 

[osli]

So the pecking order is conscious and competent patient > DPoA > written directives > spouse?

 

[RxnMan]

patient > spouse > adult children > minor children

If the patient is incompetent/comatose, I think that's how the chain of command goes.

Just some additions:

patient > health power of attorney > spouse > patient's parents > adult children > minor children

I also had a question saying that the chronology of a document is more important than type (i.e. Health Power of Attorney and living wills)

That is, if a patient's daughter with Health Power of Attorney presents asks for withdrawl of care and presents documents 1 year old as proof, and the patient's son presents a living will that would support continuing care, the living will trumps, and care continues.

 

[lilnoelle]

Just some additions:

patient > health power of attorney > spouse > patient's parents > adult children > minor children

I also had a question saying that the chronology of a document is more important than type (i.e. Health Power of Attorney and living wills)

That is, if a patient's daughter with Health Power of Attorney presents asks for withdrawl of care and presents documents 1 year old as proof, and the patient's son presents a living will that would support continuing care, the living will trumps, and care continues.

Thats what I what we were taught in school and the way I think it should be - I don't know what the USMLE wants. (Kaplan explicitly says that a health power of attorney trumps everything else).

 

[TerpMD]

Just some additions:

patient > health power of attorney > spouse > patient's parents > adult children > minor children

I also had a question saying that the chronology of a document is more important than type (i.e. Health Power of Attorney and living wills)

That is, if a patient's daughter with Health Power of Attorney presents asks for withdrawl of care and presents documents 1 year old as proof, and the patient's son presents a living will that would support continuing care, the living will trumps, and care continues.

So I am quite confused about all this now! I found http://estate.findlaw.com/estate-planning/wills/estate-planning-living-wills.html which basically gives me the idea that it depends on how you wrote the legal document. Considering that you could write either document to override the other, I would say it is unlikely we will be asked to make this direct comparison on boards (fingers crossed). I would also agree timing is prob important too.

Mayo has a nice site http://www.mayoclinic.com/print/living-wills/HA00014/METHOD=print but it doesn't directly answer the question of which one wins.

 

[lilnoelle]

So I am quite confused about all this now! I found http://estate.findlaw.com/estate-planning/wills/estate-planning-living-wills.html which basically gives me the idea that it depends on how you wrote the legal document. Considering that you could write either document to override the other, I would say it is unlikely we will be asked to make this direct comparison on boards (fingers crossed). I would also agree timing is prob important too.

Mayo has a nice site http://www.mayoclinic.com/print/living-wills/HA00014/METHOD=print but it doesn't directly answer the question of which one wins.

The thing is, the only time someone is going to sit down and ponder this all out is if they have the time to do so. If a woman comes into the ER and requires blood, husband says no - and you can assume that the doctors aren't aware of any legal document present that says wife wants one (unless its explicitly said in the question), then you have to assume the husband is expressing his wife's wishes.

If you have a patient in the hospital who has filled out a DNR order, goes into cardiac arrest, and wife comes in pleading for resuscitation - then you follow the DNR order.

I'd hope that they wouldn't make it any more convoluted than the above examples. I don't think they're going to say that a patient has a DNR AND a health power of attorney that contradict eachother. I could be wrong.... my instinct is to say that you should go with the patients last wishes - i.e. DNR was filled out the day before, health power of attorney was assigned ten years prior - but who knows what kind of answer they would want on the exam.

 

[osli]

I looked at this a little more, and it looks like the power of attorney vs. written document might even vary a bit from state to state, with some always favoring the power of attorney, some considering chronology, some dependent on just how the document in question was written, etc.

Thus I doubt (hope!?) it won't show up on USMLE.

 

[RxnMan]

Thats what I what we were taught in school and the way I think it should be - I don't know what the USMLE wants. (Kaplan explicitly says that a health power of attorney trumps everything else).

In the hierarchy I wrote, the patient (alive, well, conscious, competent) trumps everything. Then the power of attorney, then spouse. I'll tell you from experience that HPoA is a rarer event than spouse - It's usually reserved for an adult child who is taking care of a ailing, demented parent. The idea is that they already have an end-of-life care plan in place.

...Thus I doubt (hope!?) it won't show up on USMLE.

It showed up on UW. The example I gave above was on UW, so it may appear on the exam. The explanation stated that it may vary state to state, but on the whole, the last document written is the most important.