Ethics Qs

[johndoe3344]

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Q1) So I'm aware that a DPoA will supersede all other forms of advanced directives. But what if the living will contradicts an oral advanced directive?

Suppose the living will said no ventilators, but then the wife tells you that on repeated occasions the patient told her that he would want to be kept alive through any means necessary?

What do you do?

Q2) Also, suppose a family of Jehova's witnesses comes in after a car accident... it's a mother, daughter, and father. The father is unharmed but the mother and daughter (a minor) are both unconscious. The father (face to face, and with appropriate documentation) tells you that they are Jehova's witnesses and that none of them can receive blood. If the mother and daughter don't receive blood, they will die.

Do you give blood to the mother and daughter? Or just to the daughter?

 

[JRjcu08]

Q1) So I'm aware that a DPoA will supersede all other forms of advanced directives. But what if the living will contradicts an oral advanced directive?

Suppose the living will said no ventilators, but then the wife tells you that on repeated occasions the patient told her that he would want to be kept alive through any means necessary?

What do you do?

Q2) Also, suppose a family of Jehova's witnesses comes in after a car accident... it's a mother, daughter, and father. The father is unharmed but the mother and daughter (a minor) are both unconscious. The father (face to face, and with appropriate documentation) tells you that they are Jehova's witnesses and that none of them can receive blood. If the mother and daughter don't receive blood, they will die.

Do you give blood to the mother and daughter? Or just to the daughter?

For the first one - I'm pretty sure that a written living will overpowers any type of oral statement, especially if the physician didn't hear it him/herself. The wife could be making it up and the physician has no proof the patient ever said that. I think the only way that *maybe* this could change is if there are multiple people who have heard the patient say it or if there is some sort of documentation...but again I'm pretty sure if there is a legal document from the patient stating their wishes, unless the patient themself changes/updates the legal document, the living will stands.

For the 2nd one... I saw a question like this before (not sure where) except that it was the husband made the statement over the phone, and you needed to see some sort of proof that they were Jehovah's (they carry a card? never knew that.) Since the husband is physically there- I'm not sure what to do. If it's like the other question I saw unless he can submit proof they are JW's then you treat both,but you definitely would treat the daughter in any case.

 

[DroptheBop]

For the 2nd one... I saw a question like this before (not sure where) except that it was the husband made the statement over the phone, and you needed to see some sort of proof that they were Jehovah's (they carry a card? never knew that.) Since the husband is physically there- I'm not sure what to do. If it's like the other question I saw unless he can submit proof they are JW's then you treat both,but you definitely would treat the daughter in any case.

Uworld Question 783

As you mentioned, you absolutely treat the child (minor) in an emergent situation. You do not need DPOA as a husband to make a decision for his wife if he is next of kin (ie not superseded by a DPOA for her sister).

In regards to the "proof" with the card, the issue in the question was that it was a brief conversation with the husband over the phone (no way to truly verify the identity), he could not be reached again, and the doctor had no prior relationship with him, so the doctor did not know him/their religious preferences factually. The card could have been a substitute as proof since the patient was not conscious and the husband could not provide substantial support. In the scenario presented by johndoe3344, if it is in fact the husband then he does have the right to refuse care/blood transfusions based on their religious beliefs (but this does not have to be followed for the child).

That was all paraphrased from the Uworld explanation, feel free to take a look.



Where have you read that a DPOA supersedes the living will. I would assume most people would have one, not both in place, or make specifications as to what said person could decide outside of the limitations denoted in the living will. That is merely my speculation though, and I could be wholly wrong on that account.

 

[johndoe3344]

Wait so, we are refusing treatment for the wife on the assumption that she shares her husband's religious beliefs as a JW herself, right? (do you have to be a JW to marry a JW?)

Because if she's not a JW, even as the next of kin, you can't just tell the doctors to withhold life-saving care... right? 😵

Where have you read that a DPOA supersedes the living will. I would assume most people would have one, not both in place, or make specifications as to what said person could decide outside of the limitations denoted in the living will. That is merely my speculation though, and I could be wholly wrong on that account.

http://forums.studentdoctor.net/showthread.php?t=740830

 

[Phloston]

Q1) So I'm aware that a DPoA will supersede all other forms of advanced directives. But what if the living will contradicts an oral advanced directive?

Suppose the living will said no ventilators, but then the wife tells you that on repeated occasions the patient told her that he would want to be kept alive through any means necessary?

What do you do?

The only time the living will is not adhered to is if the patient had previously appointed a DURABLE power of attorney. If the attorney appointed (there are a few different types) was not a DURABLE one, then the living will persists, regardless as to whether the spouse says otherwise.

Q2)

Do you give blood to the mother and daughter? Or just to the daughter?

Interesting question. I had encountered this in USMLE Rx, and I remember that in an emergency situation, MINORS are given appropriate Tx, even if the parents say otherwise. As far as the mother is concerned, I'm not sure. I would say that she should be given appropriate Tx UNLESS there is proof of religion.

 

[peace zealot]

I remember the second question is in the UWorld. It says, as the wife has no written will and the husband is the next of kin, so he can decide for the wife, but for minors a court order should be sought for administering appropriate treatment.

 

[DroptheBop]

Wait so, we are refusing treatment for the wife on the assumption that she shares her husband's religious beliefs as a JW herself, right? (do you have to be a JW to marry a JW?)

Because if she's not a JW, even as the next of kin, you can't just tell the doctors to withhold life-saving care... right? 😵





http://forums.studentdoctor.net/showthread.php?t=740830

We're assuming that the husband is telling the truth (thereby assuming that she is in fact a Jehovah's witness). In your scenario he says that they are all Jehovahs witnesses. The physicians would certainly like to confirm that (this is where having the cards would be preferable).

I think the issue we have now based on your comment is whether or not you trust/believe the father/husband. My understanding was that as long as there is no reason to suspect foul play and with the "appropriate documentation" as you mentioned etc. you would have to follow his instruction as the next of kin.

If the wife were not a Jehovahs witness but the husband was, then indeed the husband could not just tell them to withhold care life sustaining care in emergent situation because it is HIS personal preference/religious belief. As long as he is acting on HER behalf expressing HER wishes, it is okay.

And FYI, if you transfuse a Jehovah's witness (a non-minor) against their wishes, you could very likely get charged with battery.

I am not that familiar with Jehovah's witnesses' religious practices outside of their preference not to receive blood transfusions, so I can't comment on their marriage customs/beliefs.

And peacezealot, you only need a court order to treat a child in a non-emergent situation. In this case, you could treat the child without one.

 

[ijn]

I had an ethics question from the online NBMEs that I am not sure how to answer.

You've been trying to treat a patient with depression for quite a long time. She's tried many different medications that have failed to improve her symptoms but finally we found one that worked for her. She got her life back on track - got married, has kids. Now the insurance company sent her a letter saying that the drug she's on will no longer be covered and that she should go talk to the doctor about switching to a new medication.

The options I was between were asking "do you have the money to pay for this medication out of pocket" or "appeal this decision with the insurance company and explain why this drug should be covered." The other options were along the lines of switching to a new covered medication, but from the history it's clear that nothing else has worked.

I felt that the first thing I should do is see if the patient could afford to pay out of pocket for the medication that has been proven to work for her. Appealing might take too long and kind of feels like offloading the patient to someone else. The STEP seems like they prefer immediate solutions that involve decision on the part of the physician. What do you guys think?

 

[JRjcu08]

I had an ethics question from the online NBMEs that I am not sure how to answer.

You've been trying to treat a patient with depression for quite a long time. She's tried many different medications that have failed to improve her symptoms but finally we found one that worked for her. She got her life back on track - got married, has kids. Now the insurance company sent her a letter saying that the drug she's on will no longer be covered and that she should go talk to the doctor about switching to a new medication.

The options I was between were asking "do you have the money to pay for this medication out of pocket" or "appeal this decision with the insurance company and explain why this drug should be covered." The other options were along the lines of switching to a new covered medication, but from the history it's clear that nothing else has worked.

I felt that the first thing I should do is see if the patient could afford the medication to pay for the medication that has been proven to work for her. Appealing might take too long and kind of feels like offloading the patient to someone else. The STEP seems like they prefer immediate solutions that involve decision on the part of the physician. What do you guys think?

I got a question like this before (on Kaplan maybe? I don't remember) and the answer was that you have to do the work and try to get the drug covered for the patient. Basically you are the one who is supposed to be inconvenienced by dealing with the insurance company, not the patient by having to pay more.

 

[johndoe3344]

I had an ethics question from the online NBMEs that I am not sure how to answer.

You've been trying to treat a patient with depression for quite a long time. She's tried many different medications that have failed to improve her symptoms but finally we found one that worked for her. She got her life back on track - got married, has kids. Now the insurance company sent her a letter saying that the drug she's on will no longer be covered and that she should go talk to the doctor about switching to a new medication.

The options I was between were asking "do you have the money to pay for this medication out of pocket" or "appeal this decision with the insurance company and explain why this drug should be covered." The other options were along the lines of switching to a new covered medication, but from the history it's clear that nothing else has worked.

I felt that the first thing I should do is see if the patient could afford to pay out of pocket for the medication that has been proven to work for her. Appealing might take too long and kind of feels like offloading the patient to someone else. The STEP seems like they prefer immediate solutions that involve decision on the part of the physician. What do you guys think?

You appeal.

In general, you are the advocate for the patient. If there are any insurance problems, pharmacy problems, whatever -- you have to be the one to talk to them.

On that same line, if the patient has a problem with any of your staff members, you also talk to that staff member for the patient to see what the problem is.

 

[Phloston]

Good thread.

I should point out that HY Behavioral Science has pretty good ethical scenarios on pages 92-5.

The rest of the book is mediocre. BRS Behavioral is much better.