Mock Interview question

[487806]

Thanks for your help! I appreciate it.

Unless extraneous findings are covered on consent, then they cannot be touched. Hence, why sometimes broad terms such as exploratory laporotomy are used.

A surg res/attending can correct me if wrong.

Makes sense. However, if something had "ruptured" that could lead to immediate death if untreated, would it be okay to fix it without consent? Or would it still be illegal. and simply let the patient die?

Sorry for being redundant... I'm still struggling to grasp the concept that doctors' actions to save patients are restricted without gaining consent. I need to definitely work on my ethics knowledge...

I like mimelim's idea of notifying upfront about it before the operation. That's the surefire way to avoid ethical troubles.

---

Members don't see this ad.

 

[ClemsonFirst]

I'm pretty sure in an emergency situation where the patient is incapacitated, without any documentation to DNR/give blood/etc., the physician should perform life saving procedures on the patient.

 

[mimelim]

I'm pretty sure in an emergency situation where the patient is incapacitated, without any documentation to DNR/give blood/etc., the physician should perform life saving procedures on the patient.

This is true.

 

[487806]

This is true.

So, in the end, never override patient consent. If a patient refuses an operation, let them die?

 

[mimelim]

So, in the end, never override patient consent. If a patient refuses an operation, let them die?

In an emergency consent does not need to be obtained in order to treat. You should provide care consistent with doing the maximum good for your patient (Beneficence) and minimizing harm to your patient (Non-maleficence) without violating a patient's autonomy or other central tenants of medical ethics.

IF a patient refuses an operation or specifies they don't want something done, then you shouldn't do it.

 

[487806]

In an emergency consent does not need to be obtained in order to treat. You should provide care consistent with doing the maximum good for your patient (Beneficence) and minimizing harm to your patient (Non-maleficence) without violating a patient's autonomy or other central tenants of medical ethics.

IF a patient refuses an operation or specifies they don't want something done, then you shouldn't do it.

Ok that cleared it up... sigh... already it will be tiring to understand all the procedures, and adhering to ethics makes things a lot more difficult. Well, time to muster my strength and move forward. Good thing I learned this now, before it's too late.

 

[IslandStyle808]

In an emergency consent does not need to be obtained in order to treat. You should provide care consistent with doing the maximum good for your patient (Beneficence) and minimizing harm to your patient (Non-maleficence) without violating a patient's autonomy or other central tenants of medical ethics.

IF a patient refuses an operation or specifies they don't want something done, then you shouldn't do it.

Yep, just learned about this in my genetics class and this falls under Beauchamp-Childress principles.

 

[Dires]

What if it's a suicide attempt? How does this change the situation.

As for a second scenario: I witnessed a pt come into the ED with severe burns, unconscious (suicide attempt). At one point the pt began verbally screaming DNR. Doctors ignored as they were unfit to make the decision. I'm assuming because of the suicide attempt.

 

[WorldChanger36]

The card may count as an advanced directive however it would have to be confirmed the card was not signed under duress and the card is a normal way that JW refuse treatment. Also a medical proxy needs to be contacted. If no medical proxy can be found and the card can not be confirmed transfuse. You may also want to consider auto transfusion if there is enough blood collected from the bleed and it is not contaminated. Many JWs find auto transfusion acceptable because it is the same persons blood therefore the same soul.

 

[eefen]

What if it's a suicide attempt? How does this change the situation.

As for a second scenario: I witnessed a pt come into the ED with severe burns, unconscious (suicide attempt). At one point the pt began verbally screaming DNR. Doctors ignored as they were unfit to make the decision. I'm assuming because of the suicide attempt.

I believe advance directives have to be in writing. However, if the patient just wants to refuse treatment, the staff will first probably want to establish that there are no drugs/alcohol on board and that they are mentally "there," particularly in a case like this.

 

[neurodoc]

I agree with the prevailing sentiment in this thread. Although it'd break my heart to watch a patient die from a completely fixable situation, it is not the job of a doctor to play god. Doctors cannot simply treat however they deem best without the consent of the person they are treating. Like was said, it is a doctor's job to provide care for a patient in the way the patient agrees to, and respect his/her decisions about his/her own life and rights.

My understanding (maybe wrong) is that JW's refuse blood transfusions because they believe that God will not let them go to Heaven if they receive non-autologous blood. I guess this is the reason the hypothetical patient signed her card, which I presume has the value of an "advance directive" for medical care. Let's assume that this card has the full legal force of an advance directive (and I'm not sure it does).

As a physician I've taken an oath that among other things exhorts me to do no harm or as little as possible to treat my patients. I am supposed to use my judgment in this regard and to respect the wishes of my patients. In this case the patient is unconscious and unable to consent to treatment. Yes, there is evidence of a prior wish to refuse transfusions, but for all I know the patient or her family might change their minds in this particular situation, especially if they knew that the transfusion would be very likely to save life.

I'd try to contact the patient's family and present an argument for transfusion. If the family refused transfusion, I would be in a quandry and am not sure what to do next. I might try to hand off care to another physician who would be willing to accept what I feel is unacceptable treatment (allowing the patient to die w/o transfusion). I'd certainly try in the meantime to do everything possible (IV fluid/albumin and ICU care) short of transfussion to get the patient through the crisis).

That being said, if it came to ordering a transfusion to save the patient's life, I would do so. It would likely mean being sued and perhaps losing my medical license. I'd rather take my chances with that than standing by and letting the patient die unecessarily.

I don't see this as "playing God." If God disagrees, He can punish me in the afterlife.

 

[def1]

My understanding (maybe wrong) is that JW's refuse blood transfusions because they believe that God will not let them go to Heaven if they receive non-autologous blood. I guess this is the reason the hypothetical patient signed her card, which I presume has the value of an "advance directive" for medical care. Let's assume that this card has the full legal force of an advance directive (and I'm not sure it does).

As a physician I've taken an oath that among other things exhorts me to do no harm or as little as possible to treat my patients. I am supposed to use my judgment in this regard and to respect the wishes of my patients. In this case the patient is unconscious and unable to consent to treatment. Yes, there is evidence of a prior wish to refuse transfusions, but for all I know the patient or her family might change their minds in this particular situation, especially if they knew that the transfusion would be very likely to save life.

I'd try to contact the patient's family and present an argument for transfusion. If the family refused transfusion, I would be in a quandry and am not sure what to do next. I might try to hand off care to another physician who would be willing to accept what I feel is unacceptable treatment (allowing the patient to die w/o transfusion). I'd certainly try in the meantime to do everything possible (IV fluid/albumin and ICU care) short of transfussion to get the patient through the crisis).

That being said, if it came to ordering a transfusion to save the patient's life, I would do so. It would likely mean being sued and perhaps losing my medical license. I'd rather take my chances with that than standing by and letting the patient die unecessarily.

I don't see this as "playing God." If God disagrees, He can punish me in the afterlife.

You mention "do not harm" but you would be harming this patient mentally by making her think she was going to hell now that you performed the transfusion.

Keep your beliefs to yourself. This is no different than a DNR. Its up to the patient what they see fit, you can't impose what you want to do over the patients beliefs. It doesn't make it right because you think the patient might change their mind later.

Unless you're dr. house I'd imagine you would never work in a hospital again, and now instead of being able to save people you are stuck with the consequences of saving someones life who is now miserable because you forced them to an afterlife of hell now.

Its not so much "playing God" but you don't have the right to go against the wishes of a patient for your own benefit.

 

[mcloaf]

My understanding (maybe wrong) is that JW's refuse blood transfusions because they believe that God will not let them go to Heaven if they receive non-autologous blood. I guess this is the reason the hypothetical patient signed her card, which I presume has the value of an "advance directive" for medical care. Let's assume that this card has the full legal force of an advance directive (and I'm not sure it does).

As a physician I've taken an oath that among other things exhorts me to do no harm or as little as possible to treat my patients. I am supposed to use my judgment in this regard and to respect the wishes of my patients. In this case the patient is unconscious and unable to consent to treatment. Yes, there is evidence of a prior wish to refuse transfusions, but for all I know the patient or her family might change their minds in this particular situation, especially if they knew that the transfusion would be very likely to save life.

I'd try to contact the patient's family and present an argument for transfusion. If the family refused transfusion, I would be in a quandry and am not sure what to do next. I might try to hand off care to another physician who would be willing to accept what I feel is unacceptable treatment (allowing the patient to die w/o transfusion). I'd certainly try in the meantime to do everything possible (IV fluid/albumin and ICU care) short of transfussion to get the patient through the crisis).

That being said, if it came to ordering a transfusion to save the patient's life, I would do so. It would likely mean being sued and perhaps losing my medical license. I'd rather take my chances with that than standing by and letting the patient die unecessarily.

I don't see this as "playing God." If God disagrees, He can punish me in the afterlife.

If you are planning to simply try to hand off patients who make decisions you disagree with, prepare for an unpleasant career.

 

[mimelim]

My understanding (maybe wrong) is that JW's refuse blood transfusions because they believe that God will not let them go to Heaven if they receive non-autologous blood. I guess this is the reason the hypothetical patient signed her card, which I presume has the value of an "advance directive" for medical care. Let's assume that this card has the full legal force of an advance directive (and I'm not sure it does).

As a physician I've taken an oath that among other things exhorts me to do no harm or as little as possible to treat my patients. I am supposed to use my judgment in this regard and to respect the wishes of my patients. In this case the patient is unconscious and unable to consent to treatment. Yes, there is evidence of a prior wish to refuse transfusions, but for all I know the patient or her family might change their minds in this particular situation, especially if they knew that the transfusion would be very likely to save life.

I'd try to contact the patient's family and present an argument for transfusion. If the family refused transfusion, I would be in a quandry and am not sure what to do next. I might try to hand off care to another physician who would be willing to accept what I feel is unacceptable treatment (allowing the patient to die w/o transfusion). I'd certainly try in the meantime to do everything possible (IV fluid/albumin and ICU care) short of transfussion to get the patient through the crisis).

That being said, if it came to ordering a transfusion to save the patient's life, I would do so. It would likely mean being sued and perhaps losing my medical license. I'd rather take my chances with that than standing by and letting the patient die unecessarily.

I don't see this as "playing God." If God disagrees, He can punish me in the afterlife.

The card is more than enough evidence to stop you from giving the transfusion. People who were coerced into signing something like that generally don't carry it on them. They are also written in a way to maximize their relevance (date on card, clearly laid out etc). As previously stated, the family of a patient can not over rule what the patient wants just because they are now unconscious. Practically they can, but this is wrong on a moral and a legal level. As a physician, letting them do things that are clearly not what the patient is not only wrong it makes you liable.

This is a simple case of, "Does a doctor have the right to impose their values on patients when they clearly indicate that they have different values and are unable to protest." People refuse all sorts of medically important interventions. If you can't handle that, you are going to find it very hard to practice.

 

[mimelim]

Just so people know, there is a wide range of practices in the JW community. However, devout JW will not accept blood products and will NOT accept autologous blood donations. They will not accept any blood that has been outside of the human body. Most will allow the use of cell saver or echmo as the blood is being immediately returned to them.

There is no case law in the United States that I could find regarding Jehovah's Witness cards. There is a lot about patient autonomy that makes in the opinion of the law professor I asked about this about a year ago it very clear cut, like in Canada... In Canada, there is an on point case Malette v. Shulman. That dealt with emergency need of transfusion in someone that had an undated and unwitnessed JW card. "The courts established that clinicians should not administer emergency treatment without consent if they have reason to believe that the patient would refuse such treatment if he or she were capable.... The judge stated: “To transfuse a Jehovah's Witness in the face of her explicit instructions to the contrary would, in my opinion, violate her right to control her own body and show disrespect for the religious values by which she has chosen to live her life.”

Personally, if I saw someone actively going against the wishes of a patient, I would 1) Physically block them or 2) Create a **** storm to stop them. There is no excuse in this case to give blood. You are committing battery.

 

[Geebeejay]

In an emergency consent does not need to be obtained in order to treat. You should provide care consistent with doing the maximum good for your patient (Beneficence) and minimizing harm to your patient (Non-maleficence) without violating a patient's autonomy or other central tenants of medical ethics.

IF a patient refuses an operation or specifies they don't want something done, then you shouldn't do it.

To continue off of this, in an emergency, if DNR paperwork is discovered, or a DNR tag is on the patient, CPR is stopped. I think this was implied by mimilem, but wanted to clarified.

 

[Aerus]

My understanding (maybe wrong) is that JW's refuse blood transfusions because they believe that God will not let them go to Heaven if they receive non-autologous blood. I guess this is the reason the hypothetical patient signed her card, which I presume has the value of an "advance directive" for medical care. Let's assume that this card has the full legal force of an advance directive (and I'm not sure it does).

As a physician I've taken an oath that among other things exhorts me to do no harm or as little as possible to treat my patients. I am supposed to use my judgment in this regard and to respect the wishes of my patients. In this case the patient is unconscious and unable to consent to treatment. Yes, there is evidence of a prior wish to refuse transfusions, but for all I know the patient or her family might change their minds in this particular situation, especially if they knew that the transfusion would be very likely to save life.

I'd try to contact the patient's family and present an argument for transfusion. If the family refused transfusion, I would be in a quandry and am not sure what to do next. I might try to hand off care to another physician who would be willing to accept what I feel is unacceptable treatment (allowing the patient to die w/o transfusion). I'd certainly try in the meantime to do everything possible (IV fluid/albumin and ICU care) short of transfussion to get the patient through the crisis).

That being said, if it came to ordering a transfusion to save the patient's life, I would do so. It would likely mean being sued and perhaps losing my medical license. I'd rather take my chances with that than standing by and letting the patient die unecessarily.

I don't see this as "playing God." If God disagrees, He can punish me in the afterlife.

Except that now you've risked losing your medical license and your patient is now in anguish because they believe that they cannot go to heaven. Both parties are unhappy. It's a lose lose situation here. Simply put, you don't impose your beliefs on them, if you have evidence that they don't share your beliefs.

 

[femoralgirl]

Well, thanks for clarifying the misconception. Also, mimelim or sector9 or others, would it be best to study behavioral science as a way to prepare for these questions? I would definitely get this question wrong due to my ignorance.

This is a great site for studying medical ethics: http://depts.washington.edu/bioethx/topics/index.html

 

[487806]

This is a great site for studying medical ethics: http://depts.washington.edu/bioethx/topics/index.html

. Thanks! I really appreciate your help.

 

[eefen]

Again, this is a tough situation. But people seem to keep trying to figure out ways to "get around" the card, using such arguments as, "Well, maybe it was signed under duress," or "Maybe her opinion has changed now." Not only are these going to be really tough to prove in court....they're just bad arguments. You could say the same thing about any advanced directive, but the arguments still fall flat on the ground, because they are untenable.

Regardless of what we think may or may not have happened in the past, or what we think the patient's mental condition might be now, the fact remains that they signed a document stating their wishes in advance for medical care and are actively carrying it on their person. This enough is reason to believe that the documented directives are in fact real and current. The directive, in combination with the fact that the patient is a self-identified JW (who are well-known to refuse this sort of treatment) provides, in my opinion, a perfectly good case to withhold any drastic measures. Provide stabilizing care, but do not violate the patient's wishes.

I totally understand the sentiment that there should be something more we could do, or that the whole idea may, to us, be illogical or even silly. However, that doesn't change the facts or the ethics of the situation. Part of being a doctor is being able to empathize with other people, and part of that is not imposing our own morals/judgements on them.

The situation is emotionally tough, but it isn't ethically difficult to wade through. It's unfortunate, yes, but there is a clear answer.

 

[45408]

An eighteen year-old female arrives in the emergency room with a profound nose bleed. You are the physician, and you have stopped the bleeding. She is now in a coma from blood loss and will die without a transfusion. A nurse finds a recent signed card from Jehovah's Witnesses Church in the patient's purse refusing blood transfusions under any circumstance. What would you do?

Call the family and tell them to come in. If they verify that those are her wishes, do what I can, but expect her to die.

 

[45408]

What about unwarranted surgical procedures? If a patient is scheduled for an operation, and along the way, the doctor found an unrelated tumor. Would it be right for the doctor to remove the tumor?

Unwarranted is the same thing as "non-indicated." Those would not be appropriate. That would be like doing a circumcision after an appendectomy. You should also not do "unwanted" procedures on a patient who is competent to make those decisions.

Now, if you think you're going in for an appendectomy, and it's a ruptured cecal cancer, then you do whatever you think is necessary.

Unless extraneous findings are covered on consent, then they cannot be touched. Hence, why sometimes broad terms such as exploratory laporotomy are used.

A surg res/attending can correct me if wrong.

It's almost always covered on the consent. Ours says something to the effect of "if an unanticipated situation arises, I understand it will be dealt with based on the surgeon's judgment." If it's elective and unimportant, your judgment should keep you from doing something stupid. If it's an emergency, then your judgment should force you to do something about it. The consent also covers all the possible repairs you might have to do if there's a complication, like if the laparoscopic trocar goes into the aorta.

If the situation is a grab bag, then the consent usually says "exploratory laparotomy, possible ostomy, possible bowel resection, possible open abdomen, possible multiple take-backs and washouts," etc.

I don't know much about policy or anything for that matter, but wouldn't further tests be needed first? And a surgical "gameplan" to make sure they can plan the least abrasive surgery with the least possible complications for the patient?

Depends what it is. Sometimes it would be a bad idea to close the patient back up knowing that you have to operate again in a few days or weeks. The delay (inflammation, adhesions, etc) could make things worse.

Makes sense. However, if something had "ruptured" that could lead to immediate death if untreated, would it be okay to fix it without consent? Or would it still be illegal. and simply let the patient die?

So, in the end, never override patient consent. If a patient refuses an operation, let them die?

If a competent (adult, awake, oriented, non-deranged, non-suicidal) patient says "No, I don't want an emergency operation to save my life," then I say "Okay." It's actually not uncommon. Sometimes they're 85, sick, and the operation might cause a lot of pain with no benefit, and they're not interested in trying to survive a month in the ICU before they die.

If the patient shows up in the ED unconscious with no family member capable of making their decision, then you, the physician, do whatever you think is necessary. If the patient's wife shows up and says "No, he wouldn't want this operation," then you stop.

 

[FakeEmpire]

What about unwarranted surgical procedures? If a patient is scheduled for an operation, and along the way, the doctor found an unrelated tumor. Would it be right for the doctor to remove the tumor?

Something similar actually happened to me however it wasn't necessarily life threatening like cancer might be. I had a cholecystectomy when I was 19 and while I was in surgery they also "just decided" to removed my appendix. My surgeon said he just thought "since I'm in there" My dad was pretty upset by the whole thing, but I didn't really care. At the time I was just happy to have my galbladder removed.

 

[eefen]

Something similar actually happened to me however it wasn't necessarily life threatening like cancer might be. I had a cholecystectomy when I was 19 and while I was in surgery they also "just decided" to removed my appendix. My surgeon said he just thought "since I'm in there" My dad was pretty upset by the whole thing, but I didn't really care. At the time I was just happy to have my galbladder removed.

I could be wrong, but I *think* this is actually somewhat commonplace....more of a prophylactic move than anything.

 

[JJMrK]

No transfusion. Period. The patient's wishes are clear. Different story if the patient doesn't have the card, is unconscious, and it's the family telling you this.